Connection, Not Correction: Motivational Interviewing with Dr. Allison Hadley

Mark Mullen: [00:00:00] When I think about core skills for any psychiatric provider, motivational interviewing is at the top of the list. The reason why is because our patients come to us almost by definition to change the way they feel. They are struggling with something, and so they want help. But as we know from our cognitive triangle and cognitive behavioral therapy, feelings are inextricably linked with behaviors.

In order to help our patients achieve their goals, we need to be comfortable having conversations about changing behaviors. Motivational interviewing is an approach to having these conversations. It's been extensively studied at this point. It's highly evidence-based, and I consider motivational interviewing to be the cornerstone of treatment for substance use disorders in psychiatry.

I also wanted to take a slightly different approach to motivational interviewing because it's been around for a little while. It's explained in many different educational areas, often pretty [00:01:00] dry, often using acronyms. So we are going to take a improv comedy, Tina Fey-informed lens to motivational interviewing.

Welcome to Psychiatry Boot Camp, Dr. Allison Hadley, and I will ask you to introduce yourself to our audience. 

Allison Hadley, MD: Hi, I'm Allison Hadley. I'm a psychiatrist in Portland, Oregon. I run the psychiatric emergency service, which is a big psych ED in the downtown area in Portland, and I work for Oregon Health & Science University.

Mark Mullen: So you are mostly seeing patients in the psych ED. What would you say are the two or three problems that you see most often? 

Allison Hadley, MD: So our population is a lot of folks who are underserved in the community. We see a lot of people coming in with co-occurring disorders, including methamphetamines, opioid use disorders, alcohol, and a lot of psychosis and acute depression, acute safety concerns, those types of things.

Mark Mullen: Gotcha. And so the, the way that you kinda came onto my radar [00:02:00] was we were discussing these acute patients at the ACLP conference in November, and you led a workshop on kind of emerging models for treatment of substance use disorder and how to help people when they're in these sort of crises, these really acute settings.

And I was kinda blown away by your creative approach to teaching motivational interviewing because I have learned motivational interviewing a few times throughout my training, and it always seemed a little dry, a little acronym-heavy. And then hearing you talk about it, you had a much more creative way of explaining it, so I'm looking forward to diving into it.

As context, who is motivational interviewing for? Like, for our listeners, what types of patients should they be thinking about? What types of problems should make them put on their motivational interviewing hat? 

Allison Hadley, MD: Well, in our service, we really try to focus on evidence-based treatment for psychiatric disorders and substance use disorders.

And one of the important parts of treating substance use disorders in the evidence-based world is motivational [00:03:00] interviewing. There's really good data about using motivational interviewing to help patients struggling with substance use disorders. So that's a great time to think about it. But the way I think about it in terms of the context of my practice is really more broad.

I love the ideas of motivational interviewing and how they connect with trauma-informed care and harm reduction, and I try to keep that lens on for all our patients, right? When we're approaching with curiosity, with compassion, with a real seeking of understanding of patients' goals and trying to meet them where they are, I really find that it's a great thing to keep in mind for any patient.

I also try to use those principles in my parenting and managing my team of providers at our hospital. So I really love coming from that lens broadly. 

Mark Mullen: So sort of any time you're having a conversation where you're hoping to work collaborative- collaboratively with someone toward a certain goal, right?

[00:04:00] Like maybe developmentally with children or trying to navigate professional relationships in terms of achieving some sort of goal for our work team or our patients. And then in terms of specific psychiatric problems, you mentioned that it's highly evidence-based for substance use disorders.

I would say when I was thinking about kind of what to put in our substance use disorders PowerPoint for the clerkship that I run, motivational interviewing was the first thing that I thought of. I feel like you can't really get anywhere else until you understand the foundational principles of motivational interviewing.

And then anything that requires a behavioral change, it sounds like this would be super important. 

Allison Hadley, MD: Yeah, absolutely. 

Mark Mullen: How does motivational interviewing work? Like, what makes motivational interviewing different from taking a history or, like, standard interviewing practices? 

Allison Hadley, MD: So I think when you're taking a history, you can apply some of the principles of motivational interviewing, right?

You're coming with curiosity, you're coming with a desire for [00:05:00] connection. but rather than just pulling for information, you're approaching with those attitudes and you're really trying to come from a place of being non-judgmental and allowing people to feel like they're okay and that you affirm them.

That's a really important part of motivational interviewing. And then you're trying to listen very attentively to the history for areas of ambivalence or sh- we call it, like, change talk, where people are open to changing their behaviors or expressing some dissatisfaction with the way things are, and being super attuned to hearing those things and then pulling those threads forward to help people move towards their goals.

Mark Mullen: It sounds like it's really important in motivational interviewing to be conscious that the person you're speaking with does not feel like a subject that is being interrogated so much as a partner that you're hoping to kind of learn more about and explore with. 

