Welcome back again to the online PCSS training. My name is Dr. William Wright, I'm an addiction psychiatrist, and welcome to Module 7: Evidence-Based Counseling. We'll go ahead and jump right on in. Some of the objectives to this model, we'll outline the key components of behavior, describing various evidence-based counseling approaches for opioid use disorders, explaining core principles of motivational interviewing, also known as MI, we're not talking about the cardiac arrest type, and lastly, describing the fundamentals of screening, brief intervention, and referral to treatment, also known as SBIRT. Again, view of our lovely brain here, the good old organ, the gray matter there. Talking about treatments. Several different things, I mean, there's several different aspects of treatment, if you don't mind. There's a behavioral component. There's also a pharmacologic component to this type of treatment. In the behavioral side of things, you're obviously wanting to have the patient learn on new behaviors, learn how to manage their environment, how to learn to live on life's terms. Pharmacological in reality, as discussed in the last several modules, are trying to prevent withdrawal to mitigate this phenomenon from happening as those are frequent reasons for those continual use. We're also wanting to reduce biological drives for the drug use, including those cravings for the substance. Treatment is comprised of both of these two venues, these two areas of target. As we said back in the previous modules, obviously that green spot that's highlighted there, the frontal lobe, this is where the decision-making that adult brain is living. That region is influenced by regions and other parts of the brain like the amygdala, that's your emotional response, the nucleus accumbens, the hippocampus. All these components have outreaches into that little brain, that frontal lobe. We need to target and try to go about hitting all these areas in the brain because behavior as well as pharmacological interventions have direct effects on the brain. ABCs of behavior, what is this? A, antecedents. Again, as the word says, what happened before? These are the things that we call cues, and triggers, and stresses or the things that happened prior to us using that substance. Figuring out and putting words and definitions to what are a particular person's cues, what are their triggers? One of the thing is again going back to that biopsychosocial model, what are the stressors somebody is having a lot of? Those are very important components to keep in mind. Behaviors, so what did you do? As I tell my children, it's not always just what you're feeling, but what do you do because of that feeling. What's the behavior involved? What can be done instead of that behavior? Is there a more appropriate response? Is there a healthier response? Is there a less dangerous coping strategy that we can use. C, consequences. What came after all that happened? Our brains are sometimes a very complex organ and sometimes a very simplistic organ. Our brains tend to listen to the most immediate consequences. The thing that happened most recently and most significantly. So thinking about these ABCs of behavior, this approach can definitely be applied to situations like [inaudible] missed appointments. Those parts of behavior that interfere with day-to-day life as well as treatment. So moving on to the second objective already, describing various evidence-based counseling approaches for opioid use disorders. There are obviously various modes of evidence-based counseling that haven't undertaken to help. On the flip side, again we've talked about pharmacological side of things, now were talking about the behavioral therapy side of things. So different approaches such as cognitive behavioral therapy, also known as CBT, medication management, which also is to be considered part of the counseling approaches. So don't forget that. The mutual support groups, also known as there's an honest groups, the AA, NA, Smart Recovery. There's also an approach called motivational interviewing. In short, we call it MI. Again, not the heart attack version, but a way of interviewing, a way of addressing concerns of resistance from a patient. So also though, some practitioners still use supportive psychotherapy, psychodynamic psychotherapy. So some of the evidence on those modalities is still variable, but it doesn't mean that they're not beneficial. But we're still trying to get the evidence as for exactly how beneficial they can be. Of course, we'll continue to talk about medication management. So CBT, this is an evidence-based social learning theory and principles based on operant conditioning. So some of the key features is an emphasis of the functional analysis of the drug use. Meaning understanding in the context of those ABCs, why the people, the places, the things of drug use. It's also important that there's a skills training portion of CBT for the patient that can further help the patient themselves see and recognize different aspects, such as timed situations, instances where they're putting themselves more in danger for drug use, being more vulnerable or at risk for drug use. Also in helping with skills training as far as creating, and maintaining, and utilizing strategies to avoid high-risk situations whenever possible. Again, that alludes adage of being forewarned is being forearmed. If I can come up with a plan before I'm thrust into the situation, I'm much more likely to use that plan and get out of the situation. It's just like when we put on players go into a particular game with a game plan and, of course, they may call some audibles and change the game plan, well, at least, they have a structure and something to start from, a scaffold to build on hope. We also have a CBT with skills training and trying to utilize them and have skills to cope effectively with those situation that are just impossibly unable to be avoided. Life is life. There's going to be sometimes where there's things that you just absolutely cannot avoid. Most the time we think everything is in that