Good afternoon, everybody. I'm Brian. I'm Carla. And this is the AAAP 2022 workshop on Motivational Interviewing and Harm Reduction. Before we jump in, this is our professional and financial disclosures. I don't have any financial commercial conflicts of interest to disclose. I'm not going to try to sell you anything today. However, I am the president-elect of the American Society of Addiction Medicine. Dr. Merrifield and I both run ASAM's Motivational Interviewing course, which is a paid opportunity that benefits ASAM. It's not a financial conflict for us personally, but it's certainly a conflict of interest that I wanted to be transparent about. Dr. Merrifield? Yes. And along those same lines, I'm not trying to sell you the API book. And it is not something that meets the definition of a commercial interest. But I think in the interest of transparency, I do have a book called Motivational Interviewing for Clinical Practice that I do receive very small royalties from. And then I also am a consultant for a biotech startup that has nothing to do with motivational interviewing. All right. So how are we going to spend this part of the afternoon together? At the conclusion of the session, we'll be able to recognize the overlap between motivational interviewing approaches and harm reduction practices, to identify change talk and use reflective listening to amplify patient readiness to make changes that reduce the harm associated with substance use, and apply the spirit of motivational interviewing when working with patients who are not ready to stop using substances. I regret this afternoon's workshop will be interactive. We will be asking you to participate. So for those of you that were hoping to sit in a room silently and not participate, this may not be the workshop for you. Question number one. Not rhetorical. What do you already know about harm reduction? There is a microphone if you are so interested. I will also reflect what you say back for the purposes of the recording. So if you do not want to use the microphone, you are not compelled to, we will capture it for posterity using this microphone. What do you already know about harm reduction? It's okay to just shout it out. Have you ever heard the term? Harm reduction. No, please. So harm reduction, there is a whole spectrum of services involved with harm reduction and you were about to say? So motivational interviewing, you can do motivational interviewing. There are medication services, counseling services, all of which can contribute to reducing the harms of substance use. Did I get that correct? What else do you know about harm reduction? Harm reduction is about meeting somebody where they are, understanding and evoking their goals and values in your work with them. Did I get that right? Thank you. What else? Yes. So harm reduction can be conceptualized as reducing the harm that an individual patient or person might experience and mitigating the harm to the community in which that person lives. That's part of harm reduction. What else do you already know about harm reduction? Let's do a quick, do you want to repeat back where we are? So what I have so far for harm reduction is that it encompasses many things. It's a spectrum of options, can involve things like medications, motivational interviewing, various programming approaches, that it comes from a philosophy or an approach of meeting the person where they're at and using their goals to help guide what happens. And it's a tool for helping to mitigate negative effects for both the individual and the community. Is that everything that we know about harm reduction? Yeah. Harm reduction is not necessarily focused on cure, but reducing symptoms. Anything else? Harm reduction can involve preventing health outcomes, whether, well, there's a variety of health outcomes that one could prevent. That's a whole area of services that can be part of harm reduction services. Anything else? Yes. Part of harm reduction is engaging people in treatment and meeting them where they're at. That phrase was used earlier, and I appreciate your reiterating it. Yes. Yeah, harm reduction came out of a socio-political, cultural, historical context that actively incorporated the voice of people who use drugs in designing and shaping the services available for people who use drugs. Yes. So, harm reduction is about a practical, achievable goal for a person, or depending on your unit of intervention for a community, that's possible to achieve that would be positive change, right? Rather than striving for a goal of cure that may not be possible, at least at that particular moment. Anything else? Yes. Equitable health care is part of harm reduction. I want to know what you know about harm reduction. So, there are specific tools that are oftentimes associated with harm reduction. Safer consumption supplies, such as syringes, pipes, cookers, or other injection equipment, testing supplies like fentanyl test strips, overdose reversal supplies like naloxone are all commonly associated with harm reduction. We're going to move on to the next item, but before we do, is there anything else that we missed? Dr. Maricopa? Do you want to go ahead and say what you were going to say? Sure. Uh-huh. I was going to say that for any given person, the goal of harm reduction can change at any time. So, it's a dynamic thing, not a static thing, that harm reduction can change with time, depending on the person or what's going on in the situation. That's helpful. So, a related question, but also an important exercise for us, because it will inform kind of how we proceed. What do people know about motivational interviewing? And by people, I mean you guys in this room. Strength-based. I'm sorry. Strength-based. Strength-based. Strength-based, yes. So, motivational interviewing is based on strengths. Yes. So, you elicit it from the person, as opposed to telling it to them, and because it's elicited from them, it's more believable or more salient for them. Uh-huh. Uh-huh. Most decisions are on a continuum, and so you focus on the ambivalence and try to move the needle forward towards the goal. It's, you know, patient-tooled. Uh-huh. More patient-tooled. So, there's, people are ambivalent. They're torn about which direction they want to go, and the decisions they make can be on a continuum, and you want to kind of move that needle more towards that positive change, that positive choice. Okay. Yes. Collaborative? Uh-huh. Uh-huh. It's collaborative. You're in a partnership with the person who's engaged in the motivational interview with you. Uh-huh. You can have two answers. Would someone say it's about making changes? About, it's about change, right? So, motivational interviewing is a conversation about change. So, motivational interviewing is about measuring, like, their ability to make that change, their confidence in the ability to make that change. Yeah. Okay. So, you want to know how the person feels about it, but you can also elicit from them their strengths, their supports, other people's input, and their sense of that and how they want to use that then for their own goals and values and choices that they want to make. So, fundamentally it's about eliciting from them kind of this environment that they're in and how that informs what they're going to do. So I think, yep, go for it. Yes, so that statement that came up with harm reduction, funny enough, is similar to certain statements we might think about with motivational interviewing. So motivational interviewing, if I'm reflecting this correctly, is strengths-based. It's a practice where we elicit and evoke the patient's ideas, values, and interests in change. Change can oftentimes be incremental in moving somebody from a position of ambivalence in a direction of positive change. It's collaborative, and motivational interviewing, our conversation's focused on change. We evoke