Allison Hadley, MD: Yes. And I think one of our [00:06:00] like buzzwords in motivational interviewing is connection, not correction.

So you're really attempting to connect with the patient rather than say, "Oh, you're using this drug. Don't do that." That's not helpful. It's about, okay, who is-- who are you as a person? What are your values? What are your goals? What motivates you? I hear that. I hear how you want to move forward, and then I'm speaking to that.

Mark Mullen: You mentioned that motivational interviewing jives with trauma-informed care and that you sort of see these as a very similar approach. Could you delineate that for me a little more? You know, what are the similarities between motivational interviewing and trauma-informed care? What's the relationship between those two things?

Allison Hadley, MD: Yeah. So I think like when we think about trauma-informed care, we have principles of collaboration similar to motivational interviewing. We have a really a focus on autonomy and personal choice for the patient and transparency and letting people know what to expect is, really important. And so I think approaching with a [00:07:00] nonjudgmental attitude, focusing on connection, focusing on autonomy, those are both very connected in trauma-informed care and motivational interviewing.

Mark Mullen: Gotcha. it's founded in respect for your patient that they sort of know themselves better than you could and that they're in charge of their life. And so we don't get to tell them what to do. We can only sort of connect with them and try to show them the evidence that we have, and then it's kind of up to them to, do what they want with it and that's their right and that's how it should be.

Allison Hadley, MD: Yes. Absolutely. 

Mark Mullen: Okay. So the big-- the sort of flashing red light in my brain that made me decide, "Okay, I have to have this person on Psychiatry Boot Camp," was somehow you connected Tina Fey to motivational interviewing. So I would say a very exciting topic to a topic that at times, is a little bit dry.

And I'm a big Tina Fey fan. Fun fact, actually, when I was an undergrad, I read her memoir, Bossy Pants, because the girl that I had a crush on, who I'm now married to, was a big Tina Fey fan and was reading her memoir. And so I thought, "This is so lame of me," but I, thought, [00:08:00] "I'll, read this and try to kinda get insights into her head."

And I actually loved Bossy Pants and sort of since then have been a big Tina Fey fan myself. So what does Tina Fey have to teach us about motivational interviewing? 

Allison Hadley, MD: Well, I think I was thinking about Tina Fey's rules of improv, and I was noticing that it is quite similar to some of the techniques you wanna bring to motivational interviewing.

And I also am a huge fan of Tina Fey. She's a total hero of mine, and it made me like really excited about the topic in a new way. Sometimes when you get heavy into the acronyms of motivational interviewing, there's a lot of, it's this and it's this and it's this and putting patients into a box. And- Improv and the rules of improv are all about following your partner where they're going and bringing something to the picture, and it's not anything about putting it in a box.

You're free from a box. You can create whatever you want with your scene [00:09:00] partner/patient. So, okay, are you ready? Rules of improv. 

Mark Mullen: Let's do it. 

Allison Hadley, MD: Okay. Tina, these are Tina Fey's rules of improv from her book Bossy Pants. Okay, number one: you have to agree. You wanna start with a yes. So you're starting from an open-minded place, you're approaching with cognitive flexibility, and you're showing respect for what your partner has created.

You're showing up where they are, okay? So let's-- Do you wanna do an example? Sure. Okay. So let's use an example of, a patient who is struggling with methamphetamine use and maybe some, paranoid thoughts. So they might open with a statement like, "I have to use methamphetamine to stay up at night because I need to be alert to protect my safety and the people around me."

Now, how do we say yes to that? We don't have to say yes to every part of it, but we can say yes to the part that we connect [00:10:00] to, and we can join the person in their reality. So we would maybe could say, "Yeah, your safety is so important, and it sounds like you really need to feel safe at night." And that brings us to rule number two: add something.

It's the and, yes, and of improv, right? So you want to bring something to the conversation. You want to add something of your own. Tina Fey says, "Your initiations are worthwhile." So yes, you need to be alert at night because you wanna feel safe, and that must be really hard if you don't have safe housing.

Bringing something to the table where you're trying to figure out how we can intervene somewhere to help you feel more safe. 

Mark Mullen: I like that because I think, the yes and the and could sometimes be seen as, "Oh, great. This is my opportunity now to teach the patient," and you actually kind of flipped that script a little bit and said, [00:11:00] "Let me just bring something organic to the conversation that's actually-- It's not manipulative.

It's on the same topic, and I'm, actually-- My and is I'm further agreeing with the patient." It's ye- It's almost yes, yes. I love that. 

Allison Hadley, MD: Yes, and I'm bringing something to the table. I'm gonna try to take the conversation in a way that maybe there's an intervention. Then rule number three: make statements.

