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‘Flakka’: A low-cost, dangerous high
Use of α-pyrrolidinovalerophenone (α-PVP), a psychostimulant related to cathinone derivatives (“bath salts”), has been reported in the United States, especially in Florida.1 Known by the street names “flakka” or “gravel,” α-PVP is inexpensive, with a single dose (typically 100 mg) costing as little as $5.2 Alpha-PVP can be consumed via ingestion, injection, insufflation, or inhalation in vaporized forms, such as E-cigarettes, which deliver the drug quickly into the bloodstream and can make it easy to overdose.1 The low cost of this drug makes it likely to be abused. Here we review the mechanism of action and effects of α-PVP and summarize treatment options.
Mechanism of action
Alpha-PVP is a structural parent of 3,4-methylenedioxypyrovalerone (MDPV)—the first widely abused synthetic cathinone.3 Much like cocaine, α-PVP stimulates the CNS by acting as a potent dopamine and norepinephrine reuptake inhibitor. However, unlike cocaine, it lacks any action on serotonin transporters. The pyrrolidine ring in MDPV and α-PVP is responsible for the highly potent dopamine reuptake inhibitor action of these agents.3
A wide range of adverse effects
Use of α-PVP results in a state of “excited delirium,” with symptoms such as hyperthermia, hallucinations, paranoia, violent aggression, and self-harm.1 Alpha-PVP is known to cause rhabdomyolysis.4 Some studies have reported cardiovascular effects, such as arterial hypertension, palpitations, dyspnea, vasoconstriction, arrhythmia, myocardial infarction (MI), and myocarditis.5 Alpha-PVP also may result in neurologic symptoms, including headache, mydriasis, lightheadedness, paresthesia, seizures, dystonic movements, tremor, amnesia, dysgeusia, cerebral edema, motor automatisms, muscle spasm, nystagmus, parkinsonism, and stroke.5 Death may occur by cardiac arrest, renal damage, or suicide.
Case reports. The effects of α-PVP have been documented in the literature:
- A 17-year-old girl was brought to an emergency department in Florida with acute onset of bizarre behavior, agitation, and altered mental status. It took 6 days and repeated administrations of olanzapine and lorazepam for the patient to become calm, alert, and oriented.2
- ST-elevated MI with several intracardiac thrombi was reported in a 41-year-old woman who used α-PVP.4
- In 2015, 18 deaths related to α-PVP use were reported in South Florida.5
- Deaths related to α-PVP use also have been reported in Japan and Australia.5
Treatment options
There are no treatment guidelines for α-PVP-related psychiatric symptoms. Case reports describe remission of symptoms following aggressive treatment with antipsychotics and benzodiazepines.2 Guidelines for treatment of stimulant-induced behavioral and psychotic symptoms6 may be considered for patients who have used α-PVP.
Reassurance and supportive care are the basic principles of such interventions. A quiet environment and benzodiazepines may provide relief of agitation. Antipsychotics may be helpful if a patient exhibits psychotic symptoms.
Similar drugs may emerge
In 2014, the DEA classified α-PVP as a Schedule I substance. Laws against the import of such substances via the Internet or other means also may help control the spread of this drug. However, chemically similar drugs that may elude drug screens are continually emerging. The lack of evidence-based guidelines on recognizing and managing intoxication, withdrawal, and long-term effects of α-PVP and other “designer drugs” calls for greater research in this emerging area of substance use disorders.
1. National Institute on Drug Abuse. “Flakka” (alpha-PVP). https://www.drugabuse.gov/emerging-trends/flakka-alpha-pvp. Accessed July 26, 2017.
2. Crespi C. Flakka-induced prolonged psychosis. Case Rep Psychiatry. 2016;2016:3460849. doi: 10.1155/2016/3460849.
3. Glennon RA, Young R. Neurobiology of 3,4-methylenedioxypyrovalerone (MDPV) and α-pyrrolidinovalerophenone (α-PVP). Brain Res Bull. 2016;126(pt 1):111-126.