from patients not just their motivation, but their confidence to make changes, and we meet patients where they are. Did I get all of that correct? And we evoke from patients their ideas and incorporate those ideas into the treatment plan. So we're going to shift gears and focus a little bit. So we heard some overlap in terms of what people know about MI, what people know about harm reduction, and how those two things can be somewhat similar. And now we're going to think a little bit about how we can use that information that we just elicited from you all towards what we want to get out of this workshop. You came to a workshop on motivational interviewing and harm reduction. What were you hoping to get out of it? You want to improve your skills. You'd like to potentially spend part of this time practicing. You're in luck. We will be doing some of that. Yes, in the back. I want to use motivational interviewing skills to have an effective and efficient conversation that might not be ready to talk to me about addiction. Did I get that right? And to engage patients who are otherwise difficult conversations. So some skills around that. If we do those two things, we practice skills and go through efficiently using motivational interviewing to talk to patients unready to change. Is that everything we want to get done here today? Teach the people around us how to use motivational interviewing. how to talk with our colleagues about harm reduction so that they understand it. Anything else? Yes? Examples of great interview questions in your life? Examples of techniques of motivational interviewing, some of which might not be questions that help guide an effective conversation, but might include questions, too. So what are practical examples of things you might do or say during an interview? You'd like to learn some technique. Anything else? So if I can offer a summary. So we have some things that inform what we understand harm reduction to be. We have some ideas already of things that we've been exposed to and understanding what motivational interviewing is and what it might be like. And then we have some goals. And most of the goals are, for the purpose of this workshop, are going to be around improving our skills in terms of generally improving our skills and using harm reduction approaches informed by an MI approach to engage difficult patients specifically or potentially to model our own behaviors such that we can then teach and empower other clinicians about the values and benefits of these approaches. Anything else? Yes. What could motivational interviewing look like in a digital therapeutic world? Got it. Am I in harm reduction with one human? That's right. Anything else? All right. If one does a search in the literature for harm reduction, you'll find a lot. There's an awful lot of literature in harm reduction. I've picked the set of principles that are on the Harm Reduction Coalition website because I think that they're relatively succinct. If you haven't seen them, there is an organization called the Harm Reduction Coalition. Harmreduction.org is their website. And the core principles of harm reduction, which I've done my best to coalesce onto a PowerPoint slide, are written in very, well, wonderful sentences. But the core principles of harm reduction according to the HRC are acceptance, understanding that some ways of using drugs, and in this case, drugs could mean a lot of things. It's not necessarily like non-tobacco, non-alcohol intoxicants. So, you know, we could be talking about steroids. I mean, so drugs is very broad in HRC's definition. Understand that some ways of using intoxicants are clearly safer than others, that individual and community life and well-being are the criteria for successful interventions and policies, that harm reduction is based in non-judgmental and non-coercive provision of services and resources, and that people who use drugs and those with a history of using drugs should have a real voice in the creation of programs and policies designed to serve them, to affirm people to use drugs themselves as the primary agents of reducing the harms of drug use, to recognize that the reality of poverty, class, racism, social isolation, past trauma, sex discrimination, and other social inequities, and does not minimize or ignore the real harm and danger of drug use. That's, you know, the principles of harm reduction in a nutshell. Some of these are clinically focused, acceptance being one of them. Some of them are structurally focused. They talk about like the approach that a group or an organization or a community would take rather than necessarily something that you do with a patient in the room. Some examples of harm reduction. This was brought up earlier. Syringe distribution or other safer use supplies have been a big push to give safer smoking equipment because it's harder to overdose on smoking compared to injecting. Substitution therapies, which is a tricky word in the addiction field, where people use certain intoxicants that are thought to be less risky than other categories of intoxicants. Take home naloxone programs where people have lower threshold access to naloxone. That oftentimes means naloxone distribution programs using standing orders rather than prescribed naloxone that people get from pharmacies. Supervised consumption facilities. There's a bunch of words for these. Safer injection facilities, overdose prevention sites, safer consumption facilities, or supervised consumption facilities. They're all describing a similar category of community-based interventions. Outreach and education services can be an example of harm reduction. Peer support programs can be examples of harm reduction. And one example of harm reduction that I just can't resist pointing out is designated driver programs is an example of harm reduction. Designated driver programs don't necessarily try to get people that are gonna drink to not drink. They just say, if you're gonna go drink, make sure you have a plan for a ride home with somebody who's not drinking. And this was published, what, like 11 years ago? Pragmatic strategies for managing high-risk behaviors. Why has there been, you know, the White House, the ONDCP, put out the White House Strategy on Drug Control Policy, which for the first time mentioned harm reduction. There's a little section on harm reduction. And, like, ONDCP is historically a law enforcement, I mean, it's not just law enforcement, but it's been a law enforcement-enriched or, you know, informed agency. And one of the big drivers of a lot of attention to harm reduction right now has to do with the public health impacts of substance use disorders. Now, the vulnerability to substance use disorders, and I pulled this directly out of the PCSS Ex-Waiver slide deck, so if you've ever done the Ex-Waiver slide deck, this is the schematic of genetic and environmental drivers to substance use disorders. But we're seeing, in the drugs that people use, a shift towards higher-potency compounds that people are less likely to survive if they're not tolerant to them. What am I talking about? I am talking about fentanyl. I'm talking, like, let's be clear, right? I am talking about illicitly manufactured fentanyl, which is the biggest driver of overdose in the United States today. It's the biggest driver of overdose where I live in Los Angeles. It is now overtaking other categories of intoxicants is causing overdose. Why? Because it's so potent. And it's not just fentanyl. It's Carfentanil, Sufentanil, Alfentanil, right? The now ever-proliferating fentanyl analogs, which, for the manufacturers of these analogs, it's much easier to get smaller quantities of intoxicants across checkpoints and borders through interdiction efforts when you need to put them in packages that are this big as opposed to packages that are this big. And what are we seeing with intoxicants? This