Antoni Gual Hospital Clínic de Barcelona Barcelona, Spain

Motivating patients with alcohol problems

Disclosures

FISS, Fondo de Investigación de la Seguridad Social; PND, Plan Nacional de Drogas; RTA, Red de Trastornos Adictivos.

Interest Name of organization

Grant Support Lundbeck, D&A Pharma, Teva.

Research Support FP7, SANCO, RTA, FISS, PND, DGJUST.

Honoraria and Consultancy Lundbeck, D&A Pharma, AbbVie.

Speakers Bureau No relevant conflicts of interest to declare

Scientific Advisory Board Lundbeck, D&A Pharma.

Disclosure statement regarding my presentation in the Progress in Mind: focus on alcohol use disorders symposium

Outline •  Ambivalence as a key concept •  What makes people change: exploring values •  Communication style •  Creating internal discrepancy •  Recognizing and reinforcing movements towards change •  The processes of motivation

Conversation is about change •  Conversations usually promote change •  Language is used to motivate changes in others •  In health settings, conversations are often used to

promote changes in order to improve the management of chronic conditions

Ambivalence as a key concept

http://www.youtube.com/watch?v=cgF1fzCqu-k.

Ambivalence as a key concept •  Richard Burton describes an important ambivalence

towards drinking, that leads to an internal fight (‘boxing’). Is this normal or pathological?

•  How would you rate this concept on a scale from 1 (normal) to 10 (pathological)?

A double clinical case When I woke up this morning I decided I would do some jogging just before dinner. I have good reasons to exercise. 8:00

I saw a 45-year-old man with alcohol problems at noon. He wanted to quit alcohol, starting from today. Usually he starts drinking right before dinner, with his friends in the pub.

12:00

I arrive home at dinner time, a bit later than expected. Even though I had decided to begin exercising today, I am quite hesitant about starting today or tomorrow, since it is a bit late and I’m tired and hungry.

At the very same time my patient is sitting in the pub, watching his friends drinking beer, and ambivalent about whether he should stop drinking today or tomorrow.

20:00

Ambivalence as a key concept •  Is the patient’s ambivalence a different phenomenon to

my hesitation?

•  How would you rate this ambivalence on a scale from 1 (normal) to 10 (pathological)?

Ambivalence •  Is normal •  Is often mistaken for resistance •  Must be explored, not confronted

Ambivalence •  Ambivalence is a normal human feeling •  Denial of ambivalence does not allow the patient to

overcome it, and creates discord •  Ambivalence must be accepted and discussed during

treatment, and specially at early stages •  The resolution of ambivalence is promoted by accurate

empathy, and is influenced by the counsellor’s differential reinforcement of client speech

Righting reflex

Disadvantages of ‘status quo’ Advantages of change

Disadvantages of change Advantages of ‘status quo’

By exploring his or her ambivalence, the patient can resolve it

Ambivalence

Confrontational or directing style

Motivational or guiding style

Discord

Discord

Communication styles

Miller WR, Rollnick S. Motivational Interviewing. New York: Guilford Press; 2013.

Directing Guiding Following

Informing Asking Listening

0 10 20 30 40 50 60 70 Listen with

intention Inform with permission and

options

Exploring values •  You will be presented with a list of values that are

generally relevant for most people. Please rate the importance of each of those values for you, using a scale from 1 (not important) to 10 (extremely important).

Exploring values •  Life •  Freedom •  Work •  Security •  Spirituality •  Success •  Power •  Responsibility

How can we explore patient’s values? •  Use open questions, followed by reflection •  ‘So Paul, you’ve been drinking for quite a while, and now

you’ve decided is time to do something about it. I wonder why now? What has made you think it is time to change your drinking?’

Internal discrepancy. An example. Tom: Downfall of a Functioning Alcoholic

https://www.youtube.com/watch?v=3_U58eXl0v4; http://www.thesecondroad.org.

Creating internal discrepancy •  ‘So, you’re saying alcohol makes you feel relaxed and

helps you to cope with your stressful daily life, but once you’ve been drinking you feel you’re not taking care of your family as well as you would like to, and this puts you under even more stress. How does this situation make you feel?’

Change talk What is it? •  ‘Change talk’ is any self-expressed language that is an

argument for change

Why is it important? •  It predicts future change

Miller WR, Rollnick S. Motivational Interviewing. New York: Guilford Press; 2013.

Change talk

Amrhein PC, et al. J Consult Clin Psychol. 2003;71:862-78.

Desire Ability Reasons Needs

Commitment Activation Taking steps

Preparatory Change Talk

Mobilizing Change Talk

CHANGE

Identifying change talk •  Can you identify change talk and type of change talk?

Identifying change talk •  icon indicates change talk CHANGE

Identifying change talk •  I think it will be hard and I’ve been drinking for quite a long time.

And it’s part of my life. It’s something I do enjoy. But it’s getting to a point where that if it gets too bad, I would lose my job. So I need to reduce my drinking.

•  I have to say, it’s going to be hard when I think about it, because there’s a momentum that builds up at night as well. In thinking about this, the 2 nights I really have to make a difference are the Wednesday night and the Sunday night, so that I come to work in the best shape I can. They’d be the nights I’d initially need to change. How I change it, I don’t know, but I need to change those 2 nights.

Guiding the process of change

Miller WR, Rollnick S. Motivational Interviewing. New York: Guilford Press; 2013.

Planning Evoking

Focusing Engaging

Summing up •  We use conversations to help people change •  Ambivalence is normal •  Contact with our deep-seated values is a driver for change •  A guiding style is more helpful than a directive one for raising

internal discrepancies •  Reinforcing selectively change talk helps patients move forward •  To motivate our patients we need to engage them, focus on the

problem, evoke solutions from them and plan a strategy together

Motivating patients with alcohol problems Dr Antoni Gual Barcelona, Spain

THANKS !!!!