4. Cherry SV, Rodriguez YF. Synthetic stimulant reaching epidemic proportions: flakka-induced ST-elevation myocardial infarction with intracardiac thrombi. J Cardiothorac Vasc Anesth. 2017;31(1):e13-e14.
5. Katselou M, Papoutsis I, Nikolaou P, et al. α-PVP (“flakka”): a new synthetic cathinone invades the drug arena. Forensic Toxicol. 2016;34(1):41-50.
6. Sadock BJ, Sadock VA, Ruiz P. Hallucinogen-related disorders. In: Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry. 11th ed. Philadelphia, PA: Wolters Kluwer; 2015:648-655.
Use of α-pyrrolidinovalerophenone (α-PVP), a psychostimulant related to cathinone derivatives (“bath salts”), has been reported in the United States, especially in Florida.1 Known by the street names “flakka” or “gravel,” α-PVP is inexpensive, with a single dose (typically 100 mg) costing as little as $5.2 Alpha-PVP can be consumed via ingestion, injection, insufflation, or inhalation in vaporized forms, such as E-cigarettes, which deliver the drug quickly into the bloodstream and can make it easy to overdose.1 The low cost of this drug makes it likely to be abused. Here we review the mechanism of action and effects of α-PVP and summarize treatment options.
Mechanism of action
Alpha-PVP is a structural parent of 3,4-methylenedioxypyrovalerone (MDPV)—the first widely abused synthetic cathinone.3 Much like cocaine, α-PVP stimulates the CNS by acting as a potent dopamine and norepinephrine reuptake inhibitor. However, unlike cocaine, it lacks any action on serotonin transporters. The pyrrolidine ring in MDPV and α-PVP is responsible for the highly potent dopamine reuptake inhibitor action of these agents.3
A wide range of adverse effects
Use of α-PVP results in a state of “excited delirium,” with symptoms such as hyperthermia, hallucinations, paranoia, violent aggression, and self-harm.1 Alpha-PVP is known to cause rhabdomyolysis.4 Some studies have reported cardiovascular effects, such as arterial hypertension, palpitations, dyspnea, vasoconstriction, arrhythmia, myocardial infarction (MI), and myocarditis.5 Alpha-PVP also may result in neurologic symptoms, including headache, mydriasis, lightheadedness, paresthesia, seizures, dystonic movements, tremor, amnesia, dysgeusia, cerebral edema, motor automatisms, muscle spasm, nystagmus, parkinsonism, and stroke.5 Death may occur by cardiac arrest, renal damage, or suicide.
Case reports. The effects of α-PVP have been documented in the literature:
- A 17-year-old girl was brought to an emergency department in Florida with acute onset of bizarre behavior, agitation, and altered mental status. It took 6 days and repeated administrations of olanzapine and lorazepam for the patient to become calm, alert, and oriented.2
- ST-elevated MI with several intracardiac thrombi was reported in a 41-year-old woman who used α-PVP.4
- In 2015, 18 deaths related to α-PVP use were reported in South Florida.5
- Deaths related to α-PVP use also have been reported in Japan and Australia.5
Treatment options
There are no treatment guidelines for α-PVP-related psychiatric symptoms. Case reports describe remission of symptoms following aggressive treatment with antipsychotics and benzodiazepines.2 Guidelines for treatment of stimulant-induced behavioral and psychotic symptoms6 may be considered for patients who have used α-PVP.
Reassurance and supportive care are the basic principles of such interventions. A quiet environment and benzodiazepines may provide relief of agitation. Antipsychotics may be helpful if a patient exhibits psychotic symptoms.
Similar drugs may emerge
In 2014, the DEA classified α-PVP as a Schedule I substance. Laws against the import of such substances via the Internet or other means also may help control the spread of this drug. However, chemically similar drugs that may elude drug screens are continually emerging. The lack of evidence-based guidelines on recognizing and managing intoxication, withdrawal, and long-term effects of α-PVP and other “designer drugs” calls for greater research in this emerging area of substance use disorders.
