Addiction is a very difficult subject to broach. How should you talk to your patient about their substance abuse? How can you gauge their motivation for change? Find out the answers by watching this video from our course Essentials of Addiction Medicine, written and presented by Dr. Stephen Holt, Co-Director at Yale Addiction Recovery Clinic, USA.
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Alas, it would be impossible for me to teach you all the skills inherent to motivational interviewing in this brief video. Instead, I will focus on a few essential components of this approach that you can immediately use in your next patient encounter. To demonstrate these skills I will use a conversation around smoking as an example, since this is sure to be the most common substance you encounter in clinical practice. But remember that you can use this approach to discourage any unhealthy substance use, or to promote any other healthy behaviors such as weight loss strategies, exercise routines, or adherence to medications.
First, if you want to start a conversation with your patient about their substance use, ask permission. Patients with substance use disorders are accustomed to being criticized, ridiculed, judged and berated for their behavior. So by asking permission, you've already clued in your patient that this is going to be a different sort of encounter. So Miss Roberts, is it okay if we chat a bit more about your smoking? Next, ask your patient what they like about smoking. Patients only engage in addictive behaviors, when those behaviors do something for them. Perhaps smoking helps the patient to relax, perhaps they just like the way it makes them feel. Maybe it's just something to do during a break at work. Either way, providing your patient an opportunity to explain why they continue to do what they do, tells the patient that you care about their perspective, and ultimately, it builds rapport. And hey, if your patient replies, I don't like anything about smoking. Well, you've just found something that the two of you agree on.
Next, ask the patient what they don't like about smoking. Some patients may have a litany of things that they don't like about smoking, such as the smell, the cost, the health concerns, and the nagging from their significant other. You want to use reflective listening here with plenty of mm-hmm's and I see and tell me more about that, as well as just simple silent attention. This ensures your patient has the opportunity to fully flesh out the negative associations they have with smoking in more detail. Of course, some patients may have very little to say here. This is your opportunity to gently ply your patient for the potential negatives they may not have thought of. Think about the potential complications of smoking. You might ask about any issues with chronic bronchitis or decreased exercise tolerance. You can also explore issues with hypertension, gastroesophageal reflux disease, and erectile dysfunction.
Other questions to ask to coax the negative associations out of your patient include, do you have any family history of cancer? Are there conflicts at home regarding your ongoing substance use? How much do you spend each month on your habit? All these questions should be asked with a genuine curiosity and a non judgmental attitude where you are simply gathering data to be used in the next step. Finally, ask your patient if they have ever tried to quit or cut back in the past. If they say yes, ask why? What led them to quit in the past? this detail may be the most important bit of information you obtain, since you know what was important enough at one time to have led them to make a quit attempt.
Okay, now, armed with all that information, hone in on the ambivalence. On the one hand, it sounds like smoking cigarettes really helps you to relax at night. But on the other hand, it sounds like smoking is costing you about $250 a month. You don't like the smell, and you're worried about this nagging cough you've had for the past several months. Seems like you are conflicted about your smoking. This statement draws attention to the patient's ambivalence and conveys to the patient a sense of compassion, and an acknowledgement that making change is hard. After pausing to allow the patient to reflect on their ambivalence, move on to the question of how ready they are to quit. Ask on a scale of 1 to 10 with one being you want to continue smoking exactly as you are and 10 Being you want to quit smoking right at this moment, where would you say you are along this scale? If the patient responds with any number between 2 and 10, your response will simply be, okay you pick to four. Why didn't you pick two or three?
By asking the question in this way, you're asking the patient to repeat the factors that are motivating them to contemplate change. In contrast to that paternalistic approach we described in the prior lesson in which a clinician might say, stop doing that shape up or you need to quit, inevitably leading the patient to defend the state status quo. With this new approach, you have now put the patient in the position of defending change. A patient who can defend change is clearly in the contemplation stage. So your next steps would be to try to steer them into the preparation stage by presenting a menu of options and coming up with a plan together.
Going back to the readiness scale, if the patient responds with a one, then they are in the pre-contemplation phase. All you need to do is respond with a statement that affirms their autonomy, such as you are the driver of your own ship and I appreciate you letting me hear more about your perspective. It's crucial that the conversation ends with empathy and support, even if it may appear that the patient has not budged from the pre-contemplation stage. Sometimes, a brief motivational interview is merely the planting of a seed that might bear fruit at a later time. Be sure to ask your patient if it would be okay to bring up the topic again at a later visit.
And that's motivational interviewing in a nutshell, regardless of the outcome of your first efforts, the crucial components here are that you, as the clinician, do more listening than preaching, do more empathizing than judging, and do more promoting patient autonomy than dictating. Try it. It works.