Welcome to PsychEd, the psychiatry podcast for medical learners, by medical learners.
This episode covers Motivational Interviewing (MI) with Dr. Wiplove Lamba (staff psychiatrist), Dr. Anees Bahji (PGY5 resident), and Dr. Marlon Danilewitz (PGY5 resident) who we caught up with after their workshop on MI at the CPA annual conference in Quebec City. In addition to learning the basics about MI, Alex also volunteered to do a real-play with Dr. Lamba to demonstrate some MI techniques (and all in one take!).
The learning objectives for this episode are as follows:
By the end of this episode, you should be able to…
Define MI and its utility
Appreciate some of the techniques that are used in MI to increase motivation
Start to use some of these techniques with your patients
Guest staff psychiatrist: Dr. Wiplove Lamba
Episode infographic by Nikhita Singhal
Resources:
MITI scale (available through Google search)
CPA Note: The views expressed in this podcast do not necessarily reflect those of the Canadian Psychiatric Association.
For more PsychEd, follow us on Twitter (@psychedpodcast) and Facebook. You can provide feedback by email at psychedpodcast@gmail.com. For more information visit our website: psychedpodcast.org.
PsychEd+Episode+21+-+Motivational+interviewing+with+Dr.+Wiplove+Lamba.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.
Dr. Lucy Chan:
Okay. Hey, listeners, this is Lucy Chan speaking for this month's episode. We're excited to travel to Quebec City to be at the Canadian Psychiatric Association's annual conference. Alex and our experts were able to find a small meeting room in the Hilton Hotel to discuss the ins and outs of Motivational Interviewing, otherwise known as MI. Alex also volunteered to undergo some MI himself, and we're hoping to get a sense of his experience, and we hope that it will also benefit you in your understanding of Motivational Interviewing. So let's get started!
Dr. Alex Raben:
Welcome to PsychED, the Psychiatry podcast for medical learners by medical learners. Today we're going to be doing an introduction to Motivational Interviewing or MI. This is a special episode because we are actually at the 69th annual conference for the Canadian Psychiatric Association or the CPA in beautiful Quebec City, Quebec. And I'm joined today by three experts who presented at the conference on MI for over how long? It was a number of hours, and I joined for some of it and it was wonderful. I'm going to get them to introduce themselves to you now and we'll start.
Dr. Wiplove Lamba:
So my name is Wiplove Lamba. I'm a psychiatrist who works primarily in addiction in Toronto, and I've been in practice for now about five, six years after finishing actually probably closer to seven since finishing my fellowship. I was first exposed to MI in residency and then in my later years, that's where I actually learned the skills. I was lucky enough to have a mentor, Tim Guimond, who was running the MI clinic and we had about six observed interviews using the MITI Scale and it was after that I really felt I could bring in that language because in psychiatry, I thought were so good at the diagnostic assessment and MI is a slightly different skill. And around that time, I also realised that a lot of people don't have this training and so how do I learn to guide others and picking it up? And so there were some great people at Camh that Carolyn Cooper and Stephanie and Tim Gordon who really helped me pick up those skills there through running workshops.
Dr. Alex Raben:
Great, and Marlon.
Dr. Marlon Danilewitz:
Hey there. My name is Marlon Danilewitz, and I'm a PGY-5 psychiatry resident at the University of British Columbia, and I'm also an Addiction Medicine fellow. For me, my experience with MI came through in that context of the Addiction Medicine Fellowship and having taken a few courses there. And it was really a fundamental part of my training that helped me to work with populations in Vancouver and the Downtown Eastside who really struggle with drug addiction. So that gave me a tool to engage them and also provide for me a way of resilience in working with some really challenging groups. And it's been a fundamental part of my training and it's something that's inspired me to continue working with that population. And it's been a tremendous experience now to present at this conference with such a great team of other collaborators and so awesome to be here today.
Dr. Alex Raben:
Great. And last but not least Anees.
Dr. Anees Bahji:
Now, my name is Anees Bahji. I'm a fifth year psychiatry resident at Queen's University, and most of my experience with me has actually come from working with Wiplove. But I was lucky enough to get to do concurrent disorders work in PGY-2 with Nadeem Mazhar. He was our former program director and he was an addiction psychiatrist and he really emphasized how important MI is as a core skill to being a good psychiatrist, even if you don't do addictions. And I also heard about this book "Getting to Yes"aAnd it actually turned out to be more or less about motivational interviewing. So I realised if I could learn that skill, I might be helpful in getting to yes outside of psychiatry. So, over the past couple of years I've done a few workshops and seminars and I've been able to get a little bit more experience with learning about MI and also being able to teach it to other people across the training spectrum.
Dr. Alex Raben:
That's great. So we have a wealth of experience between all of you and from different areas of the country as well. So that's great to have all of you here today. So thanks once again. And as you know, I'm Alex Raben and I'll be hosting today's show. Before we dive right in, I'm going to start with the learning objectives. So by the end of this episode, you should, number one, be able to define MI or Motivational Interviewing and describe its utility number to appreciate some of the techniques that are used in MI to increase motivation. And number three, be able to use in the real world some of these techniques or start to use them with your patients. Okay. So now that we've done introductions and done the learning objectives, let's jump into the questions and anyone can feel free to jump in. But my first question is essentially, what is MI? How do we define it? And how is it separate from other types of psychotherapy? What defines it?
Dr. Wiplove Lamba:
This is a great question and makes me wish that I had my slide deck. I mean, there's a lot of different definitions that are out there and I don't know the current most recent one. For me, motivational interviewing is really about the language of change, how we work with someone to bring out in them, evoke in them the reasons to make those changes where they're in the driver's seat and we're a bit more of a guide in some kind of way. Luckily, Merlyn has the definition here in front of us, and I'm just going to read that out so our learners actually get that. So this one is motivational interviewing is a collaborative, goal oriented method of communication with particular attention to the language of change. It is designed to strengthen an individual's motivation for and movement toward a specific goal by eliciting and exploring the person's own argument for change. So it was similar to what I said, sort of that I think for medical school you definitely need a clear definition, especially if you're asked a question on a test of some kind.