Use of α-pyrrolidinovalerophenone (α-PVP), a psychostimulant related to cathinone derivatives (“bath salts”), has been reported in the United States, especially in Florida.1 Known by the street names “flakka” or “gravel,” α-PVP is inexpensive, with a single dose (typically 100 mg) costing as little as $5.2 Alpha-PVP can be consumed via ingestion, injection, insufflation, or inhalation in vaporized forms, such as E-cigarettes, which deliver the drug quickly into the bloodstream and can make it easy to overdose.1 The low cost of this drug makes it likely to be abused. Here we review the mechanism of action and effects of α-PVP and summarize treatment options.
Mechanism of action
Alpha-PVP is a structural parent of 3,4-methylenedioxypyrovalerone (MDPV)—the first widely abused synthetic cathinone.3 Much like cocaine, α-PVP stimulates the CNS by acting as a potent dopamine and norepinephrine reuptake inhibitor. However, unlike cocaine, it lacks any action on serotonin transporters. The pyrrolidine ring in MDPV and α-PVP is responsible for the highly potent dopamine reuptake inhibitor action of these agents.3
A wide range of adverse effects
Use of α-PVP results in a state of “excited delirium,” with symptoms such as hyperthermia, hallucinations, paranoia, violent aggression, and self-harm.1 Alpha-PVP is known to cause rhabdomyolysis.4 Some studies have reported cardiovascular effects, such as arterial hypertension, palpitations, dyspnea, vasoconstriction, arrhythmia, myocardial infarction (MI), and myocarditis.5 Alpha-PVP also may result in neurologic symptoms, including headache, mydriasis, lightheadedness, paresthesia, seizures, dystonic movements, tremor, amnesia, dysgeusia, cerebral edema, motor automatisms, muscle spasm, nystagmus, parkinsonism, and stroke.5 Death may occur by cardiac arrest, renal damage, or suicide.
Case reports. The effects of α-PVP have been documented in the literature:
- A 17-year-old girl was brought to an emergency department in Florida with acute onset of bizarre behavior, agitation, and altered mental status. It took 6 days and repeated administrations of olanzapine and lorazepam for the patient to become calm, alert, and oriented.2
- ST-elevated MI with several intracardiac thrombi was reported in a 41-year-old woman who used α-PVP.4
- In 2015, 18 deaths related to α-PVP use were reported in South Florida.5
- Deaths related to α-PVP use also have been reported in Japan and Australia.5
Treatment options
There are no treatment guidelines for α-PVP-related psychiatric symptoms. Case reports describe remission of symptoms following aggressive treatment with antipsychotics and benzodiazepines.2 Guidelines for treatment of stimulant-induced behavioral and psychotic symptoms6 may be considered for patients who have used α-PVP.
Reassurance and supportive care are the basic principles of such interventions. A quiet environment and benzodiazepines may provide relief of agitation. Antipsychotics may be helpful if a patient exhibits psychotic symptoms.
Similar drugs may emerge
In 2014, the DEA classified α-PVP as a Schedule I substance. Laws against the import of such substances via the Internet or other means also may help control the spread of this drug. However, chemically similar drugs that may elude drug screens are continually emerging. The lack of evidence-based guidelines on recognizing and managing intoxication, withdrawal, and long-term effects of α-PVP and other “designer drugs” calls for greater research in this emerging area of substance use disorders.
1. National Institute on Drug Abuse. “Flakka” (alpha-PVP). https://www.drugabuse.gov/emerging-trends/flakka-alpha-pvp. Accessed July 26, 2017.
2. Crespi C. Flakka-induced prolonged psychosis. Case Rep Psychiatry. 2016;2016:3460849. doi: 10.1155/2016/3460849.
3. Glennon RA, Young R. Neurobiology of 3,4-methylenedioxypyrovalerone (MDPV) and α-pyrrolidinovalerophenone (α-PVP). Brain Res Bull. 2016;126(pt 1):111-126.
4. Cherry SV, Rodriguez YF. Synthetic stimulant reaching epidemic proportions: flakka-induced ST-elevation myocardial infarction with intracardiac thrombi. J Cardiothorac Vasc Anesth. 2017;31(1):e13-e14.
5. Katselou M, Papoutsis I, Nikolaou P, et al. α-PVP (“flakka”): a new synthetic cathinone invades the drug arena. Forensic Toxicol. 2016;34(1):41-50.