Don't just ask questions. So you wanna be a part of the solution. In improv, you might be like We're on a horse riding through the desert. Why are we in the desert? And it puts all the emphasis-- you know, the onus of solution or moving the scene forward onto the, your scene partner, and you wanna, like, contribute something as well.

So with motivational interviewing, we are asking questions in the history-gathering part about being curious about the patient needs. But in the next section, we're trying to connect to the person on, like, what the next steps are. So making statements like, "Maybe we could [00:12:00] help you find a safe housing option.

Would that be a good first step?" And then rule number four: there's no mistakes, only opportunities. So this connects great with therapy, right? We're like, it's grist for the mill. We're going to use this to-- time to process our relationship or talk about the process. maybe the patient in this scenario says, "No.

What? I don't need housing. I need to stay alert to protect all my friends that are-- I'm in the world with, and I don't even want to go into housing. I wanna be with my community and protect them." And then we have a clear place to go from there, right? Oh, sounds like community is really important to you.

Yes, your community is so important to you. How does that show up for you? What does that mean to you What-- how can we make your community feel more safe? So I love the idea that there's no mistakes. And we just keep trying to repair and connect and keep going. 

Mark Mullen: Keep rolling with it. One of the [00:13:00] things that strikes me hearing you compare improv rules to motivational interviewing principles is it's also the same in evidence-based verbal de-escalation practices for treatment of agitation, which I'm sure is something that you are often doing and seeing in the psychiatric emergency room, right?

One of the principles is find something to agree on. And you're saying that's the first step in motivational interviewing and, as it happens, improv. The first step is yes. And you also made the distinction that you're not necessarily, you know, if a patient says, "Well, I have to use methamphetamine because I have to stay awake at night and I have to be vigilant," you can agree with them without agreeing with the step-- the fact that they have to do methamphetamine, right?

You can agree with them in principle that it's very difficult to be surviving in that environment and that, it can be unsafe and that their safety is important. So starting motivational interviewing is looking for creative ways to agree with people to build that therapeutic alliance. 

Allison Hadley, MD: Yes, [00:14:00] absolutely.

And I think the other piece of it that's really important is using affirmations and finding a place to put those in authentically and genuinely is another part of that. So yes, your safety is very important. It's so smart that you thought of that. Your community is really important to you. It sounds like you're a really good friend.

Like, e- just any simple things where-- that you can harness the strengths of the patient and notice them and comment on them is a really important part of it and really is easy to find, I think, when you're in that yes and mindset. 

Mark Mullen: Do you ever find that it's difficult to come up with an affirmation for a patient who's maybe experiencing particularly difficult circumstances or who has been behaving in a repeated way that makes it very difficult to feel like you can help?

Allison Hadley, MD: We have a lot of folks that return. And, sometimes it's easy to [00:15:00] get frustrated with people that are, like you said, repeating the same behaviors and then complaining about the results. And I often tell my s- team and the patients, like, "This is what we are here for. We're so glad you keep coming in. We're so glad you keep trying.

I see you trying. I see you coming in and trying to get better." So I, don't find it too hard to find something a- affirming to say when I'm keeping in, this mindset. I think when I-- we work in the ED, it's really fast-paced, it's high acuity. It's sort of easy to get into this like, "Take a Zyprexa, we'll talk to you tomorrow."

Like, this is happening, this is what happens next. The answer is obvious. The answer is clear. And that-- when I start finding my brain doing that, I'm like, "Okay, take a minute." It doesn't take any longer to say, "Yeah, you really need to feel safe. How can that, look? How can we help you be there?

How could that look for you? How do you wanna get there?" 

Mark Mullen: Feel free to answer this with one [00:16:00] word. Is there a limit to the amount of times that you would engage in motivational interviewing or engage in trying to agree with the patient before you would take a more directive approach? 

Allison Hadley, MD: Well, s- sometimes There are acute safety things happening that are gonna trump, your ability to have a, good conversation, and then it might be like- 

Mark Mullen: Sure

Allison Hadley, MD: "Take a Zyprexa and we'll talk more tomorrow." 

Mark Mullen: Right, limit setting. Sure. 

Allison Hadley, MD: Yeah. And I think that goes to probably, you know, some of those pieces that are the stages of change that are in classic motivational interviewing training, where you might be like, "Okay, we're, in a place of pre-contemplation, and that's okay.

This is what motivational interviewing's all about." it helps you get less frustrated because you're like, "Well, this is where we are. We know what to do. We're gonna provide support, provide information, try to connect." And we can do that at [00:17:00] any place along the patient's journey. 

Mark Mullen: Yeah, I think where that, that question comes from is our residents work four weeks of nights in the psychiatric emergency department in St.

Louis in a row, and I feel like there's a resident before that month and a resident after that month in terms of sort of like burnout and overall hope for change and patterns of behaviors. And I think when you're seeing the same people frequently who have the same problems, it can be really easy to sort of give in to this, "Well, I've hit my limit.