is data through January of 2022. It was the most recent data. At the time I put this slide together, about six weeks ago, on the CDC website, which is we are seeing more overdoses than ever in US history. And if we look at what are the different categories of intoxicants, again, fentanyl is by, far, and away. Now, there's a lot of different approaches to how you deliver addiction treatment to people. One of the things we learned from Project MATCH, which was a comparative trial of 12-step facilitation therapy versus cognitive behavioral therapy versus motivational enhancement therapy, which is kind of manualized motivational interviewing, was that patients that are more motivated do better. And even the developers of the 12-step model talk about, you know, Athlox Anonymous is a program of traction rather than promotion. We wait till people are ready. So we know offhand, what's the percentage of people with a substance use disorder in the United States that are getting treatment for that substance use disorder? Six. Six percent. Six percent of people with a substance use disorder get treatment for their substance use disorder. This comes from the NSDUH, National Survey on Drug Use and Health. It's every year. We should be looking at the, this is the 2020 survey results. We should be looking at the 2021 results from last year's survey. Should be out soon. I don't think it's been published yet, but it should be out soon. Of the people in the orange, the people that have a substance use disorder but are not in treatment for their substance use disorder, the NSDUH agents, because it's a telephone survey, ask, what's the number one reason why you didn't get treatment? And they have a whole list. Does anyone have a guess? What's the number one reason the people who are in orange who are not in treatment don't get treatment? The number one reason is that they don't want it. 97.5% of the people who don't get treatment, who have a substance use disorder and don't get treatment, don't get treatment because they don't want it. Now, in United States, we do have a supply issue around addiction treatment. I'm not saying every form of treatment of addiction is uniformly or equally accessible. That's not what I was, like there are access issues for sure. But access is not the number one drag or driver of the treatment gap. The number one driver of the treatment gap is lack of demand. So if we're sitting there and waiting for people to come to treatment, right? If the whole model of addiction as well, wait until somebody's life becomes unmanageable. Once their life becomes unmanageable, then they'll get treatment. The public health data suggests that we're just gonna continue to lose more people, right? The overdose rates are just gonna continue to rise. So that means shifting the approach where rather than waiting for somebody to dedicate their life to full sustained abstinence from all intoxicants for now forevermore, that we start taking components of what we do in addiction treatment and getting it to the communities that need it even before they're ready to commit to abstinence. Now, there is, I mentioned the Harm Reduction Coalition, just, you know, this is the harm reduction principles. And these I think are, they're very helpful principles to define what harm reduction is from like a totality perspective. But what do you actually do as a clinician, right? Like if you're actually seeing patients or you're running a health, like what do you actually do clinically? So there's this other paper called Harm Reduction Principles for Healthcare. It's published in 2017. The principles of harm reduction in healthcare settings is humanism, right? The prioritization of the person's wellbeing, not necessarily the prioritization of their abstinence. Now, oftentimes we want, I mean, I'm an addiction psychiatrist. I want my patients to stop using drugs. Let me be clear. That is like, I always have that goal. But it also means that I will prioritize their understanding of their wellness and work with them towards that goal even if it's not abstinence at this time. Harm reduction principles in healthcare are deeply pragmatic. You do what is possible for the person in that moment, understanding that that shifts over time. It understands that people, the individuals are the experts in themselves and people have autonomy. So people will leave my office. I have an outpatient practice. So people will leave my office and go use or not use and that is their decision, right? It's not like I can't control whether people are gonna use or not use after they leave the office. It's also based on incrementalism, right? If somebody is going to use less or use in a way that's less harmful or they're not even gonna change their use at all but they're gonna start getting tested for infectious diseases. Any positive change, even if it's incremental change is something that I'm on board with supporting and that I keep patients accountable. We come up with goals. But if the patient doesn't meet their goals, the result is a conversation. The result is an exploration. The result isn't a termination. And there's actually an entire field of harm reduction psychotherapy which is a category of psychotherapeutic approaches so there's like motivational interviewing harm reduction therapy, there's cognitive behavioral harm reduction therapy, there's like psychodynamic harm reduction therapy. So harm reduction psychotherapy is not like one thing but it's a category of approaches that vary in theoretical orientation and clinical approach but share commitment to the reduction and the harm associated with active substance use without the assumption that abstinence is the ideal goal for all problem substance use or a necessary prerequisite for entering treatment. That's something I work on a lot locally is how do you shift admission policies where a commitment to abstinence is not prerequisite to even getting started in treatment where people can explore the pros and cons and begin to do the work of getting ready for a goal like that. So here's some textbooks if you want to read more about it. This is not a talk about harm reduction psychotherapy like writ large. This is a talk about the overlap between motivational interviewing and harm reduction. And with that, Dr. Merrifield, what can you tell us about motivational interviewing? Thank you. So we're gonna shift gears and talk a little bit about MI but I just wanna build on that comment that you just made about the overlap of motivational interviewing and harm reduction. And I'm just gonna bring you back to this slide for a second to look at some of these words, humanism, pragmatism, individualism, autonomy, incrementalism, lots of isms, right? Accountability without termination and look for some of those. I would also, let's see, bring us back just for a second before I begin to this slide here about some of the principles from the Harm Reduction Coalition and just thinking about these as we move into talking about motivational interviewing. So acceptance, a non-judgmental, non-coercive approach, affirmation of drug users themselves being primary agents or autonomous, et cetera. So with that, move into talking about what is motivational interviewing? So what is MI about? I think that based on the answers from the interactive discussion, you all have been exposed to motivational interviewing for the most part, the folks in this audience. So it's not a new concept and I think it's worth a refresher on some of the ideas to then be able to engage in a conversation of how we might apply that through a harm reduction lens. Fundamentally, motivational interviewing is about arranging conversations so that people talk themselves into change based on their values and interests. So I like this quote. It's not a definition of MI per se but it really helps me in my own mind of thinking about my role