Community Aid to WSS

Before reading further, it is necessary that you first read our statement of nonconsent to communism in general and all similarly femicidally-aligned nations. 

We are not doing this out of a low comprehension the-boss-said-to-hate-it hate/fear of communism. 

We are doing this because of an extensive history of terrorist managers, anti-truth erasure of inconvenient justices in Soviet and communist history, and actually fact-based suffering-based criticism against communism. 

Though things like libraries do not see enough people voluntarily donating to support them, we believe the crippling effects of these terroristic management behaviors that leaves everyone dependent waiting for "the other guy" to do it are to blame. This is exactly why we want to see the end of it.

Community Aid to WSS

 Thanking, Sharing, and Publishing

With the permission of the author, the following community aid from SAMHSA is hereby published.

"Good morning Alexandria,

Thank you for pointing out the need for more explicit practitioner guidance for unengaged and nonresponsive clients. The TIP 35 (Enhancing Motivation for Change in Substance Use Disorder Treatment) guidelines provide instructions for practitioners based on Motivational Interviewing (MI) and the Transtheoretical Model of Change (Stages of Change). The TIP 35 discusses how these approaches can be utilized with “resistant” patients, defining resistance as a sign of lack of motivation, the presence of patient ambivalence, or a direct response to the provider’s approach in the moment (page 8 and page 40).

In MI, when a patient is non-responsive or disengaged in a conversation with a provider, this is one form of resistance, also referred to as “discord”.  This type of resistance is a direct response to the interpersonal relationship and the means of communication between the provider and the patient. For example, when a patient feels the conversation is misaligned with their own priorities/needs, if they are feeling demeaned or judged, or otherwise feeling misunderstood, they may respond with discord. Discord can manifest in a conversation as direct defensiveness or conflict, but more commonly appears as passive participation in the conversation or unresponsiveness. The worst-case scenario when met with passive discord/resistance is to argue for change, demand responses, problem-solve on behalf of the patient, or overtly persuade the patient with information, education, or suggestions/recommendations without their buy-in. When discord/resistance occurs, it is a signal to the practitioner to change their approach and respond differently to the patient. In response, MI best practice suggests a method called “rolling with resistance”. These are strategies that can be utilized with all types of resistance, including lack of responsiveness, some tactics to consider include:

1. Avoid direct argumentation and acknowledge the resistance process. If you find yourself at a standstill in the conversation, redirect.

Example: “I can see this isn’t something you’re wanting to talk about right now, what do you think would be most useful for us to cover in our time together today?”

2. Identify a shared target behavior or goal for the conversation, ensure the topic is a priority for the patient.
   Example: “I know I have some topics I’d like to discuss today related to your treatment plan, but what are YOUR priorities for your treatment plan right now?”

3. Assess for importance, confidence, and/or readiness. Resistance (even passive resistance) can be a sign that the conversation has moved into territory the patient is not prepared for and more exploration might reveal why the patient is feeling stuck and/or elicit more discussion of positive change.

Example: Use the “MI Scales”- handout attached.

4. Emphasize personal choice and control.

Example: “It’s up to you”, “It is your choice”

5. Emphasize self-efficacy and strengths. Sometimes a patient is unresponsive due to low confidence or fear of failing. By offering affirmations or pointing out ways in which the client has achieved positive change in the past, they may be more empowered.

Example: “You have shown a lot of resilience continuing to show up even when it’s hard.”

Motivational Interviewing is a complex skill set and requires a lot of practice to achieve clinical fidelity. While TIP 35 does outline the key MI principles focusing on a therapeutic rapport through displays of empathy, support for patient autonomy, and the importance of eliciting a patient’s own insights, there are other resources available for training and continued skill-building. One resource you might utilize is the book “Motivational Interviewing: Helping People Change” written by the founders of MI, Steven Rollnick and William Miller. You may also find additional training opportunities and online resources on the official Motivational Interviewing website: motivationalinterviewing.org. We have also included a few helpful handouts- the first is a “pocket guide” with prompts for asking open-ended questions and offering reflections. The second is a handout with instructions on how to effectively use the importance and confidence scales to elicit change talk from even a “stuck” patient. Lastly, we have included a handout that outlines the principles of “rolling with resistance” in concise language that me be helpful when instructing your staff.

We hope these resources have generated useful ideas for you and may help to guide future training around working with even the most resistant patients. Remember, people are most likely to change their behavior when they feel cared for, supported, and understood. Thank you for your efforts in developing a well-prepared addiction workforce!

Sincerely,

The CBHSQ Request Team"