Well, I've tried." But I also feel like it's our sacred responsibility as psychiatrists that we don't really have a limit there in terms of like, our patience with our patients. sometimes people are on different timelines. And I think the other side of it is what's the alternative, right? Like, are we just gonna say, "Well, you need to do this now and I'm not gonna help you if you don't," because that is the opposite of evidence-based.

It's not gonna work. It's not gonna help anyone. And I actually think it's pretty antithetical to what it means to be a physician. So I feel like taking this yes [00:18:00] and approach and saying, "Wherever you're at, I'm gonna meet you there. I'm gonna find something that we can agree on to build a relationship, and then we're gonna be standing from the same vantage point and sort of looking out together."

But I do think there's a sort of temptation in psychiatry, especially in high acuity settings with high volume, to allow our patients to run out, and I just didn't know if you had any tips there. 

Allison Hadley, MD: That's another thing that I love about this improv lens because it allows you to keep your compassion and your empathy going because you're always trying to join with the patient, and then you're there with them and you can feel what they're feeling and it-- at least partially.

And it also for me is more fun and joyful and that helps me just s-stay in it. Like this is the process, this is the, journey, and we're on it together. It really reminds me of parenting too, right? Like you can never be like, "Well, I'm done with this. You didn't do what I said, and [00:19:00] I'm out." Like you gotta keep showing up And you gotta keep yes-anding with the kids 

Mark Mullen: Yeah.

I'm not there yet. My, child can't speak yet, but I could imagine. And I think there's, endless parallels between, I would say parenting and psychiatry. the chief parallel is sort of behavioral change and growth, and so there's gonna be parallels in the approach as well. You did mention affirmations.

And we have some plans to get into some acronyms after the break. I wanna jump into this one now because I feel like OARS, O-A-R-S, is probably the most common acronym that I see when motivational interviewing is being talked about. And you did mention the affirmations. Could you walk us through this O-A-R-S acronym?

Allison Hadley, MD: Yes. So this is-- I'm not good at remembering acronyms. I'm gonna look at my paper. But this is just the basics of how to behind motivational interviewing. So the O of OARS is open-ended questions. The A is affirmations The R is [00:20:00] reflections and the S is summaries. So, okay, what I'm hearing is I'm skip-- You guys know how to do open-ended questions, so I'm gonna skip to the affirmations.

What I'm hearing is you really need to feel safe. I think that's really great. Your safety is important, and I appreciate that you are focused on that. Where that's also a reflection. You can reflect and affirm in the same sentence. And then so what I'm hearing is you feel like you need to be alert at night, but this isn't working the way you're doing it.

It sounds like, you know, these paranoid thoughts are getting really strong, and you came in to get help with that. So it sounds like part of this isn't working. Like, which part is not working for you? So you're summarizing, you're reflecting, you're checking in. Does that sound right? Did I get that right?

Lots of little check-ins. 

Mark Mullen: I bet I painted a picture of what the opposite of this OARS mnemonic would be, right? So we start with open-ended questions. And we, are-- we should be pretty good at those as psychiatrists. But I also think especially when we get in a hurry, it can be really tempting to [00:21:00] think about our documentation and kind of what we're about to go write and to jump right into a yes or no approach, like a, "Well, do you have this symptom?

Well, do you have this symptom?" Especially for our medical students and for our learners, I think there is a real temptation to avoid open-ended questions. So going through a checklist with the patient, sitting down and getting out your PHQ-9 and treating an interview that way would be sort of the opposite of this foundational motivational interviewing piece.

Allison Hadley, MD: Yes. And I think, like, what I, teach the medical students too is, like, you're following their story. You're asking clarifying questions, but you're following their story and what they're saying. And then at the end, you can run back and pick up a few checklist items if you, need them. But if you're following them, you often will find you get a lot of what you need.

Mark Mullen: Follow the patient is probably the single most common piece of advice that I give out as well, so I'm glad we're on the same page there. For affirmations, I think it would be very easy for a patient to describe a challenging situation and to feel like, as the doctor wearing the white coat, it's your job to be the expert and to explain to them [00:22:00] what they could do or what services are available to them to sort of correct this pattern of behavior.

But in motivational interviewing, we're making a conscious choice to find an affirmation for the patient. And a lot of times I think that affirmation can be as simple as This person is sitting here and talking to a mental health professional right now because they care about themselves and they want to make some change.

So I feel like with affirmations, they don't necessarily need to be terribly detailed and high level. I mean, they certainly can be, but there's often a lot of affirmations that just by-- You know, patients have a choice typically with whether or not to be in the emergency department or not. And then if they are in the emergency department sort of against their will, then they have a choice on how they're going to act when they're there.

And so usually you can find something about their situation that is affirmable, I would say. 