as an arranger or facilitator of the conversation, right? So I want to use my skills to set up the conversation in such a way that people are then able to talk themselves through what they need to talk themselves through in the direction of change based on their own values and interests. And why do people change? Well, change is natural. Change is happening all the time. Every day we are making tiny and larger choices and each one of those choices can result in something being the same or continued or continuing with the status quo or they can result in subtle shifts or even dramatic shifts, right? So we are making choices all the time that can lead change and treatment and how we approach our conversations can facilitate this change. There's something that comes up a lot when we talk about motivational interviewing, something called the writing reflex, right? And this comes from that good place that most people who go into medicine want to help people. It comes from a sense of, I figured I know what the right answer is, I know the evidence base that's gonna reduce this harm, that's gonna lead to this better outcome and I want to help you make that choice to get to that because I know what that right answer is, right? So we have that reflex to fix it, to make it right, to use what we've learned to help people. And this is a common thing that we experience but that doesn't always lead to change, right? And so when we think about what leads to change, something coming from me that I think of as the right answer may not actually be the thing that's gonna drive the decision that the person has to make. And ultimately that person is the one that makes that decision. And I forget the person who said it but I think over in that direction that it comes from the person based on their values and their interests. So in motivational interviewing, we tend to shift our approach from more of a classical medical model approach or thinking about people as being fundamentally unmotivated, thinking about that 94 point whatever percent from SAMHSA that don't want to change and that they're fundamentally never going to change or that they don't want to change to thinking about them as always being motivated for something, right? So instead of thinking about why doesn't that 94% or whatever it is, why aren't they motivated to seek treatment, to get rid of this terrible thing that's causing consequences for them by definition in order to meet criteria for a substance use disorder, right? It's causing some kind of negative consequence. Why aren't they motivated to address that? For what are they motivated? What's gonna be the underlying thing for them that might result in a positive change? Fundamentally, it's about understanding what the person wants and how you can elicit that and understand that can be influenced by what you do in a conversation with that person. So when we think about change, we think about a couple of concepts. So one concept is something called change talk and we're listening for change talk. And so in general terms, change talk is something when a person argues on behalf of one position, right? When they're arguing in favor of that, they become more committed to it. We are constantly talking ourselves into or out of things all the time, right? Our own internal dialogue, our own talk can make a difference in the choices that we make. Sustained talk is kind of the opposite of this. And if we hear a lot of sustained talk coming from a person in a conversation, the more of it that's evoked during our conversation, the less likely it is that the person is gonna change. The more likely it is that they're gonna continue with the status quo. And so we listen for these two things, change talk and sustained talk, as a way of gauging our success with the person in getting them to talk about and their likelihood to make the change. So motivational interviewing originated with Bill Miller and Stephen Rolnick. And this is Stephen Rolnick who is gonna explain a little bit about some of the origins of motivational interviewing and how we think about that in forming what we call the spirit or the approach of motivational interviewing. Why the resistance if you think about? So I love that part where he says you give them the space to change, right? And so we're part of that. But I wanna go to the very back of that quote or that clip where he says at the beginning that his teenager, he says that the pathology is not fundamental to that person, right? His teenager is not a liar who exists to only lie in every context and every dynamic. The situation that that teenager is in changes it, right? So the teenager may lie to their parents because they wanna stay out late and they're saying they're at their friend's house, whatever, right? But they're not a liar to their friends, right? They might be very forthcoming to that. So the context and the situation impact the behavior and the choice that the person has. And we have the ability to shift that dynamic and that context in how we approach it. We can do that through an MI approach. We can also do that from a harm reduction approach. And so in that situation, as Miller, I think, more eloquently than I can, explains, we can change how we approach it, which then changes how that person responds and ultimately what they might do. And so when it gets back to things that you mentioned around skills of engaging difficult patients and difficult conversations, right? You walk in the inpatient door, to use the example there, and the patient says, get out, I don't wanna talk to you. You know, that's where it really is helpful to think about how can I shift my approach in some way to sort of get a tiny little toe in the door to open things up a little bit to be able to have that conversation. All right. So when we talk about motivational interviewing, yes, there's some skills, yes, there's some techniques, we will practice those. But fundamentally, it's about how do you approach somebody and how do you communicate that approach? And I think harm reduction is very similar. It's a fundamental approach of trying to work with somebody in a way that moves towards positive behaviors, positive choices. In motivational interviewing, we have a mnemonic for some of the core sort of ideas behind this spirit or this approach, including partnership, right? We're in it together. I think somebody here mentioned collaborative care, collaboration as part of something they already know about MI, right? So we think about it as a partnership. There's no power dynamic, just because I'm the doctor, you have to do what I say. But we're in this together to try to figure out what is going to be the thing that's most helpful for you. It comes from a place of acceptance, right? And both when we were talking about harm reduction and when we were talking about motivational interviewing at the beginning, this meet the patient where they're at idea really has become, I think, well accepted and understanding for the value that it has. Because that nonjudgmental approach, that acceptance of the patient, that meeting them where they're at, is an entree into eventually being able to work with them. Because they understand that you're coming towards them from that open place, that open stance and spirit that can ultimately be helpful. It comes from a place of compassion, ultimately wanting the person to do better, be better, be in a better situation. And it's fundamentally about evocation, right? It's about eliciting from others the things that you want them to know, to do, to understand, the things you need to know and understand as well. Okay. So we open with open questions a lot. We reflect back what we hear to move that gauge and support and reinforce those ideas. Questions like, what do you know about motivational interviewing? Was I being too subtle? Reflect, reflect, reflect. So going back to