6. Sadock BJ, Sadock VA, Ruiz P. Hallucinogen-related disorders. In: Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry. 11th ed. Philadelphia, PA: Wolters Kluwer; 2015:648-655.
1. National Institute on Drug Abuse. “Flakka” (alpha-PVP). https://www.drugabuse.gov/emerging-trends/flakka-alpha-pvp. Accessed July 26, 2017.
2. Crespi C. Flakka-induced prolonged psychosis. Case Rep Psychiatry. 2016;2016:3460849. doi: 10.1155/2016/3460849.
3. Glennon RA, Young R. Neurobiology of 3,4-methylenedioxypyrovalerone (MDPV) and α-pyrrolidinovalerophenone (α-PVP). Brain Res Bull. 2016;126(pt 1):111-126.
4. Cherry SV, Rodriguez YF. Synthetic stimulant reaching epidemic proportions: flakka-induced ST-elevation myocardial infarction with intracardiac thrombi. J Cardiothorac Vasc Anesth. 2017;31(1):e13-e14.
5. Katselou M, Papoutsis I, Nikolaou P, et al. α-PVP (“flakka”): a new synthetic cathinone invades the drug arena. Forensic Toxicol. 2016;34(1):41-50.
6. Sadock BJ, Sadock VA, Ruiz P. Hallucinogen-related disorders. In: Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry. 11th ed. Philadelphia, PA: Wolters Kluwer; 2015:648-655.
Familiarizing yourself with Alcoholics Anonymous dictums
From “90 minutes in 90 days,” to “people, places, and things,” to “cucumbers and pickles,” Alcoholics Anonymous (AA) slogans have been influencing the public’s understanding of the addictive process for almost a century. Regrettably, these terms have, inadvertently, alienated the scientific community. The translation and subsequent use of AA slogans has been a valuable tool in engaging science experts with mutual-help fellowships such as AA.
Recent advances in the neurobiology and neurochemistry of addiction have validated several of the memorable sayings of AA.1 As a result, physicians and scientists are now more willing to explore AA’s mottos.
Here are five well-known AA slogans that we have translated into medical terms and then briefly assessed in terms of their validity and relevance in today’s treatment of alcohol addiction:
1. “90 meetings in 90 days”
TRUE! Clinically, the first three months of sobriety constitute the most severe part of prolonged withdrawal syndrome and pose the most dangerous opportunities for a relapse.
2. “Keep it simple”
NOT TRUE! Clinical research and everyday practice of addiction treatment show that combination approaches—with medications, group psychotherapy, individual psychotherapy, involvement in mutual-help groups, family therapy, primary care, and treatment of psychiatric comorbidities—typically result in better outcomes than singular approaches.2
3. “Denial is not just a river in Egypt”
NOT TRUE! Since motivational inter-viewing was introduced in the treatment of addiction, we have learned how to effectively work with patients who are in complete denial and have absolutely no interest in changing anything about their life.3
4. “Beware of people, places, and things”
TRUE! Otherwise known as “cues” in psychology literature, triggers of relapse have been implicated in both the basic understanding of the addictive process and its treatment. “Classical conditioning” and “operant conditioning” models of behavior incorporate triggers. Additionally, cognitive behavior therapy helps extensively with maintaining sobriety. Even the DSM-5 gives a nod to “people, places, and things” by introducing “cravings” as a bona fide criterion of a substance use disorder.
5. “A cucumber that has become a pickle cannot become a cucumber again”
EQUIVOCAL. It is not clear, and highly debatable, whether an alcoholic who has been sober for more than 20 years still has a heightened vulnerability to reverting to alcoholism after consumption of alcohol. What is evident is that, even if the neuroadaptations responsible for hijacking the pleasure-reward pathways of the brain one day return to a normal, pre-addiction state, this healing process takes a long time—probably measured in decades, not years.
Click here for another Pearl on alternatives to 12-step groups.
Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Volkow ND, Baler RD. Addiction science: Uncovering neurobiological complexity. Neuropharmacology. 2013; (13)217-7.