Allison Hadley, MD: Absolutely. Yeah. You're here, you're talking to me. This is a great step. Thank you for talking to me. 

Mark Mullen: Reflections, I would say generally pretty self-explanatory, [00:23:00] although a common mistake that I'll see learners make is kind of skipping this step, right?

Like they know how to do it, but instead of having a conversation where they're catching the ball before they throw it, they are just kind of throwing the next ball. I think, again, usually because of system constraints. 

Allison Hadley, MD: Yes. And I think it can feel a little like pedantic or simplifying, like just reflecting back to the patient.

And I think-- But when you're on the other side and hearing it back and you're like, "Okay, they're hearing me. I hear that," like it actually is received pretty well to be heard. And, then, you know, is do I have that right, I think, or something just to make sure that you under- they understand why you're reflecting.

Mark Mullen: I feel that too. And I feel like since we are openly talking about how similar it is to practice psychiatry and be a functional member of a family unit, I'm always amazed when I'm on the receiving end of a reflection. Even though I know it's just a reflection of what I just said, [00:24:00] it really does penetrate.

Like it really does feel like, okay, I, matter. What I said was sort of heard and is being dealt with, and I'm not wasting my time in talking to someone that doesn't care about me. So I agree. I think it's-- I think reflections are incredibly simplistic, but also just wildly effective. 

Allison Hadley, MD: Yeah. I feel the same.

When I'm on the receiving end of one, I feel like, "Oh, okay. You heard me. That's cool." 

Mark Mullen: For summaries in motivational interviewing, when you're summarizing in motivational interviewing, is this at all different from the summarizing that you would do in like a general psychiatric interview? 

Allison Hadley, MD: Well, for me, if I-- when I'm summarizing, I'm often li- have been listening attentively for that change talk, and then I'm summarizing with an emphasis on the change talk and an emphasis on harnessing any ambivalence that the patient has expressed.

Mark Mullen: Beautiful. So change talk is where we're headed and we're gonna get into change talk and ambivalence right after this break. Stay with us.[00:25:00] 

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All right, welcome back. So we're talking about change talk, Dr. Hadley. How would you describe what change talk is? If the goal is to pursue change talk, what are we really looking for? 

Allison Hadley, MD: So we're looking for and listening for words like I have to do it this way, but, or I want to, or [00:28:00] I could. Things where you're hearing words that tell you, okay, there's some ambivalence here, or there's some desire for something different.

And patients will often drop these little pieces in and they will say something like, "I really need to drink every night to calm my nerves before bed 'cause I work so hard. I work all day," but it really is causing me to gain a lot of weight. But I know that my sleep would be more restorative if I didn't drink every night.

And then so when we're hearing those little pieces of but, then we can go back and say, "So I'm hearing that there's part of you that really feels like this is a tool you need, and then there's part of you that feels like there's some downsides. And what do you think [00:29:00] those downsides are and how do you wanna conceptualize addressing them?"

And so then you're trying to help people move towards the strengths-based pieces of what they're saying. So if they're saying, "I have the ability to make this change, I have the ability or the desire to make a little step," then you can talk about what could that little step be. 

Mark Mullen: So when we're sort of summarizing back to the patient, we are focusing on their kind of hang-ups, what their concerns might be about that behavior.

is that fair? 

Allison Hadley, MD: Yes. And the other thing I like to listen for in change talk, is something that is another concept of mo- of improv, which is when you're making choices in improv, you wanna take the part that's the most emotionally salient, the part that moves the relationship forward or has an emotional context to [00:30:00] it.

So if, I'm listening to the patient and they say, "I really want to work on my relation-- I feel so sad that this is getting in between me and my wife," or, "I feel upset that my kids won't talk to me anymore because of this," then we're kind of talking about, okay, there's an emotional piece there. Let's follow that.

Like, it sounds like that's a really painful thing that's happening for you. Can we talk more about that? I'm hearing that this is hurting your relationships or your sense of yourself. Can we talk about that? So I think that prioritizing the relationship and the emotional pieces of what the patient is saying can help us really harness the motivation and the change desires.

Mark Mullen: Yeah, I think this is another area where this actually is a little bit different than just data gathering. This gets into-- This is actually a principle of supportive psychotherapy, of finding the emotion and focusing and sitting with the emotion. So after you hear a patient's story or you hear a patient sort of talking about their relationship with substance use, I think would be [00:31:00] the most pertinent example for MI, focusing on when they bring up their feelings or when they bring up their values or things that really matter to them, not fleeing from that and not doing what is often more comfortable, I think, especially for early trainees, which is sort of dryly summarizing, but actually digging into whatever they say that is emotionally charged and saying, "This is actually right where I wanna be.

This is where I wanna sit for a little while," because in having this emotional experience, it helps us maybe to get a little bit more buy-in into how important this is for me. 