the question about teaching MI, if I can just make a point there. We try to embody a lot of the MI approaches in how we teach this course, even though it's a little bit limited, right? Because we're up here and still giving slides and didactics. But in teaching MI, a lot of it is around modeling the behaviors and people then see the value of how these approaches can have different outcomes. And that's one good aspect of teaching MI. All right. So we've actually kind of put this up in two different places, but we put it up side by side to really highlight from my mind a lot of the overlap between harm reduction and motivational interviewing. Motivational interviewing is a guiding style. We are not just reflecting what people are saying. You shift the reflection. So you reflect back. So you'll notice when you were giving us your ideas and understanding what harm reduction was, when I said stuff back to you, it wasn't exactly what you said. You would say things like, oh, you, you know, draw out from somebody. And I said, yes, elicit and evoke from the patient their ideas, values, and interests. Those weren't the words you used. But that's a lot of what is in the definition. So we're being strategic in how we reflect back. So it is possible to do motivational interviewing very much in a not harm reduction context. You can do reflections that do not necessarily meet somebody where they are. And it, you know, depending on the prioritization of the partnership, it can loosely be called motivational interviewing, even if you're not on board with harm, even if you as the interviewer are not strategically reflecting in the direction of harm reduction. But there's a lot of overlap between autonomy and acceptance, about pragmatism and accountability without termination in partnership. There is an overlap here with doing motivational interviewing in a way that is adherent to the principles of harm reduction. And probably the best illustration of this is, you know, if you feel like you're fighting with somebody, you know, I'm thinking about this instance, you're the addiction psychiatry consultant. You go into the room. I'm not going to talk to you. But you have to. Your team called me. But I don't have an addiction problem. Well, you know, I'll be the one to decide that. If you're in this fight, you're doing it wrong. If you're in this fight, you're doing it wrong. Motivational interviewing should feel like a dance. Your addiction psychiatry consultant says, I don't want to talk to you. You say, you don't want to talk to me. You're afraid of what might happen. They didn't say that they were afraid. But now you're using, you're reflecting the affect of what might be true with the goal of then getting them to respond. And you can actually get a ton of information with just reflections. Dr. Merrifield? On that. So we'll talk a little bit about, so this is Bill Miller, our other founder of motivational interviewing, and he's just going to talk for a moment and then we'll And so, so I think the other nice thing about that guiding analogy that, that, um, that I love is that idea of drawing you out, right? When I, when I think about somebody who's going to help me, you know, get to the top of the mountain or whatever, it's somebody who has to help me figure out what my strengths are, what my abilities are, and help me use those to my own success. And I like that analogy. Um, I also just want to put one more piece on the wrestling to dancing analogy. The other thing that's, um, I think helpful when we think about dancing is that in a traditional sense, there's a leader, right? And the leader sort of knows to move in such a way that it makes sense and it's a natural movement for the partner to follow into that space, right? And so the idea of facilitating the conversation in such a way that it makes sense for that person to then move with you and follow with you together. All right. Um, so with that, we're going to do a bit of an exercise. Um, we're going to ask you guys to interact with each other. Uh, and Brian will go ahead and explain that. So I'd like you to get into groups of three, groups of three to look around the room. Um, person a is going to be the speaker. You will each get to do this. Um, person a is the speaker. Choose something about yourself that is true. This is a real play, not a role play. It's true about yourself that you want to change, that you need to change, that you really should change. And you've been thinking about changing, but that you haven't changed yet. You're ambivalent about changing this thing and that you're comfortable talking about. You gotta be able to be able to talk about it. Person B has, is the listener. Their number one rule for the listener is to give no advice to the speaker. Is to give no advice. And rather than giving advice, is to ask these open-ended questions. It's a script. You follow the script and you don't give advice. You say, why would you want to make this change? What are the three best reasons to do it? On a scale of zero to ten, how important would you say it is for you to make this change? And then when they give you a number, you say, why is it whatever number? And not a zero. So if someone says, well, I'm five out of ten. Say, why is it a five and not a zero? And then ask, how might you go about it in order to succeed? You've now listened to the person's responses to each of these items. You've then summarized what they said back and then asked with interest, what do you think you'll do? And listen to the person's response. Person C is to give no advice. To observe the interaction with silent curiosity. If the person C notices person B giving advice, to offer redirection. To follow the script. Here is the it's all on one page, right? So person A, speaker. Something you want to change, need to change, should not change, think about changing. Person B, why would you want to make this change? Three best reasons to do it. On a scale of one to ten, how important is it to you? Why is it a whatever number they give you and not a zero? And how might you go about it in order to succeed? Reflect a summary. What do you think you'll do? Listen with interest to the answer. Person C observes. We're going to do three rounds of this. So everyone's going to get to be A, B, and C. And we will do this in about nine minutes. Go. And if you don't have a group, raise your hand. If you are groupless, raise your hand. Yeah. All right. Thank you for participating in a taste of motivational interviewing. For those of you that were the speakers, what was it like to be a speaker during this exercise? What was it like to be a speaker during this exercise? Yes. It was provocative. It was provocative. It pushed you in the position of needing to articulate your thoughts about something that you hadn't previously articulated your thoughts around, something that you're ambivalent about. Yes. It motivated me for change. And yes. It, it motivated me for change. And in three minutes, you noticed that there could be a shift. There's an efficiency to it. For those of you that were the listeners. Before we do that, I just want to say one quick comment on that. You know, I think what is powerful in this sort of taste of things is how it can actually make you think about things in such a short period of time. But it is a taste, right? So this, sometimes it gets confused with, is this, am I, am I doing, am I, because I've done these like three questions. This is just a taste of what using these kinds of things can, can be like and the power of them. One of the reasons this is so efficient, if you ever use this as a training exercise is by having somebody identify and ideally somebody who is like friendly and a triple AP person and coming to a workshop is you've already, you've already primed a topic and somebody who's ready to talk about, right? That's not a given in every clinical