Carla Marienfeld, MD
Professor of Psychiatry, University of California, San Diego. Director of the UCSD Addiction Psychiatry Fellowship, co-editor of Motivational Interviewing for Clinical Practice, and editor of Absolute Addiction Psychiatry Review.
Dr. Marienfeld has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CATR: Set the stage for us on how you approach psychotherapy in addiction treatment. Dr. Marienfeld: I look at every interaction as a potential psychotherapeutic opportunity, whether it is “supposed” to be for psychotherapy or not. There is no strict separation when it comes to somebody with a substance use disorder. To begin with, I approach each conversation with the “spirit of motivational interviewing,” a term coined by Bill Miller and Stephen Rollnick, the developers of motivational interviewing (MI). It describes the fundamental communication style inherent to an MI-consistent approach, and it colors every therapeutic interaction.
CATR: Can you explain the spirit of motivational interviewing? Dr. Marienfeld: Miller and Rollnick break it down into four components with the acronym PACE: Partnership, Acceptance, Compassion, and Evocation. The essence of the approach is that the best care happens when the patient is empowered to take advantage of their intrinsic strengths and resources. Rather than approaching the patient with the attitude, “I have the knowledge you need, and this appointment is about me imparting it to you,” MI says that the patient has a lot of self-knowledge, and as the provider, it is our job to partner with them to uncover that knowledge together. It can be a subtle but meaningful frame shift.
The Spirit of Motivational Interviewing
Partnership—work with or for a patient in order to provide treatment
Acceptance—appreciate each patient’s inherent strengths and vulnerabilities
Compassion—promote patient welfare and prioritize their needs
Evocation—find the knowledge patients have about themselves to change
CATR: Do you have advice about therapeutic approaches to patients during abbreviated medication management visits? Dr. Marienfeld: Thus far, we have conceptualized the provider’s role primarily as a prescriber and secondarily as someone who might do “add-on psychotherapy.” But for some patients, I flip that framework to conceptualize the psychiatrist as primarily providing psychotherapy with “add-on medication management.” Some patients undergo medication trials that are not particularly helpful, so visits primarily end up being for therapy. Alternatively, patients on a stable dose of buprenorphine may prefer to focus on therapy for co-occurring disorders.
CATR: What is a specific technique that can be utilized in brief medication management visits? Dr. Marienfeld: A 30-minute appointment is ample time to deploy psychotherapy techniques. I often use a cognitive behavioral therapy (CBT) technique called “the 3 C’s” or “Catch It, Check It, Change It” (see box at right). It is easy to run through examples in a relatively limited setting, and we can continue to revisit examples in subsequent visits. An advantage of the 3 C’s is that the catchy name is easily remembered, and with practice, it can be incorporated into everyday life.
The 3 C’s: Catch It, Check It, Change It
Step 1: Catch It
Identify a situation in which a negative experience might be influenced by a cognitive distortion
Step 2: Check It
Examine the cognitive distortion as objectively as possible
Step 3: Change It
Substitute the cognitive distortion with a more rational and less emotionally charged interpretation of events
CATR: Walk us through an example of using the 3 C’s. Dr. Marienfeld: A classic example is feeling guilty after a slip to drinking alcohol. “Catch It” is about identifying the situation and any cognitive distortion that might be leading to the feeling. One expression of that feeling might be, “I’ll never be able to stick with this!” “Check It” examines this statement for accuracy. The person might recognize that it is an overgeneralization or that it discounts the positive (two examples of cognitive distortions). Then, they can ask themselves if they’ve had any past successes that demonstrate they are capable of doing better. They might balance the reality of the slip with the recognition of the progress they had made beforehand. Then comes “Change It,” in which you can work with the patient to evoke other interpretations of events that are more rational and less emotionally charged. Finally, revisit the emotion and examine how the new cognition decreased the affect (in this case, guilt). This model can be used for many negative cognitions common in mood and anxiety disorders. “I will always be lonely,” “I will never be happy,” and “I’ll never be able to stay sober” are all examples to which the 3 C’s can be applied.
CATR: What are other psychotherapeutic techniques that our readers might find useful? Dr. Marienfeld: Behavioral activation, another technique with CBT grounding, is a go-to, especially when patients have comorbid depression. Many patients with substance use disorders have disrupted sleep, and sedative hypnotics such as benzodiazepines and Z-drugs can be addictive. I try to minimize prescribing these in patients with substance use disorders. Therefore, I do a fair amount of CBT for insomnia, a manualized, time-limited treatment. As the name suggests, it is grounded in cognitive and behavioral techniques, as well as psychoeducation. There are resources and manuals available online.
DARN CATS: Identifying Change Talk Desire: I want to make a change. Ability: I can change. Reason: I have a reason to change. Need: I need to change. Commitment: I will change. Activation: I am prepared to change. Talking Steps: I have taken specific steps toward change.
