Motivational Interviewing (MI) Regarding Substance Use in the Medical Setting

Lecture outline

John M. Wryobeck, Ph.D. University of Toledo (Slide 1)

I. Introduction

A. Importance of substance use disorders (SUD) intervention in medical setting (Slide 2)

1. SUD in the Emergency Department (ED)

a. ~ 30% ED patients (pts) have alcohol use disorders (AUD)1

b. 50% Severe trauma pts under drug influence2

c. Trauma includes falls, violence, accidents

2. SUD in hospitalizations

a. 24% hospital admissions have AUD3

b. 33% Of non-trauma admissions related to AUD4

3. SUD in primary care (Slide 3)

a. ~ 20% medical clinic pts have AUD5

b. SUD among top 3 diseases worldwide6

c. SUD related to 60+ types of injury/diseases5

            B. Current approaches to changing drinking behavior (Slide 4) 7


                        1. Through external motivation – have limitations, not effective for all


                      a. Education - information motivates change


                      b. Persuasion - logic motivates change


             2. Elicit internal motivation


                      a. Explore pts knowledge and thoughts about change


                      b. Allow pt to argue for change


C. This lecture reviews (Slide 5)

1.      Definition & Principles of MI

2.      Basic Skills of MI – communication techniques used

3.      Basic Steps of MI – strategies for use in medical setting

4.      Research supporting MI – empirical evidence in the medical setting

II. Definition and Principles of MI (Slide 6) 7

A.     Directing - Dr takes charge, leads, manages (is appropriate style for many medical situations) versus:

1.      Guiding style - helping one find their way (two active participants)

2.      Not typically taught in medical schools

3.      Prescribing behavior change requires interpersonal approach (asking one to change lifestyle is different from fixing bone, excising tumor)

4.      Guiding - input from both pt & Dr; Dr elicits, encourages, supports  

B.     Explores & resolves ambivalence – feeling two ways about change (Slide 7) 8

1.      Acknowledge & respect pt’s right to choose course of action

a. Ambivalence seen as “normal” part of change (ambivalence about “change” not necessarily about use)

b. Persuasion & confrontation avoided (if clinician argues for change, pt likely to argue for status quo if ambivalent)

2.  Elicits from pt what they need/want at this time

            a. Skills used to elicit/reinforce pt motivation/readiness for change

            b. Facilitate discussion on how changes related to pt’s desires


C. Principles Empathy (Slide 8) 8

1.                  First principle of MI is Express empathy – acceptance of pt’s experience & ambivalence 9 

a.       ­ Understanding and honesty; nonjudgmental attitude of Dr fosters environment where pt is comfortable expressing self

b.      Communicates acceptance, support

1)      Non verbal expression of empathy

i)        Facing pt, eye contact

ii)       Avoiding office/clinic distractions (phone, staff, etc.)

2)      “Reflective” empathy

i)        State the “emotion” underlying pt statement

ii)       Paraphrase pt statement to show understanding

c. Example: (Slide 9)

1)      Pt: “I always say I am going to quit drinking, but I never do.” Dr. “It is frustrating not being able to accomplish something you want so much.”

2)      Pt: “I realize that drinking is ruining my health but I don’t think I can change.”

Dr. [Ask audience for possible empathetic responses to above.

Be supportive and affirming in acknowledging their responses.]

2. Second principle of MI: Roll with resistance (Slide 10)

a.       Resistance when pt feels unheard and/or lectured to

1)      Respect pt’s right to make decisions (good/bad) for themselves

2)      Ambivalence often mistaken for resistance

b.      ¯ Resistance through reflective listening (stating back to pt the essence of or specific aspect of pt statement)

1)      Easier to ask questions – reflection requires full attention to understanding patient

2)      Invite pt to view situation from different perspective

3)      Active process - core element of the MI “guiding” style

c.       Example: (Slide 11)

1)      Pt: “What do you know about drinking?  You probably don’t even drink.”

Dr: “It’s hard to imagine how I could possibly understand.”

2)      Pt: “My drinking really isn’t that bad.”

Dr. [Ask audience for possible reflective responses to above that would minimize resistance.  Be supportive and affirming in acknowledging their responses.]