encounter. And oftentimes we have to spend a lot of time, you know, intending to engagement right before we get somebody in a moment where they're going to, but, but when you have somebody that's truly ambivalent about something and ready to talk about it, it's amazing how quickly things can go with just a few key, key questions. For those of you that were the listeners, what was it like to be the listener in this exercise? Yes. No, all the way in the back. The summary. What about the summary? It's, it's hard to summarize when you're not listening carefully and it's hard to listen carefully when you're charting. I think that we often talk about in other forms of psychotherapy that even when you're not saying much, you're still engaged. You're still doing a lot of work. You're thinking about it. You're thinking about what they're saying. You're thinking about what you might say in response. So it's an active process, not to use a cliche term, but it's an active listening and it takes some time to develop that skill of being able to engage the person, hear what they're saying, and then use it in a way where you can reflect it and summarize it back. Other experiences. I think there was another comment back here. It was hard work. It's hard. Listening to people is hard work. Absolutely. All right. Let's talk about the processes of motivational interviewing. Okay. So the processes I think are helpful and we're, this is just a quick review of MI terminology and thinking a little bit about it, but the processes of motivational interviewing I think are helpful for me in thinking about, okay, what am I doing in this moment, right? There's various MI skills that we're going to talk about. There's that spirit and that general approach, right? Like I'm always trying to communicate this nonjudgmental stance. I'm trying to communicate my acceptance, my partnership, but the processes are what am I doing in this moment? Am I really attending to engagement, right? When I walk in the door and the patient says, I don't want to talk to you, I'm really attending to engagement and I use various MI skills in that point. Am I focusing, right? Did they just tell me 50 things that we could talk about or they're not willing to talk about anything, right? So attending to focusing is really how are we agreeing upon what are we going to talk about? Am I doing the evoking? And evoking is really, you know, throughout MI, evoking, active listening, all of that can be very useful in the service of engagement. But evoking is really that part of MI where I'm trying to get the person to think about things, to tell me things, to elicit that change talk. And then do I shift into planning, right? Do we have a sense of what the motivations are? Do we have a sense of where we want to go? And now we need a concrete way to actually get there, right? So these are the four processes of doing MI. And they're somewhat, you know, linear, like it's hard to get to planning if you haven't engaged the person. But they're a little bit recursive too. They can go back and forth. You know, if you get to a certain point and all of a sudden, you know, you realize, oh, I just totally lost this person and I need to go back to engagement. Or you're thinking you're talking about one thing and then all of a sudden something comes up and you realize you need to go back and refocus the conversation and mutually agree upon again, you know, what are we going to talk about? So we think about them as somewhat stepwise, right? Engaging, being the foundation, focusing, being a necessary step, evoking. We can use an analogy of going for a walk. If I'm going to go for a walk, you know, first you need to decide are you actually going to walk with me, right? Where are we going to go on this walk? Evoking, well, why are we even going there? And then planning, how are we actually going to get there? All right. When we talk about the skills of MI, there's a mnemonic that's helpful. It's called our ORs. And these aren't specific to motivational interviewing. These are good counseling techniques that are useful in all kinds of different ways. But we use them in the service of the four processes and using that MI spirit and that confluence of things is what makes us, quote, unquote, doing MI versus not. So the core skills are really using our open questions and trying to minimize closed questions, even if you need one every now and then. Affirmations. So affirmations are really about recognizing either a behavior or a choice or a character trait, something fundamental to that person that we want to support, affirm, et cetera. Reflections. Reflections are really the bread and butter of motivational interviewing. And if you think about a conversation, right, we talk about MI as a facilitated conversation. It's really not so much an interview. It's not just question, question, question, like you think of an interview. But reflections are really the bread and butter because when we think about a conversation that I have with my friends, you know, we ask each other questions, but most conversations are statements back and forth. And those statements back and forth serve to have the other person continue the conversation, right? And reflections are useful for that. And they come in two flavors, simple and complex, and we'll talk about that. And then summarizing. Summarizing is kind of like your mega reflection. But it's also strategic in motivational interviewing. Everything is a little bit strategic in the conversation where you're selectively summarizing the change talk pieces that you've heard. You're selectively summarizing the reasons that the person wants to change in your own words, maybe adding a little to them, reflecting them, putting it all together in a nice package, restating it so they can hear what they said, and you can say it, and we can all say it. There's something called informing and advising in motivational interviewing. So it's not then MI that it's purely a following style and we just go wherever the patient wants to go. You are physicians. You are smart. You have things that you might want to tell the patient that the patient may not know. You may or may not know if they know. So there's a way of informing people and giving advice in such a way that makes it more likely that they're able to hear it, receive it, and use it. And so one way to do this is with permission. So if the patient says, hey, what do you think I should do, you have permission. They're communicating that they're open to what you want to hear. Or you can ask for permission. Do you mind if I share some thoughts I have about what you just said? Right? And just that simple act of asking for permission and them saying yes changes their stance and their receptivity to hearing what you want to say. There's some techniques that we don't necessarily get into for the purposes of this talk because we want to focus on some other things, but something called ask, tell, ask or elicit, provide, elicit that are other ways of providing information in a way that makes it more likely that the person can hear it and use it. So as I mentioned, we have open questions, right? Can't be answered by a one word or a simple response. And the goal is to invite the person to reflect and elaborate. And, you know, we had an open question in our taste of MI and the feedback from the audience member was it actually made me think about it, right? And process it a little bit. And the goal is to help you understand each other. Affirmations, as I mentioned, are really the statement of the existence or truth of something, recognizing good, a character trace, a choice. And affirmation is typically a you statement. And I struggle a lot with praise, right? It's just inborn or I was socialized into it or I don't know where it came from, but, you know, when a patient comes in and says I haven't had any alcohol