THE BRIEF NEGOTIATED INTERVIEW A Toolkit for Enhancing Motivation for Change in the Clinical Setting

EM physicians talk about their encounters with the drinking patient, their frustrations, and the reasons they decided to try a brief intervention in the ED settingEM physicians talk about their encounters with the drinking patient, their frustrations, and the reasons they decided to try a brief intervention in the ED setting see video clipsee video clipsee video clipsee video clip

It’s not easy to talk with high risk drinkers without getting the patient defensive or resistant. In this video clip, we hear a physician try to help a patient change. As you watch and listen, observe both verbal interchange and body language.It’s not easy to talk with high risk drinkers without getting the patient defensive or resistant. In this video clip, we hear a physician try to help a patient change. As you watch and listen, observe both verbal interchange and body language. –What do you like about this approach? –What do you like less about the interaction? Click here to start the video Click here to start the video

Many people say,Many people say, –“At least he brought up the topic!” –“At least he showed he cared about the problem.” –“He was passionate about drinking and driving.” But others point out,But others point out, –“If I had been the patient, I would have felt shamed.” –‘He stood over the patient and shook his finger in the patient’s face.” –“He didn’t show any respect or listen to what they patient thought or felt.” –“He was so angry he couldn’t even look at the patient except when he was pointing his finger.” Click here to review common traps Click here to review common traps

Do you think this patient will change his drinking or reduce his risk as a result of this conversation? What would you do differently? Let’s see how this scene could be played differently. Click here to continue the video Click here to continue the video Click here to continue the video

What did this second provider do differently?

Some of the things people have said about the second ED provider… sat at the bedside, eye to eyesat at the bedside, eye to eye showed concern for the patient and his problemshowed concern for the patient and his problem asked permission to talk about drinking (showed respect)asked permission to talk about drinking (showed respect) used reflective listening (open-ended questions and summary statements)used reflective listening (open-ended questions and summary statements) got a real conversation goinggot a real conversation going was willing to elicit and listen to the patient’s experience and reasons for drinking (starting from where the patient is at, without shame and blame)was willing to elicit and listen to the patient’s experience and reasons for drinking (starting from where the patient is at, without shame and blame) encouraged and affirmed motivational statementsencouraged and affirmed motivational statements gave feedback about guidelines without preachinggave feedback about guidelines without preaching delivered advice non-threateninglydelivered advice non-threateningly

In the following slides, we review some of the important principles of motivational interviewing, as developed by Rollnick and Miller, and adapted for the ED setting by Bernstein, Bernstein, D’Onofrio and Project ASSERT at Boston Medical Center Click here to continue the video Click here to continue the video

THE BRIEF NEGOTIATED INTERVIEW establish rapport and ask permission to raise subject provide feedback comparing quantity and frequency at screening with NIAAA guidelines for safe drinking ask, “What connection do you see between your drinking and this ED visit today?” assess readiness to change explore pros and cons if not ready or if resisting explore options and negotiate a feasible plan, including referral to treatment when indicated NOT READYREADY

NEGOTIATING BEHAVIOR CHANGE Principles of Good Practice “Motivational interviewing was developed from the rather simple notion that the way clients are spoken to about changing addictive behavior affects their willingness to talk freely about why and how they might change.” Stephen Rollnick, PhD Addiction 2001; 96:

PRINCIPLES OF MOTIVATIONAL INTERVIEWING Respect client autonomy, culture and choices.Respect client autonomy, culture and choices. Make clear from the start that the client is the active decision maker.Make clear from the start that the client is the active decision maker. Negotiate an agenda for change together.Negotiate an agenda for change together. Offer information in a neutral, non-personal manner.Offer information in a neutral, non-personal manner. Ask open-ended questions.Ask open-ended questions. Practice reflective listening to encourage patients to talk about their drinking and the barriers to change.Practice reflective listening to encourage patients to talk about their drinking and the barriers to change. Accept resistance as a normal response.Accept resistance as a normal response. Avoid confrontation, labeling, stereotyping and forcing patients to accept a label or diagnosis.Avoid confrontation, labeling, stereotyping and forcing patients to accept a label or diagnosis.