Dr. Alex Raben:
Yes, exactly. So as you said, it sounds like it has to do with contributing to that person's change, but they're the change that they already have in mind for themselves, is what I was hearing in that definition. But I wonder, I'm going to push a little bit, because I wonder how that differs from other types of psychotherapy, where a lot of the time we are saying or we are doing that for some degree of change in the person. What makes MI unique or what is different about it? Do you guys think compared to something like psychodynamic therapy or CBT?
Dr. Anees Bahji:
So the really cool thing about MI is that its theoretical foundations are a bit different than other forms of psychotherapy and I'm not sure if even calling it MI psychotherapy is fully appropriate because it's probably more of a conversational style. That is then also similar to psychotherapy because it's a therapeutic style. So one of the things about MI is this idea of ambivalence and it also has to do with the Festinger's theory of cognitive dissonance. So where it strikes a chord in difference from other psychotherapies is that you're not using that theory or that principle outside of MI. It's sort of unique to me where you're trying to help the person work with their inner ambivalence to promote change. The other is that you're also thinking about the stages of change models. So that's the Prochaska & DiClemente transtheoretical model. So those two elements are really at the heart of of the foundation of MI. And that's unique to MI from other forms of psychotherapy.
Dr. Alex Raben:
Right. So it's, as you say, a more of a perhaps conversational or a style of conversation in some ways, but has some commonalities. But the theoretical underpinnings are different in that it works really with the ambivalence and the stage of change. Is that correct?
Dr. Anees Bahji:
I think it's a pretty good way of putting it.
Dr. Alex Raben:
Maybe this also gets at some of the same thing, but what do you think motivated the creation of MI? What was the niche it was filling that other therapies or ways of being in the room with people were not accomplishing?
Dr. Wiplove Lamba:
For Motivational Interviewing, it was really heavily influenced by Bill Miller and he was trained in psychoanalytic psychodynamic psychotherapy. But most of his work was done using Rogerian therapy from Carl Rogers was a very humanistic approach. In the eighties, he wrote a paper and then Steven Rollnick and I can't remember if he's from New Zealand or Australia read that paper in the early nineties and started doing that therapy on his own. And then randomly he was at a conference and he saw Bill Miller and he's like, "Hey, I'm doing your therapy". And he's like "What therapy?" And then it's like, "Oh, that paper you wrote a while back." And then it started to get a little bit of momentum in that context. Bill Miller's style really came from New Mexico, where in the addiction world AA has taken over, and AA is phenomenal. For some people. It's very top down, higher power and there are certain people and I suspect some of the people that we see with some maybe some oppositional trades people that need to have their own reasons for sort of doing things where it wasn't working. And so it really was something that developed in I don't want to say opposition maybe in parallel to AA that was separate but I think was really shaped by the psychodynamic psychoanalytic with a huge emphasis on Carl Rogers. And whenever I've seen Bill Miller speak, he has like ten slides just talking about Rogerian therapy.
Dr. Alex Raben:
So was it born out of addictions management and treatment then?
Dr. Wiplove Lamba:
Yeah, so both Miller and Rollnick were using it for alcohol use disorder when they started using it and then it slowly evolved to other areas as well. And Anees and Marlon, feel free to add anything at any point because I'm sure both of you have unique things to contribute for any of these questions.
Dr. Anees Bahji:
There's some early videos where you can see Carl Rogers interviewing a patient named Gloria, and those old videos are on YouTube. And really, it was sort of as I was saying, it's really born out of this Rogerian skilful, reflectful listening and there's very little advice giving in that style. So it's a very interesting style. And I think a lot of psychiatry residents, we watch those videos just to get a sense of where it came from. And you can see how it was shaped further with Miller and Rollnick's applications.
Dr. Alex Raben:
Right. And this makes me think of the idea of the spirit of MI which I know is a very central concept to the essence of motivational interviewing. Can we talk about that? What does that mean, the spirit of MI?
Dr. Marlon Danilewitz:
I think there's like a number of ways to talk about like the spirit of MI. And one of the ways we work in MI is using different mnemonics. So perhaps in this context to share one of those. So the mnemonic for the spirit of MI is "PACE". P stands for Partnership, A stands for Autonomy, C for Compassion and E for Evocation. And it's a great acronym because it gets across the context of what MI and what it's not, and that it's a partnership, a collaborative experience between the client and the therapist, and not a hierarchical form of communication where we're pushing one particular message and the autonomy gets at that really what's happening here is in the control of the individual and that we're working with them, their strengths to help get to towards the answers that lie within them. See, the compassion aspect deals with the fact that this is really an empathic therapy where a lot of genuineness and reflection and validation affirmations come and help to provide such an important aspect. And the last part, the E for Evocation reflects that the core answers lie within the individual themselves, that it's not about providing for them external information, that the message is within you. And that's really, I think, what the heart of MI and the spirit. And I think what would be most useful for learners is getting the spirit.
Dr. Alex Raben:
And thank you for unpacking that, Marlon. And I think that's quite helpful in terms of understanding a little bit beyond the definition, what MI is actually about. And so as you were alluding to, there's lots of acronyms in MI and this is the first "PACE". So Partnership, Autonomy, Compassion and Evocation. I think I got that right? Okay. I'm getting the thumbs up. So that's something that can be helpful to to keep in mind. And later on, we're going to be doing a demonstration of MI. So keep these the spirit in mind while we go through that. Okay. So Wip, something you mentioned was that, the origins of MI was really around the treatment of alcohol use disorder. So I'm imagining that you use MI in that disorder? But are there other patient populations we use MI for? Like if I have someone who's in front of me who's depressed, is that an appropriate therapy? Who is MI tailored for in terms of patient population?