for two weeks, my inclination is to say, ah, I think that's great. I think that's wonderful, right? But who cares what I think? That's not part of it. That would be praise. And praise is helpful to some extent, but affirmations are really when you're trying to reinforce something about them, and they tend to be a you statement, right? So instead of saying I think it's great you quit drinking because who cares, you made a decision, you stuck with it, right? That's affirming that choice, it's affirming the action, the behavior. Simple reflections tend to stay close to what the person is saying, right? Sometimes they can be just sort of repeating things back, reiterating it back, rephrasing. Complex reflections take it a little bit further. Sometimes they make a guess at what the person was saying. So complex reflections can be a paraphrasing of what they said and then continuing it a little bit more. Like, you know, they're getting there, but then you kind of take it to that next step. They can reflect the feeling, right? So underlying that feeling that's in there. They can use a metaphor to help understand things. You can do something like an amplified reflection where you sort of take what the person's saying and take it to an extreme and see what they do with that. You can do a double-sided reflection that can be very helpful at developing discrepancy in what the person is saying, where you're presenting both sides of something and seeing what they do with it. With a double-sided reflection, we try to end on the positive side of change. So with a double-sided reflection, you might say I really enjoy drinking alcohol sometimes and I hate being hungover the next day, right? So that helps you kind of develop these discrepancies with a double-sided reflection. We use the iceberg metaphor where a simple reflection is really what we're seeing on the surface. It's what's available. You can kind of see what's there. But oftentimes there's a bigger thing underneath the surface, and the complex reflection is helping us to try to get at that a little more. So as an example, a patient might say to you, right now drinking doesn't help me feel better the way it used to. In fact, I feel worse now. So you could just echo it back and say, drinking makes you feel worse now. Well, yeah, you know, it used to be fun, and I would have fun with my friends and da-da-da-da, right? And then they can kind of go through and continue the conversation. You might reflect back and say, right now drinking doesn't help me feel better the way I used to, I feel worse now, and rephrase it. So you find that drinking is no longer helping you feel better the way it used to. You can do a double-sided reflection. In the past, drinking helped you feel better. Now, it makes matters worse. Or you could take what they're saying and continue the paragraph, and you want to find some way to feel better instead of drinking. All right. ORs, open-ended questions, affirmations, reflections, and summary, core counseling skills. You can do that in any kind of psychotherapy. It involves some level of that. Carly made a really good point. When we talk, natural human conversation is not question-answer-question-answer-question-answer. That's an interrogation. And oftentimes, when we come in for clinical interviews, it feels like that. Tell us about this, this, you know, you're doing through your, like, to your complaint, HBI, past psych history, past medical history, substance use history, you know, like, you were sort of just clicking through, right? In a normal conversation, we do a lot of reflections. That's natural, and it helps the conversation flow. What makes motivational interviewing unique, what makes it different, is the selective attention to something called change talk. Somebody's giving you change talk when they talk about what they want to, could, have good reasons to, or will change in a positive direction. Change talk comes in two different strengths. There's preparatory change talk, like someone identifying reasons to change, or mobilizing change talk, changes that they're already making. The acronym for this is D.A.R.N.C.A.T. Desire, ability, reasons, need, commitment, activation, and taking steps. Change talk is different than sustained talk. Sustained talk is, I won't, I can't, I love smoking cigarettes, if I could only breathe tobacco smoke as my sole source of, you know, air in my lungs, that's what I would do. So, a couple questions that you can use to evoke change talk during clinical interviews. What changes are you thinking about making? Why would you want to make those changes? How would you do it if you decided to? What are the three best reasons? These are things we've already practiced. A couple other strategies for evoking change talk is to ask evocative questions. So, you know, why would you make this change? What do you think you'll do when a change talk theme emerges? Ask for more detail. Say, tell me more about that. A couple key skills that I like are the importance ruler, scale of 1 to 10, how important is it for you to make this change? 1 being not at all, 10 being maximum. If they say 1, I say, why is it a 1 and not a 0? They usually giggle. Because when you give a number, when they give you a number of why something's important to them, and you say, why is it the number you gave me and not a lower number? It invites them to talk about why they want to make that change. Even if their motivation is only a little bit, it invites them to elaborate on it, and now you're getting change talk. But importance or motivation to make change isn't sufficient if the person doesn't feel confident. So, what goes with the importance ruler is the confidence ruler. On a scale of 0 to 10, how confident you could, say, change your drinking. And you could, if they say, well, a 4, you could say, well, why makes it a 4 rather than a 2? Or you could say, what would it take to go from a 4 to a 6? Invite them to elaborate on how they think they can be more motivated. Last thing I'll throw out is, in any conversation about change, if you end at goals, and it's an if, not a when. Like, planning is not always part of every conversation about change. But if you do planning, smart goals are a really helpful goal to attend. It's not just, I'm going to drink less. It's, I'm going to drink X less by Y date. This is what I think is achievable. This is what I think is relevant. It's being specific. And just one other thing, for those of you that teach motivational interviewing to your colleagues, some people get it right away. Like, they already, they are motivational interviewing. Some people need to work at it, and for others, it's just really, really hard. So, um, motivationalinterviewing.org has a training handbook, if you're interested in, like, learning more about training resources. And would it be okay if we showed part of a video illustrating some of these concepts? Okay, so we're going to watch a video called The Rounder. The Rounder is a video of a man who shows up to treatment, and his opening statement is, I don't want to be here. Shows up to treatment, I'm saying, I don't want to be here. A transcript of this interview is available through this QR code. So if you have a QR code reader, you are welcome to put it onto whatever device you are here with. This is also in the slide deck. So you can find this QR code in the slide deck, and you don't need the transcript in order to be able to follow along, but it can be helpful, because the transcript has each statement, and then has recommended coding of what type of motivational interviewing technique is being used here. So is this an affirmation? Is this a reflection? Is this a statement? So that you can, so it's, it's an easy way of tying back some of how we practically use motivational interviewing in clinical practice, how it ties back to some of the didactic that we've