2. Nunes EV, Selzer J, Levounis P, et al. Substance dependence and co-occurring psychiatric disorders: Best practices for diagnosis and clinical treatment. New York, NY: Civic Research Institute, 2010.
3. Levounis, P, Arnaout B. Handbook of motivation and change: A practical guide for clinicians. Arlington, VA: American Psychiatric Publishing, Inc.; 2010.
From “90 minutes in 90 days,” to “people, places, and things,” to “cucumbers and pickles,” Alcoholics Anonymous (AA) slogans have been influencing the public’s understanding of the addictive process for almost a century. Regrettably, these terms have, inadvertently, alienated the scientific community. The translation and subsequent use of AA slogans has been a valuable tool in engaging science experts with mutual-help fellowships such as AA.
Recent advances in the neurobiology and neurochemistry of addiction have validated several of the memorable sayings of AA.1 As a result, physicians and scientists are now more willing to explore AA’s mottos.
Here are five well-known AA slogans that we have translated into medical terms and then briefly assessed in terms of their validity and relevance in today’s treatment of alcohol addiction:
1. “90 meetings in 90 days”
TRUE! Clinically, the first three months of sobriety constitute the most severe part of prolonged withdrawal syndrome and pose the most dangerous opportunities for a relapse.
2. “Keep it simple”
NOT TRUE! Clinical research and everyday practice of addiction treatment show that combination approaches—with medications, group psychotherapy, individual psychotherapy, involvement in mutual-help groups, family therapy, primary care, and treatment of psychiatric comorbidities—typically result in better outcomes than singular approaches.2
3. “Denial is not just a river in Egypt”
NOT TRUE! Since motivational inter-viewing was introduced in the treatment of addiction, we have learned how to effectively work with patients who are in complete denial and have absolutely no interest in changing anything about their life.3
4. “Beware of people, places, and things”
TRUE! Otherwise known as “cues” in psychology literature, triggers of relapse have been implicated in both the basic understanding of the addictive process and its treatment. “Classical conditioning” and “operant conditioning” models of behavior incorporate triggers. Additionally, cognitive behavior therapy helps extensively with maintaining sobriety. Even the DSM-5 gives a nod to “people, places, and things” by introducing “cravings” as a bona fide criterion of a substance use disorder.
5. “A cucumber that has become a pickle cannot become a cucumber again”
EQUIVOCAL. It is not clear, and highly debatable, whether an alcoholic who has been sober for more than 20 years still has a heightened vulnerability to reverting to alcoholism after consumption of alcohol. What is evident is that, even if the neuroadaptations responsible for hijacking the pleasure-reward pathways of the brain one day return to a normal, pre-addiction state, this healing process takes a long time—probably measured in decades, not years.
Click here for another Pearl on alternatives to 12-step groups.
Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
From “90 minutes in 90 days,” to “people, places, and things,” to “cucumbers and pickles,” Alcoholics Anonymous (AA) slogans have been influencing the public’s understanding of the addictive process for almost a century. Regrettably, these terms have, inadvertently, alienated the scientific community. The translation and subsequent use of AA slogans has been a valuable tool in engaging science experts with mutual-help fellowships such as AA.
Recent advances in the neurobiology and neurochemistry of addiction have validated several of the memorable sayings of AA.1 As a result, physicians and scientists are now more willing to explore AA’s mottos.
Here are five well-known AA slogans that we have translated into medical terms and then briefly assessed in terms of their validity and relevance in today’s treatment of alcohol addiction:
1. “90 meetings in 90 days”
TRUE! Clinically, the first three months of sobriety constitute the most severe part of prolonged withdrawal syndrome and pose the most dangerous opportunities for a relapse.
