Why we are recommending this best practice
- Motivation is a key to behavior change. It is multidimensional, dynamic, and fluctuating; influenced by social interactions; and can be modified and influenced by the provider’s style. The provider’s task is to elicit and enhance motivation.
- MI is effective as an adjunct to enhancing entry into and engagement and retention in interventions that support various kinds of behavior change, including but not limited to substance abuse treatment. It has also been used to encourage rapid return to treatment following relapse.
- MI is increasingly used as a stand-alone brief intervention during routine encounters with patients.
- MI is an approach that has been empirically shown to be more effective than giving advice, which tends to occur frequently in health care delivery.
- “Readiness to change bad habits is generally a developmental process, and the precepts of MI, including patience, listening, empathy, and change talk, can be useful tools.” (Prochaska J, et al, 1995).
Strategies for implementation
Incorporate the foundational principles of MI into communication with pregnant and parenting women with OUD. These foundational principles of MI should be employed continuously over time and include:
- Express empathy through reflective listening
- Develop discrepancy between patient’s goals or values and their current behavior
- Avoid argument and direct confrontation
- Adjust to patient resistance rather than opposing it directly
- Support self-efficacy and optimism
Employ the following general style of MI in all patient communication:
- Asking Permission – Permission is a deeply respectful foundation of mutual dialogue
- Engaging – Engagement is the establishment of trust and a mutually respectful relationship
- Focusing – Focus is the ongoing process of seeking and maintaining a direction for the exploration conversation
- Evoking – Evoking refers to eliciting the patient’s own motivation for change.
- Planning – Planning is the process of deciding on a specific plan for change that the patient agrees is important and is willing to undertake.
- Linear and Iterative Processes – Change talk within MI is both a linear and iterative process.
Employ the OARS+ model as one set of specific MI skills.
- Open ended questions elicit crucial information that may not be gathered from close ended questions.
- Instead of asking “Have you used any drugs during your pregnancy?”, one might say “I treat a number of women who have used prescription medications and other drugs during their pregnancy. Please share with me which kinds of prescription meds or other drugs, if any, you have used during or before this pregnancy.”
- Instead of asking “Have you ever been in treatment?”, one could request “Tell me about your recovery journey.”
- Affirmations are statements of appreciation
- “I’m impressed that you followed up with the MAT referral”
- “You’ve stayed off drugs for 2 months. That’s great!”
- Reflections establish understanding of what the patient is thinking and feeling by saying it back to the patient as statements, not questions.
- Patient: “I’ve been this way for so long.”
- Provider reflection: “So this seems normal to you” or “So this seems like a hard cycle to break.”
- Summaries are highlights of the patient’s ambivalence that are slightly longer than brief reflections and serve to ensure understanding and transition from one topic to another.
- For a patient wanting to stop using drugs during pregnancy: “You have several reasons for quitting drugs: You want to get your life back, you want to give your baby the best chance at a healthy life, and you want to be able to manage life’s issues without relying on drugs as a crutch. On the other hand, you’re worried about what kind of recovery path would work for you; you’re worried that you won’t have the motivation and strength to stick with a recovery path. Would that sum it up?”
Developing discrepancy involves the listener/provider guiding the conversation so the patient can articulate their personal beliefs and future goals (listen especially for statements about life, family, health, financial status, living situation, and other personal considerations). Developing discrepancy between the patient’s behaviors and their broader life goals is essential because patients are more often motivated to change when they arrive at that conclusion themselves rather than hearing it from someone else.
Change Talk is defined as statements made by the patient that indicate motivation for, consideration of, or commitment to change behavior. There are clear correlations between patients’ change talk and outcomes. Once the listener/provider and patient have established a trusting relationship and have open communication about the patient’s substance use, the listener/provider can guide the patient to expressions of change talk using some of the techniques listed below. Each of these strategies is described in more detail in the Motivational Interviewing Curriculum included in the Resources section of this Best Practice, along with additional strategies for eliciting change talk.
- Preparing change talk employs the DARN model as one set of specific MI skills
- Desire to change (Ask “Why do you want to make this change?”)
- Ability to change (Ask “How might you be able to do it?”)
- Reasons to change (Request “Share one good reason for making this change.”)
- Need to change (Ask “On a scale of 0-10, with 10 being the highest, how important is it for you to make this change?”)
- Implementing change talk employs the CAT model as one set of specific MI skills.
- Commitment (Ask “What do you intend to do?”)
- Activation (Ask “What are you ready (or willing) to do”?)
- Taking steps (Ask “What steps have you already taken?”)
- 99408 – Alcohol and/or substance abuse (other than tobacco) structured assessment and brief intervention services 15-30 minutes (the comparable Medicare code is G0396)
- 99409 – Alcohol and/or substance abuse (other than tobacco) structured assessment and brief intervention services greater than 30 minutes (the comparable Medicare code is G0397)
2. What are some of the bad things about using fill in the substance?
3. What are some of the downsides of getting info a treatment/recovery program?
4. What are some of the good things about getting into a treatment/recovery program?
- American College of Obstetrics and Gynecology. Motivational interviewing: a tool for behavior change. ACOG Committee Opinion No. 423. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:243–6.
- Motivational Interviewing Network of Trainers (MINT), an international organization committed to promoting high quality MI practice and training.
- Ring, Jeff. Motivational Interviewing Practice Coach Training Curriculum.
- Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. 35. HHS Publication No. (SMA) 13-4212. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999 (revised, 2013). https://store.samhsa.gov/system/files/sma13-4212.pdf.
- Miller, William R., and Stephen Rollnick. Motivational Interviewing: Preparing People to Change Addictive Behavior. Guilford Press; 2002.
- Prochaska J, Norcross J, and DiClemente C. Change for Good: A Revolutionary Six Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward. New York. Avon Books, 1995.