Allison Hadley, MD: Yes, and I think that's the time when we're gonna be able to dig into both things that are really gonna be motivating for change and also things that create a lot of stigma and shame that prevent change.

And acknowledging those, doing your affirmations around the desire for change, and approaching it with [00:32:00] no judgment and destigmatizing language, I think, is so important for helping people to move through that. 

Mark Mullen: All right, so let's talk about that movement, moving through that, that move forward in terms of where I've been and maybe where the patient wants to go.

And I'll add maybe the patient isn't ready yet, and so maybe there needs to be multiple motivational interviewing encounters while we kind of assess the patient's readiness for change and where they're at. In terms of moving forward, we have these sort of well-described stages of change that are, I would say, shelf exam gold for any third-year medical student.

Or especially as a resident, I feel like this came out, yes, in terms of conceptualizing the patient, but also in terms of documentation, like to be able to communicate where this patient is in their relationship with a specific behavior. Could you walk us through these stages of change? 

Allison Hadley, MD: Yes. So I learned these in medical school, and I'm sure as did we all, and the stages of change are [00:33:00] boring and Artificial.

And I think in real life, people are moving back and forth through these stages, like in real time, day to day, moment to moment. But they're a very helpful concept, I agree, that just to know in the background and know that human beings are not gonna fit perfectly into them. The first is pre-contemplation.

This is, I haven't even thought about changing my behavior, but I'm here because there's a con-- there's something happening that it's not working well. Contemplation, I know this is an issue, and I'm thinking about maybe wanting to make some changes. I'm contemplating. Preparation is I'm getting ready to make a change, and I'm making a plan.

Action is making the change. And then there's maintenance, which is sustaining change. And sometimes people put like return to use or return to the behavior in there as well, as certainly that is a part of the journey for many people that are struggling with substance [00:34:00] use disorders and other behaviors that they wanna change.

So I think when we're thinking about a patient who is in a pre-contemplation pl-place, it's good to know, right? So they're maybe getting many touch points. If you're working in an emergency room, they may come to the emergency room many times, or they may stay a few days, and you can check in and try to see where they're at, at-- during the stay.

And when folks are in the pre-contemplation and contemplation phase, we use a lot of this ask, tell, ask method. So this means you ask the patient, "Hey, can I give you a little bit of information about," let's say harm reduction, "about, how Zyprexa might help you when you're starting to feel like you haven't slept in a while and you're feeling kinda nervous and scared?

can I give you some information about some evidence-based treatments that could be available to you?" And if the patient's not ready to hear it, they can say, "No, thanks. I'm good." But if they're like, "Okay, go ahead," then you can provide a brief [00:35:00] piece of information or education, and then that's the tell part, and then a l-- ask again, "How did that land for you?

What do you think of that? What are your thoughts?" And so you're just kind of using this ask, tell, ask throughout the period of working with the patient towards making a change towards the next phase in the stage of change. So trying to help people go from maybe pre-contemplation to like, "Oh, these are some interesting ideas.

Let me think about it. Maybe I am able to Keep some Zyprexa with me when I'm out and about, or maybe I would love to have some Narcan with me for me and my colleagues. Or maybe I would like to know about ways I can use less. 

Mark Mullen: I actually did learn about these sort of-- I don't know what, you're calling them, safety kits or rescue packs of the Zyprexa that you're using in the Pacific Northwest.

Allison Hadley, MD: Yes, we call them meth assist packs. 

Mark Mullen: Meth assist packs. I learned about this in the ACLP presentation, and I'm talking about it all the [00:36:00] time, so it's interesting that you're using that example. I love this concept. 

Allison Hadley, MD: Yeah. It's like a hygiene kit and some Zyprexa, and it's some information about going to, some places where we have contingency management-type treatments available in the community, peer support phone number, and we're just like, yeah, handing out these little packets to folks when they're leaving the hospital.

It's a cool harm reduction tool. 

Mark Mullen: Yeah. Giving out Narcan, I feel like, became very nationally kind of accepted and widely done. And so this is a similar harm reduction approach toward meth of choosing safety and love and meeting people where they're at and giving them something that works. I think it's super novel.

So in thinking about ask, tell, ask, this again gets into mechanisms of motivational interviewing. So yes, we have the spirit of motivational interviewing, right? We wanna connect with the patient, we wanna have partnership, we wanna have compassion. But then I've often felt after, like, a motivational interviewing lecture, okay, so then what do I actually do, right?

How do I practice it? So we have [00:37:00] our OARS mnemonic that we talked about, the open-ended questions, the affirmations, the reflections and the summaries. Some of that is standard psychiatric interviewing. Some of it's a little tailored for MI. But then a big one is this ask, tell, ask. I like that it's courteous.