talked about. I'm going to move the slide off the QR code, but before I do, is there anyone that needs it on a little bit longer? All right. Can I just make one or two more comments? Of course. So one of the things is that we're going to be watching this video, and normally we're trying to listen to what the patient is saying, but in this video, I think it's really helpful to listen to what the interviewer is doing, and seeing how the patient responds, right? So it's a slightly different way of watching it, because we're looking for what the interviewer is doing that might be MI. In addition, to tie things back together to harm reduction, you know, we encourage you to listen for a couple of things that sort of strike you. I would ask you to listen for how MI is being used in the service of harm reduction for a patient who says, I don't want to talk to you, I don't want to change, right? And how, and how those things might come together. And then we're just going to watch a portion of this video, but we'll come back and discuss things that stick out to you guys. So yeah, listen to the interviewer, and what is one thing the interviewer said that like struck you, that resonated with you, and we'll debrief. All right, here we go. Terry Moyers, the interviewer in The Rounder. I'm very well-inspired. I mean, there's nothing in this world that I wouldn't be inspired by. I haven't had a lot of emotional energy like this in years. All right. Well, we're coming to the end of it. If I have time and motivation, I'll continue to do that. I'll tell you what, it's probably your fault. What? I don't know. I'm just kind of waiting for you. You freaked out. They have a daughter in the, uh... What were you thinking? You don't remember. What are you talking about? I'm sure you can see it in the mirror. I want to be able to let her know that she's fine and she's being good to us. And she's doing very well with you. I don't know what she's thinking about. What is she thinking about sometimes? Well, she's very good at being loved. All of a sudden, I don't see it. And I'm proud of you. You've never had any fights. I don't know. Do you think she's worried about that? Everything in my life means that. Yeah. I think she's thinking about things in her life. You know, the society that we're in. I love you. I love you very much. He, you said that she didn't seem to motivate him. He identified, from my vantage point, a ton of areas that he could be motivated around. You're right. At this point in the video, in this part of the video, it was a lot of reflection without movement. Further on in the video, there's more of a shift, but you're right. At this point, there was not a lot of movement. I think when you say she didn't motivate him, it's not coming from her. It's coming from him. He's the one talking about, I want to take my grandkids around. The comment was, he wasn't demonstrating motivation during the interview. You weren't confident that he was going to make the change, and yet, he was identifying a lot of things. The courts and the lawyer fees, and maybe if I participate in this, then my life will be better in certain ways. He was coming up with motivations around the grandkids, things like that. We're starting to hear that, but so far, it didn't sound like he was actually going to make any changes. He certainly didn't have any commitment statements to anything. Yeah, so the comment was, he was bringing in a lot of discord. I don't want to be here. You're blonde. I haven't had a lot of good luck with blondes, and she was able to diffuse that. And she was able to, even though he didn't want to be there, keep him engaged. And this is a real person, by the way. So he did agree to be videotaped, but he was a real person who came in and said, I don't want to be here. I don't want to talk to you, right? And very quickly, he was talking. She was not judgmental nor particularly coercive. So, the whole video is about 16 minutes and so, you know, she has time to kind of guide the conversation and gave him the space to sort of be exploring these things. In a different presentation, we talk about some of the, like, classic sort of things to be careful of, like, beware of. And one of them is when you hear, like, that first tiny nugget of change talk where you sort of, like, jump on it and, like, oh, yeah, well, your grandkids and, like, da-da-da-da. I think it comes from that writing reflex, that fixing place, you're, like, oh, yes, I heard some change talk, now I'm going to amplify it, right, and it's that eagerness and enthusiasm, which is great and comes from a good place, but ultimately may not allow him the space to really explore and have it come more from him and for him to get there on his own. It can get us stuck, right, if we just get stuck on the first bit of change talk we hear, we might miss the lay of the land that might be more informative to where else could be fruitful areas to focus. Other things that we noticed in the rounder video. So, the comment was, he mentioned that his daughter doesn't trust him to take the kids' places. And so your comment was, would that be fair to ask a question to explore that more? What I might reflect to you is, that might be part of a summary, followed by a key question. So my understanding, you don't have your license, your wife has moved out, and your daughter doesn't trust you to take care of the kids. That's a statement, not a question. And given that you're here, what would you like to do while you're here? So you're pivoting from reflecting reasons, and then using an open-ended question, how do you want to make use of this? Rather than a, I'm going to use the word interrogating, I don't mean it that way, a question-based information-gathering approach, maybe a way of bypassing some of the resistance that might get brought up with that, and just evoke from him, okay, what is his readiness to make any actual changes, if anything at all right now? What we saw was a lot of reflective listening in the service of keeping him engaged, because he was just about to leave. I know there was another hand, I just want to, in addition to hearing what you say, I want to also ask, why did we show this video in a talk titled Harm Reduction and Motivational Interviewing? So I'm curious what people think about why, what they saw in there. What does this have to do with harm reduction? So he's motivated by a lot of things that maybe aren't pure of heart, right? Like my health or my grandkids. He doesn't want to pay his lawyer. He doesn't want to go to jail. He doesn't want to deal with the court fees, right? So from a harm reduction standpoint, there's a lot of ways that he can make positive choices that are going to improve him not drinking and driving, right? Like him not taking his grandkids in a car when he's been drinking. That from a harm reduction standpoint are still moving both him and other things towards a better place. Over there. Got it. And then there was one other comment, I think. The gentleman in the back. So she did a nice job telling her reflections towards something I missed and then towards emotionally charged, diffusing emotionally charged. His affect. His affect, I think. Well retaining curiosity and compassion is the raft on which all else floats. If ever I'm in a clinical encounter and I don't, I'm not, I'm not, I'm confused about what I'm supposed to be doing. If I think, how can I maintain intense curiosity about what's true for the person I'm talking to, that usually shifts me into a motivational interviewing context and keeps me in a space where I'm consistent with the spirit. Thank you so much for your time and attention. And we're at 90 minutes. All right. Take care, everybody.

motivational interviewing

harm reduction

MI approaches

teaching

core skills

open-ended questions

affirmations

reflections

summarizing

change talk

positive choices