category, but it's not. But there are some situations that are just absolutely unavoidable. So what do we do? How can we encourage patients and have them continue on their road to recovery when those situations are unavoidable? That's where CBT can come into play as far as coming up with skills and coping strategies to be just that. Well, folks, you may have realized this is a potential role of therapy and non-specific pharmacological stuff. There's an important framework for the work that we do. Most sessions are about 15 to 25 minutes, it could be weekly, it can monthly. During these sessions, we're asking the patient out to monitor and self-report use. We're also doing things like lab markers, videos, talking about, okay, what's going to happen if this happens, both good and bad. Well, you've done so well with things that are going on so far, let's extend out our appointment session. Instead of one weekly, let's now go every other week, or you go every other week, now lets go to monthly. There's also a pro consequences. It's not always a negative con consequences. It's also done in the appointments, we are also monitoring adherence to medication residents. How they're doing, how they're responding, are they having any problems with the medication, are they having any problems with obtaining the medication, has the pharmacy given them some push back, so addressing some of these concerns and stressors during these appointments. Again, education, education, education about substance use, problems, the consequences of leaving the treatments. Again, they may be going down one treatment but things aren't quite working, so being able to make sure they've realized that there's other treatment options available as well. Encouraging abstinence but also keeping in mind that harm reduction model on about the treatment as well. Encouraging the use of community supports, healthy lifestyle changes, healthy support systems in place during these appointments. Then, actually I'll go back for a second. Medical management appointments, there is evidence-based [inaudible] and does have some manual. If you are interested in finding out how to do this, there are manuals which you can go look at. It was designed on considering that most patients are not able to access specialty services generally and unfortunately, in a timely manner, so it's making the best of the middle ground situations so if there's inability to have the luxury of being able to do some of these things in a medication management appointment. However, it does require some more time commitment on our end as physicians and providers. Mutual support groups, again those anonymous groups, AA, NA, [inaudible] and SMART recovery are all options as good evidence-based treatments that are non-pharmacologic as well. AA was founded back in 1935, it is based on a 12-step model, a model of sobriety with some emphasis on God or a Higher Power, and visioning, and I'll get back there in a second. NA was [inaudible] of AA back in the day, and was found in 1947. It's also based on 12-step model with that Higher Power and God emphasis in there. However, there are some folks who may not be super religious or they may be agnostic, or atheistic. Much better if you tell them that shouldn't be a game changer or a no-go for them when it comes to this. It doesn't always have to be a strict deity as far as Higher Power or God. Some folks have definitely been able to make [inaudible] that AA or NA mutual support groups work when they substitute that concept of the God or higher deity with something that's significant to them, such as may be it's morality, maybe it's family, maybe it's just being a good ethical person. Those things can also be substituted for your higher power in those kinds of groups as well. Self Management and Recovery Training, SMART recovery was founded back in 1994, doesn't sound that too long ago for me, but now, I come realized it, that's about 24 years ago now. It's based on secular principles and uses the stages of change as far as their basis, as well as in MI and CBT. It is recognized by NIDA as well as NIAAA as having good evidence base behind it. The mutual support groups do have supportive evidence and can provide a very good foundation and good support network for patients in recovery. In fact, it doesn't mean that if you're using opioids that you have to go to narcotics group, whereas frequently folks that find an AA group fits them better, so they're perfectly fine and doing well attending AA groups. But it's also very important sometimes to be upfront with your patient and talking about some of these anonymous group. Some of them are not as open with medication and they do actually reject some of the them. But if you on agents such as buprenorphine or naltrexone or any kind of medication that you're not in true recovery. A lot of times, I've seen them more of the older guard. There's a lot of peer groups that definitely keep an eye out for that. That some groups do have some pretty strong opinions on that and go in so far as to recommending to some books just keeping multilevel now and are not necessarily mentioning it to their group. But if you can try to find a group that is accepting it, they make all the difference in the world. Objective 3, let's explain some of the core principles of that MI that I've been alluding to. MI was originally developed by William Miller and Steven Rollnick back in the 1980s as a clinical tool to conceptualize those folks that are just kind of on the fence. They're not quite ready for change. They are "less ready" for change. They will resist them. They are sometimes still in the not out, they are not quite into the action phase of change. There's actually been about 25,000 articles that had sited MI as far as treatment goes. There are 200 randomized controlled trials. Though like a lot of modalities, the effectiveness of MI does vary depending on who's providing it and depending on the counselors, studies, and sites within studies. It is a good model but again, depends on sometimes who and where it's being provided. Again, on the