Dr. Wiplove Lamba:
For me I believe it can be used in any clinical encounter. And every year, if you look at the number of publications in PubMed, they just keep going up and up. And so it includes medical management adherence and other disorders as well. There was a great study out of a group from York where they did an RCT comparing CBT alone versus MI plus CBT for Generalized Anxiety Disorder. And the group with both did phenomenal compared to the ones who just had the CBT piece for it. For me, it's sort of what Anees was saying earlier, where it's more of a tool for engagement. It's a way to have that dialogue and it's a way to potentially set the stage for some structured kind of treatment. It's almost a special way of gift wrapping it in some kind of way. And even when you talk to Bill Miller around it, he'll usually just do two or three MI sessions with someone and then they'll move on to whatever else it is that they plan on doing. So it's almost like this complement thing as opposed to a separate thing for some people.
Dr. Alex Raben:
So if I'm understanding correctly, rather than other types of psychotherapy where you have a course and it may for CBT for instance, be like 12 to 20 weeks, you meet once weekly for an hour. It sounds like MI is a little bit less structured and is actually more of a style of talking to people that you can incorporate in your day to day and perhaps do a couple of sessions.
Dr. Wiplove Lamba:
Yeah, absolutely. It's a bit of a starting point for engagement to get them on to board to other kinds of treatments.
Dr. Alex Raben:
Is there a recommended length for a session if you can even have kind of a session in MI or what would the literature generally do in that instance?
Dr. Wiplove Lamba:
So I'm not really sure about the answer for the ideal time frame for MI. Once you go through the training, you almost incorporate that spirit and sprinkle it in for a lot of different things. There is clear evidence for MI for HIV risk, diet, exercise. There's stuff for groups and stuff as well. That's there. I just remember hearing Bill Miller speak maybe he'll do three sessions for about 30 minutes to an hour and then have the person move on to whatever the next treatment is for them.
Dr. Anees Bahji:
Maybe one thing I could add, I've noticed in the literature is that there's MI and then sometimes it gets operationalised into this Motivational Enhancement Therapy and then that can be turned into a module or I've seen it incorporate into some randomized controlled trials. So even some of the research out of Toronto where they're doing treatments for Cannabis Use Disorder, where they're testing a pharmacotherapy and they might have adjunctive motivational enhancement therapy which is actually it's still MI based. So it can be used in that way quite well but it's based on MI.
Dr. Alex Raben:
Right, so MI seems to be quite flexible in terms of time frame and how you incorporate it. And then some people will take that a step in a different direction and they'll formalize it a little bit and call it something slightly different. That makes sense to me, and I think that's quite different than other psychotherapies. So it's interesting. If we now turn to how we actually do MI, I'm wondering like, what does it look like when you're doing it on someone? What are the techniques you're actually using in that encounter that make this conversational style, so to speak, different?
Dr. Wiplove Lamba:
The key ingredients for Motivational interviewing is for basic interview skills, and they love acronyms and motivational interviewing, and so they use the "OARS" acronym for this. So when you're watching an interviewer, the things that'll be coming out of their mouth, if they're doing MI or Open-Ended Questions, Affirmations, Reflections and Summaries, and it's almost like a recipe where you can pick the dose and the amount of each one's those to use and the ways to use them as well. When you hear these words, they're really straightforward, considering the complexity that we're used to doing as health care providers. It's also something that doesn't always come naturally because in medicine we're so good at getting a focused history, figuring out what the problem is. We're not used to having this dance and dialogue to elicit more things.
Dr. Alex Raben:
So that's helpful to have another acronym "OARS" Open-Ended Questions, Affirmations, Reflections and Summaries. Can we unpack what each of those words mean? I know they sound somewhat self-explanatory, but I think there's probably a bit of meat to each of those.
Dr. Wiplove Lamba:
So closed-ended questions would have one or two answers: What is your age? When did you start school? To make them open-ended would be more like: Can you tell me a bit about yourself? Tell me a bit about how school was like for you? Things like that. There will come points where you will need to direct them more, but that's just sort of a way to start. For me, affirmations are one of the key skills for Motivational Interviewing, and when I'm doing a psychiatric assessment, I'll sprinkle those in throughout any time. Someone talks about a skill, something they've worked for all affirm it in some kind of way with the statement that was really important to you. "You really care about your mother", "Your health is something that you really want to work on". And then I stop and then I wait and I see what comes up then. It's surprising how many of our patients get such little encouragement and how many of them that it's hard for them to see their accomplishments at their values, and sometimes they'll even say stories. I see a lot of people with depression and for some of them certain days, it's a huge accomplishment to get out of bed. And when they hear that, it can sometimes hit them because it is a huge accomplishment on some days to get out of bed. Reflections are probably the most challenging skill, at least for me they were to pick up. And these are statements that we use and there's various different kinds, simple and complex. Simple have to do with repeating what the person is saying, paraphrasing, getting the gist and the complex are where we're sometimes strategic on the statements we take and give back. Sometimes we can add emotion to it, sometimes we can add extra meaning to it as well. Summaries are almost like a bouquet of reflection, so it's almost like you hear the full interview and then you selectively pick the points that you want to share and bring out and repeat for them to hear as well. And it's also a way that people can really feel heard.
Dr. Alex Raben:
Thank you. That makes a lot of sense. The one that sometimes gets me is affirmations. But if I understand what you're saying, it's rather than just reflecting, you're actually putting a positive you're emphasizing the positive of what that person is doing with the statement you're making. Is that what differentiates an affirmation from just simply reflection?