2. “Keep it simple”
NOT TRUE! Clinical research and everyday practice of addiction treatment show that combination approaches—with medications, group psychotherapy, individual psychotherapy, involvement in mutual-help groups, family therapy, primary care, and treatment of psychiatric comorbidities—typically result in better outcomes than singular approaches.2
3. “Denial is not just a river in Egypt”
NOT TRUE! Since motivational inter-viewing was introduced in the treatment of addiction, we have learned how to effectively work with patients who are in complete denial and have absolutely no interest in changing anything about their life.3
4. “Beware of people, places, and things”
TRUE! Otherwise known as “cues” in psychology literature, triggers of relapse have been implicated in both the basic understanding of the addictive process and its treatment. “Classical conditioning” and “operant conditioning” models of behavior incorporate triggers. Additionally, cognitive behavior therapy helps extensively with maintaining sobriety. Even the DSM-5 gives a nod to “people, places, and things” by introducing “cravings” as a bona fide criterion of a substance use disorder.
5. “A cucumber that has become a pickle cannot become a cucumber again”
EQUIVOCAL. It is not clear, and highly debatable, whether an alcoholic who has been sober for more than 20 years still has a heightened vulnerability to reverting to alcoholism after consumption of alcohol. What is evident is that, even if the neuroadaptations responsible for hijacking the pleasure-reward pathways of the brain one day return to a normal, pre-addiction state, this healing process takes a long time—probably measured in decades, not years.
Click here for another Pearl on alternatives to 12-step groups.
Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Volkow ND, Baler RD. Addiction science: Uncovering neurobiological complexity. Neuropharmacology. 2013; (13)217-7.
2. Nunes EV, Selzer J, Levounis P, et al. Substance dependence and co-occurring psychiatric disorders: Best practices for diagnosis and clinical treatment. New York, NY: Civic Research Institute, 2010.
3. Levounis, P, Arnaout B. Handbook of motivation and change: A practical guide for clinicians. Arlington, VA: American Psychiatric Publishing, Inc.; 2010.
1. Volkow ND, Baler RD. Addiction science: Uncovering neurobiological complexity. Neuropharmacology. 2013; (13)217-7.
2. Nunes EV, Selzer J, Levounis P, et al. Substance dependence and co-occurring psychiatric disorders: Best practices for diagnosis and clinical treatment. New York, NY: Civic Research Institute, 2010.
3. Levounis, P, Arnaout B. Handbook of motivation and change: A practical guide for clinicians. Arlington, VA: American Psychiatric Publishing, Inc.; 2010.
New edition can benefit psychiatrists in all settings
It has been more than a decade since Dr. William R. Miller and Dr. Stephen Rollnick unveiled the last edition of their bestselling book, "Motivational Interviewing: Helping People Change." In that time, more than 200 randomized clinical trials have been published, and the understanding and practice of motivational interviewing (MI) has continued to evolve.
MI is a collaborative conversation between a patient and clinician that addresses ambivalence about change through attention to the language of change. MI is designed to help patients mobilize their strength, commitment, and personal resources for transformation. In addition, MI embodies acceptance and compassion, and has been described as a "way of being" that can break down barriers and establish open lines of communication between patients, clinicians, and supervisors in a profound way.
This new edition of "Motivational Interviewing" (New York: The Guilford Press, 2012), provides clinicians with an updated guide to help understand and use the principles of MI. Specifically, clinicians are taught the four confluent processes of MI: engaging, focusing, evoking, and planning. They also are taught the five communication skills, which are open questioning, affirming, reflecting, summarizing, and informing. These principles are instrumental to fostering change and promoting integrity in the lives of patients.
The authors contend that MI is about "evoking that which is already present, not installing what is missing." The authors emphasize that MI is done "for" and "with" a person as opposed to "on someone." The book does a fine job of dispelling commonly held myths associated with MI as being "a panacea" or "a gimmicky technique."
Another common myth that has persisted since the first edition of "Motivational Interviewing" is that the patient-centered approach is a passive psychotherapy, during which the therapist never reveals her or his agenda, never disagrees with the patient, and—God forbid!—never gives advice. In fact, first and foremost, MI is a collaboration and, as such, sharing information and coming up with suggestions from both sides of the therapeutic dyad is welcome and encouraged.
