Conversation with Matt Tierney Part 2
Motivational Interviewing and Working with Families
Matt Tierney is a Nurse Practitioner who holds a Master of Science degree in Nursing from UCSF. He directs two opiate replacement treatment programs that are part of San Francisco General Hospital’s Department of Psychiatry in the Divisionof Substance Abuse and Addiction Medicine. he is the former director of San Francisco General Hospital’s Addiction Medicine Consultation and Treatment Service. Matt is clinical faculty at the UCSF School of Nursing, and is a member of the Motivational Interviewing Network of Trainers (MINT), the American Psychiatric Nurses Association (APNA), and the Association for Medical Education and Research in Substance Abuse (AMERSA), He also has a consulting practice that focuses on addiction treatment needs, education and training in Motivational Interviewing, and topics related to co-occurring disorders.
Q: Dr. Forster
M: Matt Tierney
PART 2 MOTIVATIONAL INTERVIEWING AND WORKING WITH FAMILIES
Q: We also talked a lot about motivational interviewing. That is sort of the model most often used when talking to family members. During motivational interviewing, there are questions like, “What stage is this person at?” or “What is the next step here?” Can you describe a little bit how to use motivational interviewing, how you would talk about that with a family member, or use it yourself with a patient?
M: I think the starting point is always ambivalence and how certain behaviors match up –or don’t match up–with a person’s values. If ambivalence isn’t there, then there is no real evidence that motivational interviewing will work. How it works from a clinical standpoint is to first find where a patient is and where the ambivalence stems from. It is important to promote “change language,” that is, the words someone is using that indicate they are thinking about change. Motivational interviewing is not meant to be coercive in any way, but it is meant to acknowledge that change happens in the patient’s own time.
Q: If the individual goes back a step; for example, a situation where someone is completely unwillling to consider taking medications for an out of control psychosis or a drinking problem, what do you do if a family member is an adult at great risk but has no ambivalence? What do you tell the family about what they should or should not do in that situation.
M: Motivational interviewing is not always appropriate. There are ethical dilemmas: the behaviorally out of control or psychotic drug user, or the real and present danger of a DUI. You don’t want to wait for change in those situations. You have to say as a family, “We can’t do this anymore.” Sometimes that is the most ethical thing to do. However, there are times when a gentler approach may be more appropriate. For example, the clinician may ask to check in with the patient once in a while and explain that medication is part of what they do with patients. Families can also “check in” as well. The first stage of motivational interviewing is engaging the patient. But when the approach is really confrontational, the natural human response is to fight back. The model for motivational interviewing should be like dancing rather than wrestling: a fluid, harmonic interaction between two people rather than a combative one.
Q: What are your thoughts regarding enabling? Is someone that doesn’t want to throw out an alcoholic inadvertantly supporting the alcoholic’s behavior? They want to see the alcoholic make changes, but are concerned they are enabling and exacerbating the problem by not being hard enough on the individual.
M: That’s so tricky. There are a million definitons of “enabling”. In order to detect the difference between beneficence (the best thing for the family) versus actually creating a harmful situation, each situation has to be looked at carefully. Are family members taking care of themselves as well? Is more good being done than harm? These are the hard questions that need to be answered, and they are often situation-dependent.
Q: A woman was very depressed and had both a severe alcohol and drug use problem. Her family had been working with an accountant and decided to cut her off in the event of another relapse. The woman did relapse, and because she knew what her family was going to do, she ended up hanging herself because she felt she had no support from her family. I think about that story and wonder if there is a way of avoiding that kind of scenario or if that is an inevitable consequence of this terrible illness.
M: I think so much of recovery is involved in these real stories. The big book of AA is a collection of true stories that gives us an understanding of how complex addiction is, both for addicts and for the families who care about them. The story you recounted shows the complexity of the relationship between addicts and their families. In the situation you just described, an outsider, the accountant in this case, said, “This is what you need to do.” The result of this was a tragic outcome for both the addict and the family. In this case, I think the addict’s need for support from her family was not being acknowledged.
Q: The importance of support in an addict’s recovery can definitely be overlooked. In a randomized experiment, a group of addicts all participated in the same recovery process. The only difference was that half the group was randomly selected to receive a personalized letter each month. The study revealed an immense difference in terms of recovery. Often, families are told they can vary the amount of their involvement in the recovery process, but it is a really big step to say, “I’m not going to have any more involvement.” Recovery is a marathon; not a sprint. If the family is getting exhausted with the addict’s behavior, then it is advisable for the family to slowly pull a way rather than to completely cut ties. It is a big thing to say, “We’ll have no more part of this. We want nothing to do with you.” This can actually be enough to drive an addict over the edge.