definition of skills when it comes to what we mean in this category. A brief definition, it's a collaborative conversation style for strengthening a person's own motivation and commitment to change in the spirit of acceptance and compassion. It's also person-centered counseling style for addressing the common problem of ambivalence about change. It's trying to turn the conversation on its head, that way the patient themselves is kind of leading the conversation as far as what are some the outcomes, what are some of the things that they want to do the change or why they will change as opposed to a physician or counselor or provider kind of directing that action. They may feel a bit uninteresting but this type of interviewing technique can be used for all kinds of resistance including medication adherence or other problematic areas. We have folks that have uncontrolled diabetes, uncontrolled hypertension. Using technique is not just obligated to the realm of substance use disorders, you can use the same technique for multiple different areas where folks find some resistance, some [inaudible] "less ready" [inaudible] change. Some of the core skills and interviewing that MI has is using a lot of open-ended questions, so was the user graduated Medical school in the last several years or there has been a tremendous push toward this interviewing style as opposed to close-ended questions? Those questions which encourage more lengthy responses as opposed to just a yes or no or a path answer. Uses affirming skills, uses affirming questions and responses, uses a lot of reflection and reflecting back to the patient what they've been hearing both in the simple as well the complex manner. Lastly, a great skill of summarizing what we've been hearing and definitely utilizing the patient's own words is definitely important and that's kind of a venture in skill set. During MI, we also definitely pay particular attention to languages of change because it's designed to strengthen somebody's motivation [inaudible] to a specific goal. We do that by listening and trying to explore a person's own reasons for change within an atmosphere like in Will Ferrell's character. The trust rate where somebody is in an atmosphere of acceptance and compassion and trust. Some of the practical sides of MI, so again, one of the skills is you definitely have to be open-minded and then being able to think differently as far as how interacting and asking questions to the patients. We want to listen more than we ask and we want to ask questions more than we give advice. [inaudible] a little bit to take away from here, that's probably one of the most important ones that we want to listen more than ask and ask questions more than give advice. In that vein though, you don't want to ask more than three consecutive questions. Why is that? Well, that's in attempt to again, get the patient and the person to start speaking and what we're going to start engaging or we start getting more spontaneous answers and not just an interrogation type interaction. Unlike myself, I definitely have to constantly work on this as being [inaudible] so being concise, being efficient with your words, and attempting to avoid interruptions. Again, we have this expanse knowledge that we're trying to help people with and sometimes, we know what you want to say and we want to get through it. Well, no, slow down, let them get their say. There's a lot of reasons behind that but avoiding interruption is a [inaudible] Cooperate, don't force your knowledge upon somebody, they may not be ready to accept that knowledge yet. But the more you try to force upon them, it's going to trying to [inaudible] from medical school as well, trying to drink from a fountain, a fire hydrant. There may be too much that's coming out of it at once. So letting them be able to accept on their own terms. Using the patient as a consultant, they're the experts of their own body and so having to realize that they do know about themselves. Again, being open and being direct with the patient. So the full processes here and the MI, the foundation, as you can see here, is basing on engaging. So it's the engaging phase on the process for establishing this working relationship and we're engaging on the individual a mutually negotiated and agreed upon goals. Again, mutual goals. We may have some goals, we may have some but if we're not on the same page, we're going to both missing. That second part, we have focus, clarifying the agenda, we're focusing our impact, we're focusing what we're trying to do so that we're not all over the place in a scattered manner. So evoking. We're also trying to get and elicit these reasons for change. Why is somebody actually wanting to do this? So the evoked change talk, we need it, and then managing sustain talk, and that's what we're [inaudible] as well. During these conversations, when having a patient talk about their own experiences, you can start picking up and developing discrepancies in their own story and they start realizing and seeing the discrepancy that they are saying themselves through that and then they're hoping to continue to foster motivation and resolve some of that and goals they may have to change. Coming from their own words, when they hear it out loud, like yeah, that does sound strange, that doesn't make a lot of sense, that is contradictory of what I'm saying. I'd never thought about it that way. When they themselves say it out loud, sometimes, that's a big focus and part of this process as well. Lastly, we have planning. We're developing and committing to a plan of action, we're going to do something. We're planning for the long run by setting again, the short, achievable, and gradually challenging goals. Not just looking at a giant mountain and saying, "Yup, I want to go one step from here to the top of that mountain." You see, that's unrealistic and undoable. But we focus down, set our sights on that first five feet, it makes that much easier to accomplish. Again, so there are some question that each one of those processes of MI, so the engaging. How comfortable is this