3.      Third principle of MI: Support pt’s confidence in ability to change     (Slide 12)

a.       Develop confidence 10, 11

1)      Pts unlikely to change until they believe they can

2)      Emphasize pt’s ability to change

b.      Support small changes

1)      Any positive change seen as good, fosters confidence & optimism in patient

2)      Elicit change behaviors pt willing to make

c.       Eliciting/Strengthening statements regarding confidence

1) Evocative questions (Slide 13)

i)        What might be a good first step?

ii)       What gives you confidence that you might do this?

iii)     [Ask audience for another possible question.]

                        2) Review past successes

i)        What change have you made successfully and what did you learn in making that change?

ii)       When you abstained for 3 months, what worked for you?

iii)     [Ask audience for another possible evocative question.]

D.     Transition: We have reviewed definition & principles of MI covering major points: (Slide 14)

1.      MI is a guiding style

2.      MI addresses ambivalence through

a.       Empathy

b.      Open Questions, reflections

c.       Offering support


III. Basic Skills that reflect the principles of MI (Slide 15) 7

A. Asking

1. Open-ended questions – use to gain understanding

a.       Avoid repeated closed ended questions (can be answered yes/no or with one word) feels more like an interrogation vs. collaboration. “How much do you drink? Do you want to stop drinking? Don’t you think it is hurting you? Are others telling you to stop?”

b.        Good open-ended questions get more info faster 12,13

c.       Skillful asking is element of guiding style

d.      What makes for good open-ended questions?

                        1) Simple

                        2) Focused

                        3) Tone neutral – not sarcastic

e.   Examples of questions (asking) (Slide 16)

1)  Learning questions ,asking the pt to recall any past success with any behavior change, use following questions

                                          i)  What went well and why?

ii)  What would you do differently now?

iii)  How might the outcome be improved?

iv)  [Elicit additional examples from audience]

                        2)  Value questions (Slide 17)

i)  What are your priorities at this time in your life?

ii)  What matters to you?  

iii)  How does alcohol fit in your life?

iv)  [Elicit additional examples from audience]

                        3)   Skill questions (Slide 18)

i)        What did you learn about your skills as you cut back on your drinking?

ii)       Were there any surprises?

iii)     What are you doing when everything is going well?

iv)     [Elicit additional examples from audience]


B. Second skill of MI: Listening - as a tool to guide pt (Slide 19)

1.      Reflect resistance; don’t confront. Use pt’s statement to show you hear and understand – not agree.

2.      Reflect change-talk

a.       Change talk predicts commitment which predicts change 14

b.      Change talk builds up, tips balance in favor of change

c.       Identify change talk: desire, ability, reasons for change, eg:

Pt: I know I should stop drinking but I am not sure I really want to.

Dr:  Why do you know you should stop drinking? Focus is on change

C. Third skill of MI: Informing (Slide 20)

1.  Information exchange vs information receptacle

            a. Learn what pt knows, assume nothing

            b. Inform based on what pt knows

2.  Provide choice

            a. Giving pt options keeps them in control

            b. Your help in defining the options keeps you as guide

3.  Skillful ways to inform

            a. Avoid advice giving, provide options based on evidence

            b. If asked, provide list of options that have worked for others

D.     Transition: We have reviewed basic skills of MI covering major points: (Slide 21)

1.      Asking

2.      Listening

3.      Informing

IV. Basic steps of MI (Slide 22)

A. Establish rapport

1. Ask permission, respect pt’s decision making capacity

2. Use non threatening language and be reassuring

3. Case example, preface this with it is known that the chart indicates that the patient consumes alcohol (Slide 23)

a.       I know from your chart that you drink.  If it is alright with you, I would like to spend a few minutes talking about how alcohol fits into your life.  Would that be ok?