Dr. Wiplove Lamba:
I mean, affirmation. People do say it's a type of reflection. I see it's commenting on something positive in them. And the key thing about that is because, I mean, you could praise anything someone does, you can say, "Oh, I like your hair" or "I like your jacket", "I like" whatever it might be. You want to find something that's a genuine praise and feels authentic from within when you when you do it. There are certain people where it's not hard to get out of bed. And if you don't believe it's you think it's really easy for them to talk about and you say, "Oh, it's so great that you came in saying you go to bed", people are really good at picking up the nonverbal and the inauthenticity that sometimes comes with it as well. Usually we really try to affirm the strengths and values, especially when the person's less ready for change as well.
Dr. Alex Raben:
Gotcha! And I understand there's two kinds of reflections broadly anyways, simple and complex. What are what's the difference between those two things?
Dr. Marlon Danilewitz:
Yeah. So I think that really gets to an important aspect. So I think simple reflections have to do with just repeating back kind of the virtual statements kind of parroting back, whereas more complex reflections get beyond just what was said in the content and get to perhaps some of the underlying emotion values it brings together more than just what was at the surface level.
Dr. Alex Raben:
Can you give an example of those, like what would be an example of a simple reflection versus a more complex?
Dr. Marlon Danilewitz:
So if someone said "I had a rough day" and yet said back to them "it sounds like your day was pretty lousy". That might be more in keeping with a simple reflection, whereas taking into account what they were saying before, you might respond back with a complex reflection saying "It sounds like you've had a really challenging day and it's really had an impact on your relationship with your wife at home, and it's really seeming to be overwhelming for you".
Dr. Alex Raben:
So you take it one step beyond. You make some inferences when you're doing a complex reflection.
Dr. Marlon Danilewitz:
Yeah, you kind of have to take a little bit of a leap with a complex reflection, and sometimes you're right on the money and sometimes you may be a little bit off. But it also helps to, if you're able to follow with that, develop a stronger rapport with the individual.
Dr. Alex Raben:
So to kind of summarize what we have so far, we've defined what MI is we talked about the spirit which is "PACE" Partnership, Autonomy, Compassion and Evocation, evoking what the person already has inside of them to help them with change. And then we talked about the "OARS" acronym, which is how one actually talks in the room with the person using Open-Ended Questions, Affirmations, Reflections and Summaries. But how do we know we're accomplishing what we're setting out to accomplish, and what are we trying to set out to accomplish with MI if that makes sense? How do we measure our our success? How do we know where we're going?
Dr. Wiplove Lamba:
What a fantastic question! So when we're doing workshops on MI, I mean, we can cover the didactic within an hour. It's all done through experiential exercises. And once people learn the skills. But what the therapist says, eventually they start picking up what they're listening for in the conversation. And the thing that we listen for is something called "Change Talk". And there's different kinds of change talk; there's Preparatory Change Talk, there's the Action Change Talk and there's also an acronym as well. I feel weird sharing all these acronyms because the learning happens through the experiential exercises when you're training, it doesn't happen for memorizing the acronyms. And I know that from my own learning, I memorized the acronyms I wasn't doing it by and then I go through the experiential I get it. So, Preparatory Change Talk is about desire to change, ability to change, reasons to change and need to change. And so whenever you hear somebody say something like "I want to", "I can" "if this then that", "I need to", "I have to". These are the things that you want to try to encourage. And you can even go further for the Action Change Talk, which is commitment, activation and taking steps. One thing to remember is that Change Talk is that there's opposite end of it as well, which is Sustained Talk. And they're two sides of the same coin. And the whole goal that you have when you're working with someone is you listen very carefully what they say. You're very strategic and the reflections and things that you respond with and you really want to soften the Sustained Talk. So Sustained Talk could be like "I need to smoke", "I have to smoke to sleep at night" whatever it might be. So soften the intensity of that and then amplify the other side of it where it's like "I really care about my health", "I can't be coughing every night", "I want to play soccer with my kids".
Dr. Alex Raben:
That makes sense to me. So there's with ambivalence, we haven't really talked about ambivalence too much, but my understanding is that it's kind of a conflict in a way or there's two sides to the coin, as you're saying. So one side of yourself may want to continue doing the thing you're doing, and then another side of yourself does not. And the Change Talk would be heading in one direction, the Sustained Talk would be heading in the opposite direction, and they can be at different levels of intensity. So sort of preparatory, I'm thinking about that versus action like "tomorrow I will do this".
Dr. Wiplove Lamba:
Yeah. And there's also this thing in Motivational Interviewing where it's like I believe as I hear myself speak. And so there's something that happens when people start to verbalise those things inside. We have all that stuff. I mean, I'm sitting right here. We got some of this hotel dessert in front of us and I'm going in both directions the entire time. Part of me is like "Oh, I'd love how it tastes right now. I'm really tired. I need some energy". And then I'm thinking about, like, how I've started some cardio. I've convinced my wife to let me pay for a trainer short term. Every time I eat this stuff, it shows on the scale. And both those sides are going very well. And it's almost like by verbalising the part that's important to me, I'm more likely to do it. And the great thing about Motivational Interviewing is that a lot of the research they've done, they actually have psychotherapy researchers where they code the words that are being said. And they find that at the end of the interviews, if you have more Change Talk, the person is more likely to make the behaviour change as well and there is some literature in that regard to.
Dr. Alex Raben:
So that does seem to be part of the driving force of MI is getting some of that Change Talk, I see.
Dr. Wiplove Lamba:
And preferably around the end of your interview as opposed to having that Sustained Talk at the end. So say if we're talking about this dessert thing and we finish off and the last thing I'm saying is that, "Oh, it looks really good" and I walk out, I'm going to be more likely to have it. But if as you walk out, I'm thinking more about my health, how I don't want that sugar crash afterwards, I'm going to be more likely to not eat something when I leave.
Dr. Alex Raben:
Right. I know we talked about the process of MI already but how do we get more change talk? What are some specific techniques that allow us to drive that Change Talk? It sounds like ensuring we get it at the end of an interview is helpful, but are there other ways to support that?
