As clinicians, it’s important to distinguish between sustain talk, vague talk and change talk. How can you help your patients get to the change stage? What role do SMART goals play? Should you recommend cognitive behavioral therapy, contingency management, or twelve steps programs, like AA? What about inpatient rehabilitation programs? Find out the answers by watching this video, presented by Dr. Stephen Holt, Co-Director at Yale Addiction Recovery Clinic, USA.
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After a discussion with your patient about their substance use, you have succeeded in motivating them to change their behavior. Let's talk now about how to best capitalize on that motivation.
As clinicians, it's important that we recognize the difference between sustained talk, vague talk, and change talk. Recall the transtheoretical model of change that describes the five stages of change a patient goes through in the process of adopting healthier behaviors. Sustained talk is the talk of a pre-contemplative patient, I'm comfortable staying right where I am, and marijuana doesn't really affect me, I like smoking crack.
And then there's vague talk. This is where a patient appears to be in the contemplation or preparation stage, but they haven't yet made a firm commitment to change. They make statements such as I'm going to try to quit soon, I should cut back on my drinking, I'm going to think about what you said. Vague talk tends to not take the patient very far.
Change talk is what we're looking for statements of action, of commitment of necessity. I have to quit drinking or my wife will leave me, I'm ready to start a medication to help me quit smoking, I'm going to attend a Narcotics Anonymous meeting tonight. Your job is to guide the patient towards using change talk by the end of the encounter. This can be done by helping your patient develop their own smart goals.
A smart goal is one that is specific, measurable, achievable, relevant, and time bound. So when your patient says, I should do something about my drinking, suggest goals based on these criteria. For a specific goal, you might ask, Are you thinking of cutting back or quitting altogether? For the goal to be measurable, you might ask, how many drinks do you think you could cut out each week? An achievable goal can be framed as, are you confident that you can make this change? A relevant goal can be framed as would you like to make this change in honor of your son's birthday then? And finally, to ensure the goal is time bound, you can ask, how soon should we have you back in the office?
Note that it is the patient was generating their own smart goals with your prompting. It's crucial that you schedule a timely follow up visit. At the follow up visit if they have achieved their goal, well, great. That boost of confidence and hopefully some concomitant improvements in quality of life might incentivize their next goal. Alternatively, if they failed at their goal, that should engender a conversation about the severity of their addiction, and perhaps the need to put a more robust treatment plan in place.
While the focus in the remainder of this course will often be on pharmacotherapy it's worth mentioning the variety of other non pharmacotherapy treatments for substance use disorders so that you can educate and refer your patients accordingly. We've spoken about motivational interviewing already, which has an extensive body of literature, supporting its efficacy in the treatment of patients with unhealthy substance use. Another commonly used behavioral approach with a similarly large literature of support is cognitive behavioral therapy, or CBT. CBT is a psychosocial intervention, facilitated by any suitably trained professional geared towards identifying and challenging maladaptive thoughts, beliefs and behaviors over a series of several sessions.
It is an action oriented approach that focuses on building coping strategies and enhancing emotion regulation. One more behavioral intervention is contingency management best studied for cocaine and tobacco use disorders. This approach involves rewarding patients, typically with cash for maintaining abstinence from the target substance, in short money talks. Typically, patients receive a small cash reward for their first cocaine negative urine sample and then get rewards of increasing cash value over 10 to 12 weeks, so that the stakes of maintaining abstinence increase from week to week. Patients who remain abstinent for 12 weeks have usually escaped from the most severe cravings and can hopefully stay in the maintenance phase thereafter without the financial support of a contingency management program.
Lastly, let's briefly discuss 12 Step programs like Alcoholics Anonymous or AA and Narcotics Anonymous or NA. AA has been around since the 1930s and is based on a 12 step recovery model that describes specific attitudes, beliefs and actions regarded as critical to the recovery process. Meetings take place at multiple times of the day, every day of the week, in multiple locations throughout the country and the world, with nearly 2 million members when last counted. Now this is naturally a very tricky intervention to effectively study for several reasons.
It's a very self selecting group, it tends to be ineffective when people are mandated to attend, and you can't randomize people to a placebo meeting. Nonetheless, a variety of study designs have looked at the effectiveness of AA and meta analyses of over 100 studies have demonstrated a moderate beneficial effect of attending 12 Step groups on par with professional treatment by a psychologist. As such, I recommend AA and similar 12 Step programs to all of my patients with unhealthy substance use, fully acknowledging that it's not for everyone, because I know that it is effective for many, it's free, and there's no evidence of harm.
You might have noticed that I haven't really mentioned anything about inpatient rehabilitation programs. That's because they don't work. They are widely advertised, heavily marketed by private industry, and often advocated by politicians who don't know any better. It's true that they can work for a very, very small subset of patients with the most severe substance use disorders but generally speaking, our focus within the addiction medicine community is on meds, not beds.