STEPS IN BRIEF NEGOTIATION Click here for pdf file of pocket card Click here for pdf file of pocket card

Make the connection between drinking and the reason for visit This is the patient’s chance to name the problem.This is the patient’s chance to name the problem. If there is resistance or lack of awareness of a connection, the provider can help the patient see the connection.If there is resistance or lack of awareness of a connection, the provider can help the patient see the connection. Listen carefully for the patient’s own concerns— it will help you make the link.Listen carefully for the patient’s own concerns— it will help you make the link. It is important during this process that provider feedback is given empathetically without shame or blame.It is important during this process that provider feedback is given empathetically without shame or blame. see video see video

strategies for keeping the conversation moving forward towards a prescription for change

Use the Readiness Ruler How ready are you on a scale of 1 to 10 to change your drinking if ‘1’ means not ready and ’10’ means very ready?How ready are you on a scale of 1 to 10 to change your drinking if ‘1’ means not ready and ’10’ means very ready? Use the ruler to elicit and enhance motivational statementsUse the ruler to elicit and enhance motivational statements –“So why did you say 5 instead of 2?” –“Well, I certainly don’t want to have another car crash like this…it made me think about things.”

Exploring the Pros and Cons If you encounter resistance or the conversation is not going anywhere, exploring the pros and cons can help you understand where the patient is coming from and the obstacles to change.If you encounter resistance or the conversation is not going anywhere, exploring the pros and cons can help you understand where the patient is coming from and the obstacles to change. Pros and cons strategy (as illustrated by the 2 nd provider):Pros and cons strategy (as illustrated by the 2 nd provider): –Ask, “What do you like about drinking?” –Acknowledge that you have heard what they say. –Elicit statements about consequences by asking, “What do you like less about drinking?” –Repeat and affirm statements that lead to change. –Summarize briefly: on the one hand you said.., and on the other you said…. –Ask, “Where does that leave you?”

THE ROLE OF PHYSICIAN ADVICE timing is important—the patient should feel heard and respected before the physician weighs intiming is important—the patient should feel heard and respected before the physician weighs in conversational style matters—advice should be brief, and non-judgmentalconversational style matters—advice should be brief, and non-judgmental advice should be based on fact and weave in medical eventsadvice should be based on fact and weave in medical events see videosee videosee videosee video

STRATEGIES FOR EACH STAGE OF READINESS NOT READY Don’t – shame, blame, preach, stereotype, confront….this just builds resistance Do – listen empathetically – explore pros and cons of use “Help me to understand through your eyes…What do you like about drinking. What do you like less? – challenge person to move along the ruler, e.g. “So what would it take to get you to a 5?” – give feedback and show concern – offer information, support, further contact

STRATEGIES FOR EACH STAGE OF READINESS UNSURE Don’t – jump ahead, give advice or confront resistance – expect agreement Do – practice empathetic, reflective listening – ask neutral, open ended questions – explore pros and cons of change

STRATEGIES FOR EACH STAGE OF READINESS READY Don’tDon’t –jump in with single or simple bits of advice DoDo –explore pros and cons of referral / services –emphasize: alternatives and choice (menu of options) alternatives and choice (menu of options) known community role models known community role models autonomy autonomy –“You’re the best judge of what will work for you.” optimism paired with back-up optimism paired with back-up – “If this doesn’t work, call me.”

IN NEGOTIATING A PLAN, EXPLORE…. previous strengths, resources and successesprevious strengths, resources and successes –“Have you stopped drinking/using drugs before?” –“What personal strengths allowed you to do it?” –“Who helped you and what did you do?” or or –“Have you made other kinds of changes successfully in the past?” –“How did you accomplish these things?”

Developing and Using a Referral Network Use the referral services networkUse the referral services network – Methods for negotiating changeMethods for negotiating change –start video start videostart video Provider expectations: setting realistic goals for change in a chronic diseaseProvider expectations: setting realistic goals for change in a chronic disease –start video start videostart video

ED Residents Speak Out about Screening and Brief Intervention In this video, residents who practice alcohol screening and intervention speak about their experiences.In this video, residents who practice alcohol screening and intervention speak about their experiences. Start videoStart videoStart videoStart video