Dr. Wiplove Lamba:
When we go through workshops, there's all these questions that we typically do that try to evoke things in people in some kind of way. There's one question where they it's like this imagination question, a dream question for the future "What would you like that to be in some kind of a way?". Maybe I'll let Marlon or Anees share a little bit because I know they've talked about this recently.
Dr. Marlon Danilewitz:
So, I think that's a great question. And there's like a whole variety of ways you can do it and I think it depends on the individual. Things that I've tried before that are perhaps helpful is one like what's called like an Importance Ruler. So speaking with the person and helping to put on a scale, so to speak, where they might say their motivation is on a scale between like 0 to 10, their confidence with changing on a scale of 0 to 10 and then engaging them in a conversation around where they might fall on that scale in terms of eliciting the reasons why it wasn't lower or higher to create some kind of curiosity with where they actually lie. And that oftentimes elicits new reasons for wanting to change and helps to generate more insights into what's going on internally. Other things that are helpful or kind of considering where things might be in a few years from now, or looking back of where things were before and helping people to kind of get a better sense of what their internal values are and their goals are. That also helps to sharpen people's motivation.
Dr. Alex Raben:
Gotcha! And just going back to your ruler question, Marlon, because I learned this just recently from you guys. It kind of matters which direction you say that question, right? So you ask them to rate themselves on a scale of how important it is to them. And if I say a five, then it's better to ask why not a four than it is to say why not an eight, isn't it? Or am I maybe I'm missing that up?
Dr. Marlon Danilewitz:
Yeah. So I think you're right on the money. So sometimes it's helpful to ask people why not a lower score in particular, because that often helps them to consider what is actually motivating them to get back to their core values. Whereas if you were to ask people why not a higher number, so to speak, in my attempt to kind of occupy the conversation over obstacles or barriers or reasons why it's not the most salient value for them at that particular moment.
Dr. Alex Raben:
More ustained talk too potentially.
Dr. Marlon Danilewitz:
Right. Well, I'm glad you took away something from our show.
Dr. Alex Raben:
No, it was very helpful. And I think you guys summarised nicely at the end. You had all of us take away something. But I guess I've taken away two things now. We've spoken a lot about what MI is in the abstract and we've tried to use examples here, but what I'm thinking might be most helpful for our listeners is to actually do what we call a real play and demonstrate live or I guess this is recorded, but we'll try to do one take, we'll see how it goes. How this actually works in reality, what it sounds like. So I am volunteering myself to do the real play. So I'm going to bring something that I'm ambivalent about to the group and then Wip is going to be doing the actual MI and a Anees and Marlon are going to be evaluating and listening in to allow for a more fulsome debrief at the end. So we can point out some of the techniques to you guys. Are you guys ready?
Dr. Wiplove Lamba:
Sure. Let's try this out. And Anees and Marlon, are you going to be using the "EARS" Exercise or the MITI? Okay, perfect.
Dr. Alex Raben:
So, we're referring to some scales here that we have on a piece of paper that can allow us to get a better assessment of all the times, reflections we're used or affirmations and that kind of thing. And my understanding is this is actually used in the training for MI as well.
Dr. Wiplove Lamba:
So the MITI Scale is used in the research. So there's this motivational interviewing, a treatment integrity that was developed by Moyers in New Mexico. And for all research studies, they use those scales, they're available online. But the ones we're doing are they're basically going to be tracking the stuff that I say, the open-ended questions, affirmations, reflection, summaries. And this is something we'll do in workshops so people can practice those things.
Dr. Alex Raben:
And I guess we should also mention "frequency" there. Is there an ideal frequency to how many reflections versus questions?
Dr. Wiplove Lamba:
Yeah, so they say a good Motivational Interviewing is about 2 to 1 reflections to questions. And if you're Bill Miller or I guess Carl Rogers, it's like 4 to 1. I still remember some interviews I've watched with Bill Miller and the patient says everything and he's not asked a single question. And I'm like, his ratio might even be higher than that 4 to 1 that we sometimes say.
Dr. Alex Raben:
Right. And for the listeners, we will link to some of these assessment sheets so that if you want, you can pause the episode right now, download them and kind of mark along with us. Or you can just listen in and see if you can pick up reflections and affirmations and summary statements and open-ended questions on your own. All right!
Dr. Wiplove Lamba:
Alex, thank you for meeting with me today. And this is an opportunity for you to talk about something that you want to change in your life. It could be something that you used to do and want to do again, or it could be something that you sort of imagine yourself doing down the road, right?
Dr. Alex Raben:
So for me, the thing I would like to change is my use of caffeine.
Dr. Wiplove Lamba:
Your caffeine use?
Dr. Alex Raben:
Yeah, I'm quite addicted, I think to caffeine. I drink quite a bit of Diet Cokes, Coke Zero throughout the day, some coffee as well. And previously I went a year without caffeine and then I've kind of relapsed in the last year. And I'd like to go back to the old way, but it's difficult.
Dr. Wiplove Lamba:
Yeah. So you keep drinking it for the taste.
Dr. Alex Raben:
Not just the taste. I do enjoy the taste, but I think it's more the caffeine and avoiding the withdrawal of the of stopping. It's kind of both.
Dr. Wiplove Lamba:
You actually get withdrawal when you don't have it.
Dr. Alex Raben:
Yeah, pretty significant. Like I know some people don't quite understand that because I don't know, maybe genetics, but I do get quite substantial withdrawal. And so it does make me quite irritable for a number of days, quite tired, lethargic, headaches, the whole kind of nine yards. And so I really can't function very well. So in the past when I've quit, I've actually quit on vacations because I don't need to function at a high level, obviously.
Dr. Wiplove Lamba:
So when you're like a nice resort or you can sleep in, irritability doesn't affect you or your family.
