Motivating Patients in Alcohol Use Interventions

What Is Motivational Interviewing?

Motivational interviewing is a directive, client-centered approach to patient-provider interactions intended to help individuals explore and resolve their ambivalence about unhealthy substance use behaviors in order to inspire motivation to make healthy behavior changes (BSAS, 2012). The initiation and development of patient motivation and readiness to change is critical for successful treatment of alcohol use disorder (Le Berre et al., 2012).

In order to motivate patients to make changes in their alcohol use to improve their health:

• Try to elicit statements from the patient about what motivates them with respect to a problem health behavior, such as their alcohol use (Miller & Rollnick, 2012; Resnicow & McMaster, 2012).
• Assess the patient’s recognition of a problem and their explanation for their behaviors.
• Consider their desire and intention to change a behavior, as well as their ability to make the change.
• Exploration of the patient’s values can stimulate motivation for change (Resnicow & McMaster, 2012).
• Elicit cognitive or affective statements about a time when things were better or hopes for the future (Harmon-Jones et al., 2012). These may help highlight strong motivations and help move the patient towards change. Reinforce these motivational statements with reflective listening, stating a brief, paraphrased version of what they said (Miller & Rollnick, 2012).

Each Patient is Unique

Keep in mind all the contributing factors that may lead a patient to seek or not seek treatment. Elicit, through questioning, personal motivations for seeking treatment. Recognizing why a patient has reached the decision to come in for treatment or to reject treatment at this point in time, can help lead to a treatment experience tailored to their interests and needs. For example, money or time commitments may not allow the patient to commit to a more intensive treatment choice, even if it would be the best course of action for them.

Goals of Motivational Interviewing

1. Develop discrepancy: MI aims to draw patients’ attention to the difference between their current state of health as affected by substance use and the way they would like their life to be. Focusing on the discrepancy between a patient’s current behavior and his or her values and goals serves as a form of motivation to change, and increases their likelihood of adhering to a treatment plan. (Moyers, 2014)
2. Express empathy: MI seeks to encourage patient self-efficacy, or the belief in his or own ability to change their behavior (BSAS, 2012). This is accomplished through empathetic, non-judgmental expression of acceptance, rather than criticism, of the patient’s unhealthy alcohol use behavior (BSAS, 2012).
3. Roll with resistance: It is important to accept that resistance to change and ambivalence about current behaviors is normal (BSAS, 2012). This principle of MI requires inviting the patient to consider new approaches to decreasing their alcohol use (Norcross, Krebs, & Prochaska, 2011), including reframing statements of resistance, meaning offering a different perspective, rather than opposing them (BSAS, 2012).
4. Support self-efficacy: Patients must believe and be confident in their ability to reduce or cease their alcohol use in order to make positive health behavior changes (BSAS, 2012). This can be accomplished through the provider’s use of negotiation and confidence-building tactics, including sharing his or her beliefs in the patient’s capability for change.

Motivational Interviewing Approaches

The Motivational Interviewing (MI) approach involves being both directive and non-directive with patients (SAMHSA, 2013, Westra & Aviram, 2013):

1. Directive: Direct or guide patients toward being introspective and discussing certain topics that are likely to lead toward readiness for change and resolving any ambivalence about it. Use gentle, guiding questions to direct (Resnicow & McMaster, 2012).
2. Non-Directive or Patient-Centered: Be non-directive or patient-centered by allowing patients to come up with their own motivations, goals, and ambivalent feelings surrounding their problem behaviors and even their own plan to resolve their problems (Westra & Aviram, 2013).

Motivational Enhancement Therapy

Motivational Enhancement Therapy is a brief psychotherapy treatment that uses the principles of Motivational Interviewing to elicit motivation for change by clarifying patient goals (Ager et al., 2011).

This form of therapy aims to help individuals resolve their ambivalence about ceasing substance use and entering into treatment (NIDA, 2012). It is often performed in 4 sessions that last approximately 30-45 minutes each (Dieperink et al, 2014) For a detailed description of what each session should entail, see Miller et al.’s Motivational Enhancement Therapy Manual (1999).