B. 2nd step used in MI: Assess pt motivation (Slide 24)

1. Importance ruler, goes for understanding & elicits change talk

a.       On 10-point scale (10= most important), how important is changing drinking?

b.      Point out that most of us want to ask “Why isn’t it a “10?”

c.       When given #, ask why not less important (Why did you say a 3 and not a 1?).  This produces reasons for change.  Asking “Why 3 and not a 10” produces reasons against change

2. Confidence ruler, goes for understanding and elicits confidence talk

a.       On 10-point scale (10= most confident), how confident are you that you could make changes? 

b.      Point out that most of us want to ask “Why isn’t it a “10?”

c.       When given #, ask why not less confident (Why did you say a 3 and not a 1?). This produces why Pt feels some confidence.  Asking “Why 3 and not a 10” produces why Pt is not confident

3. Rulers allow one to focus intervention (Slide 25)

a.       Low importance, low confidence e.g. “this is not important and I can’t change”

b.      High importance, low confidence e.g. “this is important but I can’t change” (often  we continue to educate on importance rather than focus intervention on confidence)

c.       Low importance, high confidence e.g. “this is not important but I can change if I wanted to”

d.      High importance, high confidence e.g. “this is important and I can do it”

4. Case example (Slide 26)

Dr: How important is it that you make any changes to your drinking?

Dr: Now if you were to decide to make a change to your drinking, how confident are you that you would be successful?

C. 3rd step used in MI:  Elicit motivational statements (Slide 27)

1. Use basic skills discussed earlier

            a. Examples of open-ended questions

            b. Reflections of change talk

2. Case example (Slide 28)

Pt: I know I sometimes drink too much but I don’t think it is a real problem.

Dr: Tell me what makes you think there are times you drink too much. (Focus is on having patient expand upon potential reasons for change.)

Pt: There are times I don’t know when to quit and I get myself into trouble.

Dr: You don’t feel you need to stop drinking but you are concerned that drinking heavily, causes you problems, and you’d like to prevent that. (Reflecting potential ambivalence; concerns with negative consequences; and desire to change behavior.)

D. 4th step in MI: Resolving ambivalence (Slide 29)

1. Develop discrepancy

            a. Discrepancy between values and behaviors

            b. Discussion of pros and cons of change 15

2. Identifying for what the pt is motivated

3. Case example (Slide 30)

Pt: I need to cut down on my drinking because of stomach problems, but my job has me out entertaining clients.

Dr: The need of your clients takes precedence over your health.

Pt: No, no, my health is important to me.  I shouldn’t have to make bad health choices just to entertain clients.

Dr: You can entertain clients without having to drink and the reduction in alcohol use will result in your being healthier.

E.      Transition: We have reviewed basic steps of MI covering major points: (Slide 31)

1.      Establish rapport

2.      Importance & confidence ruler

3.      Eliciting motivation

4.      Pros & cons of change & ambivalence


V. Research supporting MI (Slide 32)  

A. Meta-analysis of RCT’s: advice giving as control, MI as intervention and represented by gold, rear row (N-72)16

1.      Address addiction (vs advice giving) 75% had an effect, # = good

2.      Rx diabetes, asthma & weight problems 77% had an effect

B. RCT interventions in medical & substance use settings (Slide 33)  

1.      Pts misusing pain medication N=126, after 3 months 52% ¯ drug use by 25% or more  vs 30% in TAU 17

2.      Pts in primary care setting (N=723) received two 15 minute MI interventions, after 12 months # of drinks per week ¯by 82% in MI group vs 60% in Treatment as Usual (TAU) group 18

3.      Pts in substance use treatment setting (N=42) received 2 sessions and at 12 months drinks per week were ¯ by 76% in MI vs 35% in TAU 19

C. RCT ED interventions for harm reduction - % recurrence.  In this slide MI is now represented by gold in the front row   (Slide 34)  

1.      Population = Motor vehicle accident & BAC or AUDIT N=126,  after 3 years 11% in MI reported DUI vs 22% in TAU 20

2.      Teens (age 18 & 19) N=94 treated in ED with + screen followed 6 months only 21% in MI reported alcohol related injury vs 50 in TAU 21

3.      % Drinking excessively: 18% vs 47% at baseline MI; 32% vs 48% TAU

VI. Summary (Slide 35)

            A. Pt’s w/ AUD will be seen in medical setting

            B. Guiding is alternative to directing style in behavior change

            C. Goal is to understand/explore Pt’s ambivalence

            D. Use MI principles/skills/steps to:

                        1. Support the Pt. & reduce resistance

                        2. Elicit change-talk & internal motivation

            E. Research supports use of MI in medical & mental health settings




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