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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 !!!!
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