Motivation Techniques

Guideline for Communication

Four steps can be adapted from the counseling technique, Motivational Interviewing, for briefly counseling patients on alcohol use (Miller & Rollnick, 2012). The basic steps are:

• Engaging the patient: It is important to understand how to build rapport quickly with a patient to help the patient feel comfortable speaking with you. A few things to keep in mind when speaking with patients include minimizing distractions, maintaining eye contact, and paraphrasing the patient’s statements to show you are listening (AAFP). It is important to spend time on this step because alcohol use is a sensitive topic for many people and they will be more responsive to your bringing it up if you have connected with them and shown that you care about them.Example: “I lost my job about two months ago and now I am having a tough time keeping up with rent. I have been drinking and full of anxiety the past 3 to 4 weeks.”Example: “It sounds like a very tough time you are going through right now and things have not been getting better, let’s see if we can get you back in the right direction.”
• Focusing: Next bring up the topic of their alcohol use in the same context of caring and relevance to their main concerns. Relating it to a health concern is often effective.Example: “I am concerned because your alcohol use is higher than the recommended limits. The excess drinking can contribute to health problems down the road. Can we talk about that?”
• Evoke/Elicit: Three quick questions can help you understand where your patient stands with respect to reducing alcohol use. Elicit from the patient one or more of the following according to how much time you have: Example: “How important is reducing alcohol use to you?” Example: “How confident are you in making the necessary lifestyle changes?” Example: “How ready are you to make the changes?”
• Plan: Work with the patient to come up with a plan to move toward reduction. Again, the plan depends upon the individual patient’s history, health, and interest. After a plan is made, the provider can start acting on it immediately. If a referral and/or a follow-up appointment is necessary, the provider can offer a warm referral and schedule a follow-up appointment before the patient leaves. Example: “What steps would you be willing to take of the possible healthy changes we have been discussing?”

(Miller & Rollnick, 2012)

Patient Responsibility, Self Efficacy, and Resistance

Acknowledge Patient’s Responsibility for the Change Decision

It is important to emphasize that the patient holds sole responsibility for changing his or her own behavior as well as making the decision to participate in a brief intervention (BSAS, 2012). If a patient is pushed towards change too quickly, and against their will, their motivation to change will be weak (SAMHSA 2013).

Promote Self-Efficacy

Much of the success of brief interventions rests on patients’ belief that they can and will be successful in changing their drinking practices. This aspect of a brief intervention is especially important to emphasize with at-risk patients, with a goal of motivating them to reduce or cease drinking (CDC, 2014).

Two major determinants of self-efficacy are (SAMHSA, 2013):

• The patient’s set of coping skills
• The effectiveness of these skills in specific high-risk situations

Overcoming Patient Resistance to Behavior Change and Treatment

Motivational interviewing aims to help patients resolve their ambivalence about their alcohol use and help them progress through the stages of change (BSAS, 2012; SAMHSA, 2013). It accomplishes this goal by teaching patients to accept ambivalence as normal and that ambivalence is an important motivational obstacle to overcome during recovery (SAMHSA, 2013).

Employing reflective listening to elicit greater recognition of alcohol use problems is an effective method of addressing and working toward ambivalence resolution (BSAS, 2012). An empathetic reflective listening style helps patients determine and articulate their values and intrinsic motivations that can be used to overcome ambivalence (SAMHSA, 2013).

Video: Motivational Interviewing

The following video (3 minutes) illustrates the use of motivational interviewing in a patient interview regarding substance use.

Learning Points

Summary

• Motivational Interviewing is a patient-centered approach to facilitating health behavior change that is effective in alcohol interventions.
• Goals or procedures of Motivational Interviewing include drawing attention to discrepancies in what the patient says, showing empathy, finding something to agree with if they are resistant, and supporting self-efficacy.
• The steps of Motivational Interviewing, which can be use as alcohol interventions, are engage the patient, focus the interview on a topic related to alcohol use, evoke feelings about the topic, and work with the patient to make a plan.
• Other Motivational Interviewing skills to appy with patients having alcohol use problems include use of open-ended questions, facilitating talk about changing, affirming strengths of the patient, and use of reflective listening and summarizing.