M: First, I believe addiction is a medical illness. One of my suggestions for families of people struggling with addiction is to replace the word addiction with another health condition like diabetes. Instead of saying, “My daughter is an addict,” try saying, “My daughter has diabetes. She keeps eating cake and not taking her insulin. She’s not taking care of herself, and I don’t know how to help her.” What are you going to do? This word switch offers a new perspective on addiction as an illness. Instead of cutting ties, maybe say, “This a ‘no soda’ household.” Now apply your response to the problem using the word addiction. Now, maybe say, “No alcohol in the house,” or “This is a ‘no intoxication’ household, and if you are in this house while intoxicated, you will have to find some other place to sleep.” This difference in perspective helps people get a handle on how they want to respond to the problem. You have to ask as a family, “What are our limits?” Once you establish these limits, you need to make them very clear. You also need to ask: how we we combine those limits with support for our addicted loved one? I also think a lot about this: everyone who suffers from addiction suffers from guilt and shame. Guilt is when you feel badly about something you do, and shame is when you feel badly about who you are. When dealing with individuals suffering from addiction, before taking action, ask yourself, “Will my interaction help, or will it make them feel even worse about themselves?”
Q: One other aspect of addiction that has really come to the forefront in my thinking is lying. I would love your impression about it. I’ve been thinking in many ways that a lot of what is bad about addiction is lying. The things that destroy relationships and that are most horrible are tied up with lying.
M: I’ll read from the big book: “Men and women drink essentially because they like the effect produced by alcohol. The sensation is so elusive that while they admit it is injurious, they cannot after a time differentiate the true from the false. To them, their alcoholic life seems like the only normal one.” Whenever I think about lying and addiction, I go back to the medical illness of addiction. I recall that every drug of addiction activates the rush of the neurochemical dopamine through the limbic system in our brains. The dopamine rush in the limbic system is a fascinating design of Mother Nature intended to help sustain life. Water, food, and sex activate it. What happens with drug addiciton is that an unnaturally large surge of dopamine activates the limbic system. The brain gets a message from the drug that “this is important,” and that you need to keep doing this to sustain life. So, if the brain gets the message thta to drink alcohol or use cocaine means surviving, then you are going to do anything to support that; even lie. Lying in addiction has to be seen in that context: where the addict’s brain believes the drug is essential to sustain life.
Q: There is great importance of working with families to use motivational techniques in order to uncover truth to avoid inadvertantly rewarding lying. How do you get an individual to take a look at the whole picture of what are the benefits and disadvantages of addiction? Often, addicts distract themselves from seeing disadvantages. Motivational interviewing is saying, “Let’s just look at these things to understand the negative effects of the addiction.” A lot of advice is bad in regards to if an individual has a lapse, then they should be kicked out from homes or help centers.I think most people will have a lapse, and kicking someone out in response to the mistake is encouraging most people to lie.
M: Good point. It takes most people several attempts and lapses before recovery and exit from addiction occurs. For cigarette smokers, it is socially acceptable to say, “I tried quitting 5 times, but the 6th time was when it took.” However, we do not yet have that attitude with other drugs of abuse. I think it has to do with addicts being historically vilified. The symptoms of addiction are behavioral: people don’t act like themselves. The problem of addiction cannot be fixed just by telling someone to change his or her behavior. The issue is much deeper and more complex that that. Let’s look at another example: sedentary lifestyle and poor eating habits are behaviors that can lead to type 2 diabetes, but you would never say to a diabetic, “You have this one chance for a cure, but after that if you haven’t licked it, forget it: no more insulin for you!” Instead, you would more likely say, “Let’s look at this again and try a different approach. What is hard about addressing this problem? Where do you need the most support?” If you know an addict is “lying” or masking behaviors in hopes of getting a more positive and supportive response, the helping person or family member might consider shifting the way they address the addict in need; rather than drawing a line in the sand once a relapse or binge has occurred, they might consider a preventive course: how can the next lapse be prevented? Also, the family should always take an honest look and assess whether the addicted loved one needs more help than the family alone can offer.
Q: What are your thoughts on a family’s response to a family member just returning from residential treatment?
M: Families that see an addicted loved one in residential treatment for 30, 60, or 90 days might believe that when the individual returns, they will be cured. It is much easier to be clean and sober when everyone around you is doing the same and you get support 24 hours a day. When you get discharged to home and have the stress of work, kids, and marriage, it is suddenly much harder to resist the temptation of relapse. I think it is important for families and addicts to understand that it is a great challenge and requires work to master living a sober life in the real world, outside of the treatment facility.