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Motivational Interviewing Regarding Substance Use in the Medical Setting

Motivational Interviewing Regarding Substance Use in the Medical Setting. John M. Wryobeck, Ph.D. SUD in the Medical Setting. ~ 30 % ED Pts have AUD 50% trauma Pts, + for drugs 24% hospital admits have AUD 33% non-trauma admits related to AUD. SUD in the Medical Setting.

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Motivational Interviewing Regarding Substance Use in the Medical Setting

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  1. Motivational Interviewing Regarding Substance Use in the Medical Setting John M. Wryobeck, Ph.D © Alcohol Medical Scholars Program

  2. SUD in the Medical Setting • ~ 30 % ED Pts have AUD • 50% trauma Pts, + for drugs • 24% hospital admits have AUD • 33% non-trauma admits related to AUD © Alcohol Medical Scholars Program

  3. SUD in the Medical Setting • ~ 20% medical clinic Pts have AUD • SUD among top 3 diseases worldwide • SUD related to many injuries/disease © Alcohol Medical Scholars Program

  4. SUD Interventions • External motivation • Education – information motivates change • Persuasion – logic motivates change • Elicit internal motivation • Explore Pts knowledge/thoughts about change © Alcohol Medical Scholars Program

  5. This Lecture Reviews • Definition & Principles • Basic Skills of MI • Basic Steps of MI • Research supporting MI © Alcohol Medical Scholars Program

  6. Directing style 1 active participant Manage Lead Take charge Go along Guiding style 2 active participants Enlighten Encourage Support Elicit Definition & Principles © Alcohol Medical Scholars Program

  7. Principles - Ambivalence • Ambivalence is normal • Persuasion & confrontation avoided • Elicit/reinforce own motivation • Discuss how change relates to desires © Alcohol Medical Scholars Program

  8. Principles - Empathy • Express empathy •  Understanding & honesty • Communicates acceptance, support • Non-verbal & “reflective” empathy • State emotion underlying Pt statement • Paraphrase Pt statement to show understanding © Alcohol Medical Scholars Program

  9. Example: Empathy • Pt: I say I am going to quit but don’t. • Dr: It is frustrating not accomplishing what you want. • Pt: Drinking is ruining my health but I can’t change. • Dr: ? © Alcohol Medical Scholars Program

  10. Principles – Roll w/ Resistance • Resistance  when Pt feels unheard • Ambivalence & self determination ≠ resistance •  Resistance through reflective listening • Requires “active listening” • Invites Pt to view situation differently © Alcohol Medical Scholars Program

  11. Example: Reflective Listening • Pt: What do you know about drinking? • Dr: It’s hard to imagine I could understand. • Pt: My drinking really isn’t that bad. • Dr: ? © Alcohol Medical Scholars Program

  12. Principles – Confidence • Develop confidence • Pt must believe they can change • Support small changes • Any + change Pt willing to make is supported • Elicit/reinforce statements of confidence • Use reflection, evocative questions © Alcohol Medical Scholars Program

  13. Principles - Confidence • Evocative questions • What might be a good first step? • What gives you confidence that you might do this? • Past success • What change have you made successfully and what did you learn in making that change? • When you last abstained, what worked for you? © Alcohol Medical Scholars Program

  14. This Lecture Reviews • Definition & Principles  • Basic Skills of MI • Basic Steps of MI • Research supporting MI © Alcohol Medical Scholars Program

  15. Basic Skills - Asking • Asking • Open-ended questions gain more information • Skillful asking is element of guiding style • What kind of change makes sense to you? vs • Are you willing to make any changes? • Open-ended questions are simple, focused, neutral © Alcohol Medical Scholars Program

  16. Example: Asking • Learning questions • What went well and why? • What would you do differently now? • How might the outcome be improved? • Other? © Alcohol Medical Scholars Program

  17. Example: Asking • Value Questions • What are your priorities at this time in life? • What matters to you? • How does alcohol fit in your life? • Other? © Alcohol Medical Scholars Program

  18. Example: Asking • Skill Questions • What did you learn about your skills as you cut back on your drinking? • Were there any surprises? • What are you doing (behavior) when you find abstinence/reduction is going well? • Other ? © Alcohol Medical Scholars Program

  19. Basic Skills - Listening • Listening • Reflect resistance • Reflect change-talk Reasons Ability Resistance Desire Status Quo © Alcohol Medical Scholars Program

  20. Basic Skills - Informing • Informing • Information exchange vs receptacle • Provide choice • Inform skillfully • Elicit-inform-elicit © Alcohol Medical Scholars Program

  21. This Lecture Reviews • Definition & Principles  • Basic Skills of MI  • Basic Steps of MI • Research supporting MI © Alcohol Medical Scholars Program

  22. Steps - Rapport • Establish rapport • Ask permission • Non-threatening language © Alcohol Medical Scholars Program

  23. Steps - Rapport I would like to spend a few minutes talking about how alcohol fits into your life. Would that be ok? © Alcohol Medical Scholars Program

  24. Steps - Scaling • Assess Pt motivation • Importance Ruler • Confidence Ruler Change Talk Resistance 1 2 3 4 5 6 7 8 9 10 © Alcohol Medical Scholars Program

  25. ↑ Confidence ↓ Confidence ↑ Importance ↓ Importance © Alcohol Medical Scholars Program

  26. Case Example - Scaling • Dr: How important is it to make changes to your drinking? • Dr: How confident are you that you would be successful if you tried to quit? © Alcohol Medical Scholars Program

  27. Steps – Reflect Change talk • Elicit Motivation • When you hear change talk: • Reflect it • Use open-ended question to elicit more © Alcohol Medical Scholars Program

  28. Case Example • Pt: I sometimes drink too much. • Dr: What makes you think that? • Pt: I don’t know when to quit. • Dr: You don’t feel you need to stop but drinking causes you problems. © Alcohol Medical Scholars Program

  29. Steps – Resolve Ambivalence • Resolve ambivalence = identify inconsistency • Inconsistency between values & behaviors • Discussion of pros and cons of change • Identify for what Pt is motivated © Alcohol Medical Scholars Program

  30. Case Example • Pt: I need to cut down but I entertain clients. • Dr: Client’s take precedence over your health. • Pt: No, my health is important to me. • Dr: You can entertain clients and be healthy by altering drinking. © Alcohol Medical Scholars Program

  31. This Lecture Reviews • Definition & Principles  • Basic Skills of MI  • Basic Steps of MI  • Research supporting MI © Alcohol Medical Scholars Program

  32. % of RCT’s Finding MI Effective in Medical Settings © Alcohol Medical Scholars Program

  33. % Reduction in Use Medical/SUD Setting © Alcohol Medical Scholars Program

  34. % Occurrence, Emergency Dept Setting 6 Months 3 Years © Alcohol Medical Scholars Program

  35. Summary • AUD’s will be seen in medical settings • Guiding as alternative to directing • Understand Pt ambivalence • MI principles/skills/steps support Pt • Research supports use in medical settings © Alcohol Medical Scholars Program

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