I like that it's treating psychoeducation as an intervention with the patient, right? Just like any other intervention, you wanna make sure that the patient is open to this, and this is actually what they want, right? If they didn't come to the hospital for advice, and they don't want to get into a conversation about psychoeducation, then we're kind of assessing their readiness for that before we dive into it.

Although almost always the answer is, "I'm in the hospital. I wanna know what you think." And so the, "Can I share some information with you?" Usually, you're gonna get a yes from that. And then I think you're right-sizing the tell, right? So you're not immediately diving into the ventral tegmental area and the nucleus accumbens and, you know, cycles of reward and return to use.

you're kinda bite sizing it because you've now gotten to know [00:38:00] your patient well enough to know what they are ready to hear and what might be helpful for them. Like, so in the case of someone who is recurrently using methamphetamine and recurrently coming to the ED, what they might be ready to hear is, "Here's this pack for you, and here's what's in it.

And, I think this would be helpful for you." And then you are reassessing where they're at and seeing where you're going to follow them next as you hopefully start to move through these stages of change. 

Allison Hadley, MD: Yes, exactly 

Mark Mullen: So you're using motivational interviewing in the psychiatric emergency department.

What percent of visits do you think that you're using motivational interviewing in the psych ED? 

Allison Hadley, MD: I think I try to come with compassion, curiosity, and connection in every case. Where you're using the actual, like, ask-tell-ask and providing a bite size of education and checking in with the patient, that might be half the patients.

Mark Mullen: Yeah. So you're trying to lead with the spirit of MI in 100%, but sometimes the patient, let's say [00:39:00] they're acutely psychotic, you might not really be diving into the mechanisms. That's, fair enough. Do you think-- where do you think it belongs in our healthcare system? Do you feel like motivational interviewing is sort of solely belongs in acute care settings or more appropriately belongs in ambulatory settings, et cetera?

Allison Hadley, MD: Oh, I think it's really useful tool in every setting because it's so flexible to meet the patient where they're at and help them with their goals. That's appropriate in every care setting. 

Mark Mullen: Okay, Dr. Hadley, so every little bit counts. So let's do-- let's kinda end here with an example for our listeners about how we're going to employ some of these techniques in real-world practice, and I'm gonna do my very best to be a common patient presentation for you and be realistic with my, portrayal of a standardized patient.

Allison Hadley, MD: Okay. 

Mark Mullen: So I walk into your emergency department and my chief complaint, you know, what kinda gets handed off to you from the staff, let's say it is-- let's say it's panic attacks. that's why you're seeing me [00:40:00] in the ED. 

Allison Hadley, MD: Okay. Hi, Mark. I'm Dr. Hadley. I hear you're having some trouble with anxiety. You wanna tell me a little bit about what's going on?

Mark Mullen: Yeah, I just can't seem to get it under control. I feel like I've had anxiety for a little while, but lately I've been getting more chest pain and sweating episodes. And usually I just smoke a little weed and it goes away, but lately not even that's helping. 

Allison Hadley, MD: Okay, so I'm hearing that your anxiety's been really, tough and strong lately, and that You, used to use cannabis to help with the symptoms, but lately that hasn't been working very well.

Can you say more about what your experience is when you are trying to use the cannabis? 

Mark Mullen: Yeah, I mean, I, feel like for a long time, I would get a little kind of wound up at, work or, you know, in other situations and I would find that, like, just a little bit of THC really took the edge off for me.

But lately what I've been finding is that I'm just so anxious that, like, even when I do that, or it might even be making it worse. It just feels like the one thing that [00:41:00] always worked for me isn't working anymore, and, maybe even making me a little paranoid too. 

Allison Hadley, MD: Okay. Well, I think it's really great that you're here and that you kind of recognize this.

It sounds like you're really self-aware, and I'm so glad that you're here. I wonder about how the cannabis is making you feel a little paranoid. Do you think that could be something that has-- was a tool that worked and now isn't working as well? 

Mark Mullen: I mean, that's what it seems like, but I don't, I just don't see why.

I feel like it's something that I've been using for a decade now, if not longer, and, I, don't think I've changed. So I-- it, it's possible. 

Allison Hadley, MD: Yeah. Okay. Well, can I talk to you a little-- give you a little bit of information about cannabis and anxiety? 

Mark Mullen: Sure, if you think it'll help. 

Allison Hadley, MD: Okay. Well, you know, we know that as we get tolerance and get more used to cannabis, sometimes we'll use stronger strains or [00:42:00] more, and sometimes that can affect our brain differently.

And there's parts of cannabis that do make- People have some paranoid thoughts and sometimes some hallucinations. And so the part that's helping is sometimes also causing some things that aren't as great for our mental health because it's such a complicated molecule and hits so many different receptors.

It's sometimes hard to predict how it will affect our brain. is that something that you've heard, or how does that sound? 

Mark Mullen: Yeah, that, that seems right. I definitely have seen the THC concentration kind of skyrocketing at the dispensary lately. 