Dr. Alex Raben:
Well, it may affect them slightly, but it's not going to be like irritable at work where I need to be cool and collected.
Dr. Wiplove Lamba:
You like to be on when you're at work, you want to be sharp and on and productive.
Dr. Alex Raben:
Exactly. Yeah.
Dr. Wiplove Lamba:
What are the things that make you really want to stop using it?
Dr. Alex Raben:
Well, cost is one thing. I know that individual cans of coke or coffee is not that expensive, but in the long run, it does certainly add up. I also just don't like the idea of being kind of under the thumb of a substance. I'd rather, because I know when I've quit in the past, I actually feel better. So it's really not a great feeling to know you're just kind of staving off withdrawal in some ways. I guess I do get some pleasure from drinking it, but those are the reasons I would want to stop.
Dr. Wiplove Lamba:
Yeah, you really want to be able to control your day, choose what you do and when and you don't like having to count the hours before your next caffeine hit, so to speak.
Dr. Alex Raben:
Like before coming here today to record this, for instance, I had to have a Coke Zero because I knew I would be too low energy if I didn't, which is kind of a bit of a, I don't know, ball and chain or something like this.
Dr. Wiplove Lamba:
So when you have no caffeine at all, you can't actually function at all at work.
Dr. Alex Raben:
Not function at all. But it's difficult. And if I were to go like days, like if I were to go a day without it, I would be pretty miserable and irritable. Then, my work might suffer and I don't want that to happen.
Dr. Wiplove Lamba:
What did it take you to get to the point where you had those moments where you're caffeine free and you actually feel like you're functioning better?
Dr. Alex Raben:
I think it was like an opportunity. The other thing was that it was around New Year's, and so it was a resolution.
Dr. Wiplove Lamba:
And you had to follow through and finish it.
Dr. Alex Raben:
It was a symbolic time of year. And because it was the vacation over that period and I didn't have any like I wasn't even going on a trip. It was a staycation. So I knew I could just kind of stay in and have some lazy days and just get through it. And then once you're once I was through it, then it was immediately much better. I still had some cravings, but I could kind of deal with that for the most part.
Dr. Wiplove Lamba:
And you're able to stay away from caffeine for a full year?
Dr. Alex Raben:
Yes. And then I'm trying to remember why I relapsed. I think it was probably being on-call and not getting a lot of sleep and then, you know, allowing myself that one drink of caffeine to feel a little better and then it just kind of snowballs from there.
Dr. Wiplove Lamba:
I'm really interested in hearing about what it's like for you when you're off caffeine, maybe like the second or third month when you talk about your overall life being different.
Dr. Alex Raben:
Well. I mean, I'm saving money. I'm not going to Starbucks every day, which, again, adds up. I'm. My energy is actually higher, sleep is better.
Dr. Wiplove Lamba:
You sleep better without caffeine?
Dr. Alex Raben:
I think so.
Dr. Wiplove Lamba:
Just not for the first week. But once it's clear, you sleep better.
Dr. Alex Raben:
Yeah, exactly. And then I just don't have to have it. So if I'm in a rush to get somewhere, I don't have to plan my day around ensuring that I can get some Coca Cola or I can get a coffee or something like this.
Dr. Wiplove Lamba:
So, you have more freedom when you're caffeine-free about where you go and when you're not really forced to take certain routes in certain places, you can explore a little bit more.
Dr. Alex Raben:
That's true.
Dr. Wiplove Lamba:
How exactly did you work through that withdrawal? It sounds like you're at home. You didn't have work. How did you get through that?
Dr. Alex Raben:
I was literally on the couch writhing and sweating. And not quite so bad. But it was a lot of Netflix, a lot of just like lying on the couch. Some just naps during the day. It was not very productive and it was kind of miserable. But because I had no obligations, it was helpful. Also, my girlfriend at the time was supporting me in this endeavour. And so team effort.
Dr. Wiplove Lamba:
So on a scale of 1 to 10 where ten is like the most and one is at least, how important is it for you to get through that withdrawal and be caffeine-free?
Dr. Alex Raben:
It's funny because I think I would have put it as a lower number prior to this conversation we're having. And actually I did the same real play at the session yesterday. We didn't get very far because we didn't have much time, but I put the number then at three out of ten and now I'd probably say about a 5.
Dr. Wiplove Lamba:
And why is it a five and not like a three? Where to?
Dr. Alex Raben:
Well, it was helpful to hear myself and kind of reflect back to me the things I like about it, particularly the freedom piece. I don't think I think about that very often that I am kind of shackled in a way by it.
Dr. Wiplove Lamba:
Not having to go here and there at certain times and plan your whole day around it.
Dr. Alex Raben:
I don't like to have that extra thinking on board. It's distracting.
Dr. Wiplove Lamba:
And what do you think it would take for you to get up to six or seven in terms of the importance?
Dr. Alex Raben:
It's interesting because it's almost like dependent on time of year or like if I had vacation coming up shortly, I would feel, I think, more confident or more I would prioritize it more. But I think because I know I still have a few months before a vacation that I'm prioritizing it less.
Dr. Wiplove Lamba:
It's almost like your last hurrah. And then when vacation comes, you're going to stop.
Dr. Alex Raben:
I guess so. I mean, like I said, I do enjoy aspects of it. I do like the taste.
Dr. Wiplove Lamba:
On a scale of 1 to 10, how confident are you that you can cut back on your caffeine use for 10 is unbelievably confident and 1 is like not at all.
Now it would probably be about three or four. But again, it kind of depends on the timing. If I was coming up to a vacation and I knew it wasn't going to be a busy vacation where I was doing a lot of things or going somewhere where there's really good coffee or something. Then I would be much more confident, maybe like an eight or nine, even because I've quit the one time I've talked about already, and then I've also quit in the past.