CATR: Your specific area of expertise is motivational interviewing. Can you provide our readers with specific MI tools they can use during brief appointments? Dr. Marienfeld: When meeting with patients, I always try to 1) build a positive therapeutic alliance, and 2) increase the likelihood that my patient will make positive choices. During encounters, I actively listen for statements that we can classify as “change talk.” The mnemonic to remember the types of statements that qualify as change talk is DARN CATS (see box at right). The opposite of “change talk” is called “sustain talk”; these are statements made against making a positive change, or in favor of maintaining a status quo. For example, a change talk statement is one in which a patient describes why they want to stop drinking, and a sustain talk statement is one in which a patient says why stopping drinking is so challenging. If I am hearing change talk, then I know to continue on the same track with that patient in a given session. If I am hearing sustain talk, then I go back to the basic MI skill: reflections.
CATR: Can you describe the concept of reflections? Dr. Marienfeld: A reflection is simply a statement, not a question, in which a provider essentially tries to capture what a patient has experienced or is expressing in their discourse. For example, if a patient describes being hospitalized for a detoxification, a reflective response might be, “You don’t ever want to experience that again.” Depending on the patient’s tone, an appropriate simple reflection of the patient’s feelings might be, “That hospitalization was really scary for you.” Finally, again depending on the patient, you might offer a complex reflection like, “Avoiding more hospitalizations like the one you just had is one of the reasons you would like to maintain sobriety going forward.” When used properly, reflections can be a great way to facilitate a natural flowing conversation that steers the patient toward change talk, which is exactly where we want the conversation to go.
CATR: Can’t this lead to stilted conversations? Dr. Marienfeld: As providers, we are very comfortable with directly questioning our patients, but if you think about the average conversation between friends or colleagues, these are not exchanges of sequential back-and-forth questioning. The typical flow of a conversation is the progression of alternating statements, each one containing a bit of a reflection and building upon what was previously said. When done well, a clinical encounter with a high frequency of reflections is a much more natural-sounding exchange than a typical doctor-patient interview; it helps facilitate a strong therapeutic alliance and is just as effective at gleaning useful information as direct questioning. Interested readers can familiarize themselves with some of the common simple and complex reflections (see box at right). Simple reflections are called “simple” because they do not add any meaning to the patient’s original statements, whereas complex reflections do just that. Ideally, providers should offer complex reflections whenever they can. I would suggest practicing these frequently; providers are often surprised by how easily they can be adapted into practice.
Continuation Reflection of feeling Double sided Amplification
CATR: Can you suggest another MI tool that would apply to caring for patients with opioid use disorder? Dr. Marienfeld: I use the “Ask-Tell-Ask” feedback model, also called the “Elicit-Provide-Elicit” model—another quick go-to therapeutic intervention for short encounters. This is especially useful to gauge a patient’s understanding of a diagnosis or intervention. In this model, you begin by asking a patient about their understanding of the proposed intervention (the first Ask). For example, if I am talking to a patient about the use of buprenorphine as a treatment for opioid use disorder, I might begin by simply asking, “What do you know about buprenorphine?” Once the patient answers, I would be able to establish what they already know and what deficits remain. I would then provide any missing or misunderstood information (the Tell), and end by requesting that the patient repeat back the information or describe what they think about what I’ve said (the second Ask) to ensure proper understanding. For instance, I might say, “Given the discussion we just had, could you tell me what you have learned about buprenorphine so I can make sure we are both on the same page?” I find this model especially useful for informed consent as it applies to medication management encounters.
CATR: Many providers refer patients to separate psychotherapy providers. Do you have any tips on how best to collaborate with these providers? Dr. Marienfeld: Get releases of information up front whenever possible; it is important to be informed if there are any significant status changes. It is useful to have a sense of the material being covered and the therapeutic modality being utilized. For example, I might be able to reinforce or build upon an ongoing CBT approach during a focused medication visit. Likewise, if a patient is undergoing cognitive processing therapy for PTSD, I might know that the patient could be experiencing heightened levels of anxiety. Keep in mind that the flow of information should go both ways. For example, as an addiction psychiatrist, I always try to keep other providers aware if a patient has returned to using substances or is not participating in treatment.
CATR: Do you have any specific resources to recommend? Dr. Marienfeld: I think the 3rd edition of Bill Miller and Stephen Rollnick’s book, Motivational Interviewing: Helping People Change, which came out in 2013 (New York: The Guilford Press), is a great resource. It is a textbook, but it’s very enjoyable to read and isn’t too dense. There is also a paper by Bill Miller and Terry Moyers called “Eight Stages in Learning Motivational Interviewing” that is a really nice read (Journal of Teaching in the Addictions 2006;5(1):3–17). It reviews both how to learn effective MI skills and how to build them into your practice. Finally, there are many shorter MI books, including one that I co-edited called Motivational Interviewing for Clinical Practice (Levounis P, Arnaout B, Marienfeld C, eds. Arlington, VA: American Psychiatric Association Publishing; 2017).