person speaking with me? How supportive and helpful am I being? Am I being a little bit of a [inaudible] Am I being a little close-minded? Do I understand this person's perspective and concerns? That empathy. Again, from that biopsychosocial, do I understand where this person is coming from? How comfortable do I feel in this conversation? Am I present? Am I feeling uncomfortable with the topic? Because of that, is this feeling like a collaboration or is it feeling like one person is trying to totally dictating and control of the show? Again, it should be a mutual collaborative, gauging partnership. Focusing, so what goals for change does this person really have? Have they even thought about it? Do they have things written down or are they coming in totally blank and they never even thought about their goal? Besides that, "I just want to stop", that's the most common goal. What exactly else is there? Do I have different aspirations for change for this person than they do for themselves? Again, are we working together and I come up with this or am I working over here and they're working over there? Are we moving together or are we splitting off? Do I have a clear sense of where we are going or are we just still shooting in the dark? That's why we need to focus. Does it feel more like a wrestling match where I'm getting constantly pinned or I'm feeling I'm trying to pin down the person? That adversarial type of interaction or is it more like a sultry dance where partners were working together to make this beautiful masterpiece of movement and choreographed expression. That's two different mindsets or two different versions there. Some of the responses you can get from a MI-consistent standpoint versus a MI-inconsistent standpoint. From MI-consistent, that you want to be asking permission as opposed to directing and dictating advice. You want to affirm and support the patient as opposed to constantly confronting disagreements and arguing, correcting, and belittling, and tweaking, and criticizing. That's not very helpful. That doesn't mean that you can't leverage supportive manner to expose some of those discrepancies. But in a blunt in your face confrontational style, that's MI-inconsistent. Then of course, emphasizing freedom of choice, the autonomy and control the patient have, you want the patient to come to these understandings themselves because if they do, they're much more likely to establish them, they're much more likely to incorporate them, they're much more likely to actually use those as opposed to somebody telling them what to do. So either you use folks out there that have children who know that if you can get your kids to want to do things on their own as opposed to telling them, how much less struggle that is when you get the buy-in from your children to do things on their own as opposed to being, though it's needed sometimes, the parent and dictating what happens. So through all of this, it's still important to provide advice about ongoing options of that kind of stuff. So again, education is still [inaudible] any point of life they're on. So about evoking. So what are the person's own reasons for change? Is their reluctance more about confidence of importance of change? Am I hearing any change talk? What kind of change talk am I hearing? Am I seeing too far or too fast in a particular direction? Am I wanting more stuff and more things quickly than the patient themselves? Is that Righting Reflex pulling me to be the one arguing for change? So when we talk about a Righting Reflex, it's the desire we all went into, the field of healthcare to help folks, and in the process, we learned a lot, we have a lot of background knowledge. Because of that, we have, sometimes, this innate urge and desire to fix what seems wrong with other people and to pick them up and put them on the right path, what we consider a better course as opposed to directing them and guiding them and letting them see that that path down that way is pretty filled with barbs and darkness and scary stuff, over here is better. Letting them come to that decision as opposed to you doing it for them, that's the Righting Reflex. So facilitating change in the change talk. So what does that look like? So different aspects of things like desire, what would you like to be different? That's still in the preparatory stages of change. What do you think you could do? Again, that front part, we try to engage and see where things or what you would like to be or what you would want to do kind of stuff. [inaudible] that preparatory phase as opposed to when you're starting to actually do things. So that's where those commandment type questions. So what will you do? What are you willing to do? What steps have you already taken? See, if you hear the subtle changes in those questions, that is going from what's available to what are you doing. The change talk, the person is talking and arguing on behalf of one particular position, he or she has apparently become more committed to it. Sometimes, we can talk ourselves into or out of things just by hearing things out as opposed to sustained talk where the more [inaudible] counseling session, this type of talk, the more likely the person will continue to use that sustaining talk. Well, this is what I am doing, these are the things that I'm currently utilizing, that's more sustain talk. That planning part of the process. What would be a reasonable next step towards change? What would help this person move forward? Am I offering information, advice, direction with permission or am I, again, just assuming? Am I still here listening and reflecting or am I not working necessarily the best interest for the patient of what I think it's going to be or what the patient is saying isn't the best of interest as opposed to what I think will be of my best interest? Ambivalence, oftentimes, the elephant in the room. The resistance we feel when forks he or she why they wanted to do it. Understanding, this is a very, very, very normal step on the road to change. Rarely, is it somebody is always ready to make all the changes. There's