This text is filled with exemplary phrases that psychiatrists can incorporate into their lexicons. The authors delineate the importance of using empathic reflections and garnering respect for a patient’s autonomy while eliciting the patient’s core values. Clinicians are encouraged to acknowledge autonomy and emphasize personal choice, even when patients directly ask the clinician what to do: "I could suggest some things that have worked for other people, but the most important thing is to find what will work for you, and you’re the best judge of that. Would you like to hear some ideas?" (p. 148). Clinicians are encouraged to provide patients with "a menu of options" and continually convey compassion, respect, and hope.
MI is compatible with evidence-based clinical skills and a variety of psychotherapy perspectives, including psychodynamic psychotherapy, cognitive-behavioral therapy, experiential therapy, and family systems theory. The book illustrates clinical case examples to prepare psychiatrists who work in all different types of settings. For example, clinicians will learn how to incorporate MI into the brief medicine management visit, and the standard intake interview and assessment. MI can increase a clinician’s capacity to tolerate uncertainty while potentially decreasing clinician burnout.
The authors underscore the importance of direct feedback, coaching, and observed practice to develop proficiency in MI. The process of developing MI skill is a lifelong endeavor. In sum, this is a user-friendly, engaging, and comprehensive text that should be required reading for all practicing clinicians.
Dr. Ascher is a senior resident in psychiatry at Beth Israel Medical Center, New York, and a member of the Motivational Interviewing Network of Trainers (MINT). Dr. Levounis is chair of the department of psychiatry at the New Jersey Medical School, Newark, and also the coauthor of the book "Handbook of Motivation and Change: A Practical Guide for Clinicians" (Washington: American Psychiatric Publishing Inc., 2010).
It has been more than a decade since Dr. William R. Miller and Dr. Stephen Rollnick unveiled the last edition of their bestselling book, "Motivational Interviewing: Helping People Change." In that time, more than 200 randomized clinical trials have been published, and the understanding and practice of motivational interviewing (MI) has continued to evolve.
MI is a collaborative conversation between a patient and clinician that addresses ambivalence about change through attention to the language of change. MI is designed to help patients mobilize their strength, commitment, and personal resources for transformation. In addition, MI embodies acceptance and compassion, and has been described as a "way of being" that can break down barriers and establish open lines of communication between patients, clinicians, and supervisors in a profound way.
This new edition of "Motivational Interviewing" (New York: The Guilford Press, 2012), provides clinicians with an updated guide to help understand and use the principles of MI. Specifically, clinicians are taught the four confluent processes of MI: engaging, focusing, evoking, and planning. They also are taught the five communication skills, which are open questioning, affirming, reflecting, summarizing, and informing. These principles are instrumental to fostering change and promoting integrity in the lives of patients.
The authors contend that MI is about "evoking that which is already present, not installing what is missing." The authors emphasize that MI is done "for" and "with" a person as opposed to "on someone." The book does a fine job of dispelling commonly held myths associated with MI as being "a panacea" or "a gimmicky technique."
Another common myth that has persisted since the first edition of "Motivational Interviewing" is that the patient-centered approach is a passive psychotherapy, during which the therapist never reveals her or his agenda, never disagrees with the patient, and—God forbid!—never gives advice. In fact, first and foremost, MI is a collaboration and, as such, sharing information and coming up with suggestions from both sides of the therapeutic dyad is welcome and encouraged.
This text is filled with exemplary phrases that psychiatrists can incorporate into their lexicons. The authors delineate the importance of using empathic reflections and garnering respect for a patient’s autonomy while eliciting the patient’s core values. Clinicians are encouraged to acknowledge autonomy and emphasize personal choice, even when patients directly ask the clinician what to do: "I could suggest some things that have worked for other people, but the most important thing is to find what will work for you, and you’re the best judge of that. Would you like to hear some ideas?" (p. 148). Clinicians are encouraged to provide patients with "a menu of options" and continually convey compassion, respect, and hope.
MI is compatible with evidence-based clinical skills and a variety of psychotherapy perspectives, including psychodynamic psychotherapy, cognitive-behavioral therapy, experiential therapy, and family systems theory. The book illustrates clinical case examples to prepare psychiatrists who work in all different types of settings. For example, clinicians will learn how to incorporate MI into the brief medicine management visit, and the standard intake interview and assessment. MI can increase a clinician’s capacity to tolerate uncertainty while potentially decreasing clinician burnout.