Dr. Wiplove Lamba:
So the number would jump up if you were in an environment that made it easier to do.
Dr. Alex Raben:
Yeah, exactly.
Dr. Wiplove Lamba:
And you can't think of any ways to bring some of those principles in now.
Dr. Alex Raben:
No, I guess I can like I guess there's like long weekends coming up. So that would be one possibility. Thanksgiving weekend is coming up. So here in Canada, Thanksgiving is in October for our international listeners. I could see that being possible opportunity and I will be going home with family and whatnot. So I could perhaps enlist their help as well. And then I guess another thing that you kind of made me think of is like because work is such a driver of this, if I can find work at the moment, I'm sort of getting a bit more used to my rotation and if I have no call for a little bit, perhaps that would also be helpful, if I planned around that.
Dr. Wiplove Lamba:
Right. So you've talked about a lot of things today. You talked about briefly what you like about caffeine, the way it's almost like this ball and chain. It sort of captures you. You don't like the withdrawal you go through and you don't have it. And it's tough to have to think almost every few hours when you're going to get your next caffeine piece. You've been through this before, right? You made a decision. You picked a date. You were able to do it for a full year with a little bit of support. And part of you wants to go back to it. You just haven't figured out when and how. Yes. And there's clear things about this current pattern that bothered you and upset you to the point that this was the one thing that you're like "This has got to change".
Dr. Alex Raben:
Oh, it's a really good point. I think that this was the thing I chose and I chose it twice in a row, technically. So clearly it's one of the things on my mind and one of the things I'm quite ambivalent about. And I think the when in the "how piece" you just said makes a lot of sense. I think I am still figuring out "the when and the how", and that's the big piece I have to work on.
Dr. Wiplove Lamba:
What do you see as the next steps in this?
Dr. Alex Raben:
I well, I can see myself, at the very least looking at my calendar and seeing what are my next call shifts. When are there longer weekends or opportunities where I have slightly less work or I might be able to chart out a period of time where I can just go through the irritability and the withdrawal and all of that.
Dr. Wiplove Lamba:
I want to thank you a lot for sharing these kinds of things. And from a personal standpoint, I love to hear how it goes down the road at any point that's there. Thank you for putting this on the air.
Dr. Alex Raben:
Well, same to you. Thank you. All right. So why don't we debrief that?
Dr. Anees Bahji:
So we kept track of the "EARS". So, a few elaborating, exploring questions were used. There was a few affirmations. But the thing that's really important here is that they're all interwoven with each other. So there was times when you can combine multiple different techniques. So, I think at the very end, one of the things that really stood out was when he said, you did this for a whole year. So there was a bit of affirmation built in there that you're really building on that previous success that you had had with that attempt and then building some confidence that you may be able to experience that again.But that was also partly a more complex reflection at the same time, because it was building on something you had said previously. There was a few things that were combined.
Dr. Alex Raben:
Yeah. That made me feel really listened to as well because it seemed like you followed along the entire story you brought back, even the reference to the ball and chain that I had kind of thrown out there. You brought that back towards the end, and I think it was like little touches that made me feel quite listened to and supported.
Dr. Marlon Danilewitz:
I'm also very happy to report that for Wip, the reflections definitely outnumbered the collaborations. And what I think was also quite interesting was that you really had a good base of engagement early on, and towards the end of the conversation, the questions that were posed really helped to move ground and to by asking the ruler question to assess your level of confidence, it really helped to evoke a sense of change talk there, which I think really shone through.
Dr. Alex Raben:
And you brought up engagement, Marlon, so maybe we can elaborate on that a little bit because how does that play a role in MI? Because in this situation, we already know each other from before and the engagement was kind of good from the get go. But I could imagine scenarios where you don't have good rapport with someone and you're trying to use these techniques.
Dr. Marlon Danilewitz:
So, I think that's a great question because oftentimes in our clinical interviews, we spend a lot of time on the questions and getting the content. But developing rapport and engagement is such a fundamental aspect of my in a successful interview. And it really sets the stage that only through having a solid foundation of engagement can you start to begin to move on to the next stages. And that's really an integral part of my is that knowing that where the person's at and their readiness for change and where they are at any particular moment.
Dr. Alex Raben:
Right. And we've talked about this on past episodes. Just for the listeners reference, our episodes on the Psychiatric Interview really focussed on that because building rapport is so fundamental in psychiatry, all the things we do. And I guess the same is true in using me as well.
Dr. Wiplove Lamba:
Yeah. And from what I remember about the evidence MI, it tends to work really well when people are bit more oppositional traits when they're quick to anger and it's quite effective at bringing you down that level of anger in our case, because we know each other, we've worked together before. I suspect if I took a non-MI approach, if I took it direct, it might even have an impact, especially because you know what's coming from a good place. MI is one tool of many and there are situations that do require us to be direct as well. And I don't want people to think that we're coming in and say "Oh, I use MI all the time". I have a suspicion that if we did a different interview that wasn't my based or was a bit more direct, you might have gotten something from it as well. It would have been a different experience for sure but just to think about that for the relationship. One thing I did want to comment on quickly is just that with these interviews, at least when I've been recorded and people have scored me on the MITI, I tend to do okay in terms of reflections, I do okay in terms of listening Change Talk. The thing I'm not that great with is a softening Sustained Talk piece. And there was a couple of times that you made a few sustained talk questions, and I just went over like that. The only reason I'm bringing this up is that just like any psychotherapy, there's levels of which people can improve. And with Motivation Interviewing because they're so careful about tracking the language when they review you, they're actually very specific about which things you could do differently and how.
Dr. Alex Raben:
Right. Now that makes a lot of sense. We can all obviously continue to improve in these techniques. And I think you brought up the point that it's not the be all, end all. It has a time and place that there are other techniques that one can use with patients. And sometimes advice giving can be helpful. You know, thinking outside of the doctor-patient relationship, good friends are often in a position where they can give that hard advice because you've had years of building a relationship with that person. So that's just an analogy in a way. But to emphasize the point that advice giving is not a part of me, that's actually sort of counter in a way to the spirit.