going to be some hesitancy. There's going to be some resistance, some concerns, some fear and anxiety causing and feeding answers to ambivalence. That ambivalence needs to actually be explored and not necessarily confronted so we can understand why they are in this ambivalence on. This ambivalence can and resolving other's ambivalence can be a crucial key to actually change so, what is the person wants. Sometimes for what is the person motivated rather than why isn't the person motivated. It involve simultaneously conflicting motivations. Maybe I want this, but I also want this and they're opposite and that's why I'm stuck. I'm ambivalent. I'm being pulled into different directions and I don't know which way to go. When we're contemplating change, it also involves self-talk, thinking about the pros and cons of available options, and picking the best choice for ourselves. Lastly, one of our objective list is describing the fundamentals of SBIRT. Again, it stands for Screening, Brief Intervention, Referral, and Treatment. In the United States, Preventative Services Task Force, it's a mouthful, they recommended that all adults in primary care be screened to identify unhealthy alcohol use, and that those with unhealthy use should receive some brief counseling intervention. This brief intervention is based on a harm-reduction model. This stuff emphasizes reduction use rather than full on abstinence from the get-go and there is a lot of reasons behind that. But for the brief intervention, there is also a very time-limited kind of intervention. It's client-centered as well to reduce substance use. It's not linked to "readiness to change". It can be used in the pre-contemplative patient. With folks that are not quite ready to be on action phase, they still have to go to the conservative update as well. Generally, delivered by health care professionals in different settings, usually doesn't take very long and that's why we call it brief. Average duration 5-20 minutes long. In multiple brief intervention sessions have been found to be more effective than one marathon session, so sometimes shorter is better. According to the 2014 National Survey on Drug Use and Health, about two and a half million people aged 12 or over, in 2014 have a substance use disorder, and about 2.6 million of those folks had both an alcohol use and illegal drug use, so roughly 10% of the folks. That's not an insignificant number though. We're trying to pick up [inaudible]. Again, we have a five A's within SBIRT. We have asking, advising, assessing, assisting, and arranging. All during this 15-20 minutes sessions. We try to use some quick screening assessment of risk level. That's where we can use some of those questionnaires in the labs. some physical findings to screen out what's going on with the advising part, giving direct advice from the clinician about the patient substance use. They may not know, they may still assume that things are okay. Reviewing that in a very objective manner, assessing the patient, evaluating where they are. Are they willing to change? Are they close to coming to a decision about potential unhealthy behaviors? After hearing his permission, give their advice and speaking with them, or are they don't want to change looks whatever, having to be cognizant and that made be not harmless at all. Assisting, so if somebody is ready to change, helping them whether they agree to develop a treatment plan and according with what the patient himself goals are. Again, the preference of the patients should always be, in mind. Again, using those motivational interviewing techniques and starting with small achievable goals, very concrete specific plans. Then, of course, helping them follow up with visits. Helping with follow-up visits. Do they need a referral? Could they benefit from some more educational materials to read in-between? You've been talking with them and they are saying the next professional. So there's some evidence of individuals who reduced or stop drug use have a lower risk and obviously having some negative health outcomes. However, with SBIRT, the timing is a component as well. So individuals, especially men who receive some of this brief interventions did have an evidence of lower alcohol consumption after bringing follow ups. So there is some change that goes on with this type of intervention. You can actually play single question to have high sensitivity and specificity. In the past year, how many times have you have? Five and for women, four who we're more drinks in one day. So it has an 84% sensitivity and 78% on specificity for hazardous drinking, an 80% sensitivity and 67% specificity for current alcohol use disorder. So again, just with one question, you can get a lot of information. So in summary, again, we've talked a lot of things during this module. So the key components of behavior, those ABCs, the antecedents, the behaviors and the consequences, can go about being part of the change both double pharmacologic, but also behavior, so there is behavioral components. Motivational interviewing, what is it? Again, it's that collaborative, goal-oriented style of communication, paying particular attention to change, the language of change, designed to strengthen somebody's own resolve or own personal motivations for and commitment to a specific goal. Goals that you should be I hope [inaudible]. We get these goals by eliciting, exploring their own reasoning, their own rationale for change in an atmosphere that's compassionate, emphatic, safe, and accepting. So that way, they can feel okay to come up with their own reasoning and rationale. So the spirit of MI is also marked by this partnership, this collaboration for acceptance and compassion and evoking this change. It occurs in those four processes that we talked about, the engaging, the focusing, the evoking, and the planning. Lastly, on the use of SBIRT as a technique can lower alcohol consumption, but also can be used for [inaudible] disorders as well. I thank you so much for listening to this module. I look forward to seeing you guys back and continue learning.