The authors underscore the importance of direct feedback, coaching, and observed practice to develop proficiency in MI. The process of developing MI skill is a lifelong endeavor. In sum, this is a user-friendly, engaging, and comprehensive text that should be required reading for all practicing clinicians.
Dr. Ascher is a senior resident in psychiatry at Beth Israel Medical Center, New York, and a member of the Motivational Interviewing Network of Trainers (MINT). Dr. Levounis is chair of the department of psychiatry at the New Jersey Medical School, Newark, and also the coauthor of the book "Handbook of Motivation and Change: A Practical Guide for Clinicians" (Washington: American Psychiatric Publishing Inc., 2010).
It has been more than a decade since Dr. William R. Miller and Dr. Stephen Rollnick unveiled the last edition of their bestselling book, "Motivational Interviewing: Helping People Change." In that time, more than 200 randomized clinical trials have been published, and the understanding and practice of motivational interviewing (MI) has continued to evolve.
MI is a collaborative conversation between a patient and clinician that addresses ambivalence about change through attention to the language of change. MI is designed to help patients mobilize their strength, commitment, and personal resources for transformation. In addition, MI embodies acceptance and compassion, and has been described as a "way of being" that can break down barriers and establish open lines of communication between patients, clinicians, and supervisors in a profound way.
This new edition of "Motivational Interviewing" (New York: The Guilford Press, 2012), provides clinicians with an updated guide to help understand and use the principles of MI. Specifically, clinicians are taught the four confluent processes of MI: engaging, focusing, evoking, and planning. They also are taught the five communication skills, which are open questioning, affirming, reflecting, summarizing, and informing. These principles are instrumental to fostering change and promoting integrity in the lives of patients.
The authors contend that MI is about "evoking that which is already present, not installing what is missing." The authors emphasize that MI is done "for" and "with" a person as opposed to "on someone." The book does a fine job of dispelling commonly held myths associated with MI as being "a panacea" or "a gimmicky technique."
Another common myth that has persisted since the first edition of "Motivational Interviewing" is that the patient-centered approach is a passive psychotherapy, during which the therapist never reveals her or his agenda, never disagrees with the patient, and—God forbid!—never gives advice. In fact, first and foremost, MI is a collaboration and, as such, sharing information and coming up with suggestions from both sides of the therapeutic dyad is welcome and encouraged.
This text is filled with exemplary phrases that psychiatrists can incorporate into their lexicons. The authors delineate the importance of using empathic reflections and garnering respect for a patient’s autonomy while eliciting the patient’s core values. Clinicians are encouraged to acknowledge autonomy and emphasize personal choice, even when patients directly ask the clinician what to do: "I could suggest some things that have worked for other people, but the most important thing is to find what will work for you, and you’re the best judge of that. Would you like to hear some ideas?" (p. 148). Clinicians are encouraged to provide patients with "a menu of options" and continually convey compassion, respect, and hope.
MI is compatible with evidence-based clinical skills and a variety of psychotherapy perspectives, including psychodynamic psychotherapy, cognitive-behavioral therapy, experiential therapy, and family systems theory. The book illustrates clinical case examples to prepare psychiatrists who work in all different types of settings. For example, clinicians will learn how to incorporate MI into the brief medicine management visit, and the standard intake interview and assessment. MI can increase a clinician’s capacity to tolerate uncertainty while potentially decreasing clinician burnout.
The authors underscore the importance of direct feedback, coaching, and observed practice to develop proficiency in MI. The process of developing MI skill is a lifelong endeavor. In sum, this is a user-friendly, engaging, and comprehensive text that should be required reading for all practicing clinicians.
Dr. Ascher is a senior resident in psychiatry at Beth Israel Medical Center, New York, and a member of the Motivational Interviewing Network of Trainers (MINT). Dr. Levounis is chair of the department of psychiatry at the New Jersey Medical School, Newark, and also the coauthor of the book "Handbook of Motivation and Change: A Practical Guide for Clinicians" (Washington: American Psychiatric Publishing Inc., 2010).