Dr. Wiplove Lamba:
Yeah, unless you ask for permission first. I have that little trick there so you can still be a doctor and ask for permission. A little twist in the MI book for health care.
Dr. Alex Raben:
Right. And that would be sort of the autonomy, peace of the spirit, making sure they're okay with you, giving them some facts. I guess I'll just give a bit of my subjective experience in terms of a debrief. I mean, I found that to be quite helpful. And as you saw, my rating scale even had changed from yesterday to today. And particularly pinning me to thinking about next steps was helpful. And I didn't think I would get there. I thought I was too entrenched. I really do appreciate that because it is, I think something I will potentially do or consider, which was not something I expected coming into this today. I hope it shows the power that MI has to the listeners. Was there any other comments any of you had in terms of that interview before I ask sort of the final question?
Dr. Marlon Danilewitz:
I'm just excited to see whether you come with a coffee to next academic day.
Dr. Alex Raben:
Yeah, that'll be the true test, right? Maybe we'll do it. Update in the next episode. All right. Well, I have one final question for you guys, because I want to make sure we're bringing it back to the junior learners. What do you think a clerk or a junior resident ideally should take away from from this talk? Where can they start to use MI? Sorry, it's a double-barrelled question, but how can they access resources to learn more as well?
Dr. Wiplove Lamba:
I think all of us have our favourite resources and you'll find MI is very individual in terms of how it's taught. There is a British Medical Journal article that's six things you can do in the medical interview that are MI adherent includes things like the Importance and Confidence Scales. It includes ways to give advice in my adherent way, and it covers the guiding principle and it's available for free online. And the British Medical Journal also has a two-hour free CME that covers some of the basics. This is something I would strongly recommend practising. You could do it at any point in the interview you could do when you give the treatment recommendations, you could do it to try to elicit more things. It's really important that people try it out and figure out for themselves if it works or not, because we tend to do things that we believe are effective, you know? And for me, I wasn't sure if it would work at first. Some of these skills, they seem so basic. It's only when you have those experience of responses that are there as well. So those are my thoughts. But usually what happens for people in medicine, it's usually when they're working for three or four years, they're seeing the same patients over and over again that aren't getting better. That's when the motivation comes, because in medical school and residency, you're just learning how to be a good doctor, right? And there's so much content, so much practice, all that kind of stuff. So those are my thoughts.
Dr. Alex Raben:
And Marlon.
Dr. Marlon Danilewitz:
There's always the book Motivational Interviewing by Miller and Rollnick. There's also a great opportunity in the community at large through training those who are extra keen to pursue excellence in MI.
Dr. Alex Raben:
How do people access training? That's online?
Dr. Marlon Danilewitz:
Yeah.
Dr. Alex Raben:
We'll make sure to put these resources in the show notes as well.
Dr. Wiplove Lamba:
Yeah. It's the Motivational Interviewing Network of Trainers. They have a national conference every year, one year it's in North America, the next year it's somewhere nice to visit. And it's really how to get to that next level of MI. A colleague of mine who taught me a bunch was actually three years below me, and he went there when he was a resident and he got really quite good at MI quick by attending those intensive workshops.
Dr. Marlon Danilewitz:
I think the last thing is just practice.
Dr. Alex Raben:
Yeah. Get the experience. That's terrific and I agree completely. Thank you guys so much for taking time out from the busy schedules here, your busy schedules at the CPA conference and I'm taking you away from dinner and the lovely day outside now, night outside in the beautiful city of Quebec City. I really appreciate that and hope to have you back at some point as well.
Dr. Wiplove Lamba:
Thank you.
Dr. Marlon Danilewitz:
Thank you so much.
Dr. Anees Bahji:
Thank you.
Dr. Alex Raben:
Take care. That's all for now. Listeners, we're going to sign off and we'll see you next time. Thank you all for listening. If you can, I suggest you stick around for some important announcements about our new email, our new infographic initiative, and to hear about my progress since the episode was recorded over a month ago, we first of all have a new email psychedpodcast@gmail.com. Our old email is no longer operational, so please send all your comments and questions to our new email. In terms of our next update.
Dr. Alex Raben:
Thanks to our newest member, Nikhita Singhal, who is a first-year resident at the University of Toronto in Psychiatry. We now are making infographics to accompany our episodes. The first one being with this episode on Motivational Interviewing. These are meant to allow you to refer back to key concepts from the episode, using a quick one-page graphic available through our show notes for that episode or on our website Psychedpodcast.org. We hope that you'll find them useful. Finally, a bit of an update since I did the real play with Dr. Lamba on this episode. Although it sucks to admit I have yet to make a meaningful change in my caffeine use since the episode was recorded a little over a month ago. However, I did take some actions towards change. I did look at my calendar and I looked for opportunities to set a quit date.
Dr. Alex Raben:
Also, since listening to the recording during the editing of this episode, I have noticed I've started to think about change again in this area. And so we'll see where that leads me and I may share some updates as we go. I think for me, this highlights how difficult change can be in general and for our patients. And it's given me a new renewed empathy for our patients that find themselves in similar situations, but with drugs and other behaviours that often have a far greater impact on their mental health than caffeine. I hope that you'll reflect on this as well. So that's all for updates.
Now let's go to the end credits. PsychED is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode was produced, audio edited and hosted by Alex Raben. Lucy Chen provided our episode intro. Our theme song is Working Solutions by all of music. Nikhita Singal created the infographic to accompany this episode. A special thanks to our incredible guests, Dr. Wiplove Lamba, Dr. Anees Bahji and Dr. Marlon Danilewitz for serving as our experts for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.
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