Allison Hadley, MD: Yeah. So I'm wondering if you're feeling like there'd be-- if it'd be good to explore, different ideas about h- managing your anxiety.

Mark Mullen: Yeah, I mean, I'd like to, but I also feel like it's really important in my relationship, like my significant other and I, it's something that we do together and, like, it's definitely, like, my top way of sort of de-stressing and dealing with life. And so, [00:43:00] I mean, I hear what you're saying, doc, but, I also think it's just so important to so many other areas of my life that I would really rather you just be able to treat my anxiety.

Allison Hadley, MD: Yeah. So I'm hearing that it's a really important part of your social life, your connection with your spouse or your partner, and, an important part of, like, your time to relax. 

Mark Mullen: For sure. 

Allison Hadley, MD: Yeah. And it sounds like your relationship with your partner is, really important to you. And do you feel like there's other ways that you and your partner connect, or is this, like, the most important way?

Mark Mullen: I mean, I think there are other ways, but usually it's kind of a both/and situation. 

Allison Hadley, MD: Yeah. And- What would it look like if you changed your behavior? 

Mark Mullen: well, I just worry that my partner would think that I was lame or not wanna hang out with me anymore, and I worry that, like, I would be more stressed because I don't have it.

Allison Hadley, MD: Yeah. So it sounds like there's a... It's, scary to think about not [00:44:00] having that tool. 

Mark Mullen: For sure. 

Allison Hadley, MD: Yeah. And it sounds like right now you don't, you haven't explored maybe other tools that could be available, and that's kind of why you're here. It's really great that you're thinking about that. 

Mark Mullen: Yeah, that's right.

Allison Hadley, MD: Yeah. Okay. It sounds like right now you're feeling like this is a really important part of your life, and you'd like to explore some other ways to manage your anxiety in addition to cannabis. Is that accurate? 

Mark Mullen: Yeah, I mean, I just gotta get this anxiety under control. 

Allison Hadley, MD: Okay. Well, let's start there. Let's talk about your anxiety.

Mark Mullen: Okay. I think, Finn, I am very impressed by, I think there were times where it would be very easy to be directive and kind of risk losing the patient. But it feels like now putting my shrink hat back on, that you kind of assessed where I was as a patient and what I was and wasn't ready to discuss, and made some strategic decisions accordingly.

Allison Hadley, MD: Yeah. I think I was trying to align with your goals, which it [00:45:00] sounded like were to maintain the connection with your partner and to have, some other tools to start using for your anxiety, and that may eventually lead to cutting down on cannabis use. But your main goal you came in with was to address your anxiety.

And so I tried to kind of stick with you in that goal, as well as trying to provide some information about cannabis use and anxiety to try to just open that door a little bit. 

Mark Mullen: I think the key here is connection too because this is my emergency department encounter, right? And so in theory, this is the first time I've ever reached out and thought, "I'm going to take the risk of trusting a professional and actually talking about this."

And if I come in and the professional says, "Why are you doing what you're doing? Don't you know this is bad for you?" I would think that you really are running the risk of kind of, you know, as the patient, I might feel like I burned and like, "Well, I knew I couldn't trust these people anyway, and I figured they would just tell me that.

And so this is exactly what I expected." 

Allison Hadley, MD: [00:46:00] Yeah. If we come in saying, "Well, stop using the weed, and then we can talk. Come back 30 days clean, and we'll see what we can do," you're gonna be like, "Pfft. No, thanks" Never come back. Yeah 

Mark Mullen: Exactly. I think that makes perfect sense. Dr. Hadley, before we wrap up, did you have any final thoughts for our audience?

Allison Hadley, MD: Well, I just want to leave your audience with, "Yes, and..." This is a beautiful way to live life. Be open to new experiences. Start with yes, start with aligning with the person that's in front of you, and I think it's a wonderful way to live your life and be open to new experiences. 

Mark Mullen: Yes, and it has been a pleasure to have you on Psychiatry Boot Camp, and I am looking forward to seeing you the next time.

Allison Hadley, MD: Thanks so much, Dr. Mullen.

Mark Mullen: Thank you so much for listening to this episode of Psychiatry Boot Camp. You can connect with us on Instagram or TikTok @psychbootcamp. You can email me directly, [00:47:00] mark@psychiatrybootcamp.com. You can also connect with the rest of the Human Content Podcast family on Instagram and TikTok @humancontentpods. If you enjoyed the show, we'd love to know what you think.

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Thanks again for listening. I'm your host, Mark Mullin. Executive producers are Aron Korney, Rob Goldman, Shahnti Brooke, and me, Mark Mullin. Our editor and engineer is Jason Portizo. Theme music is by one of my favorite bands, Cave Radio, who generously donated our theme music. Other music is by Omer Ben-Zvi.

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