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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 Adic...
Outline
•  Ambivalence as a key concept
•  What makes people change: exploring values
•  Communication style
•  Creating i...
Conversation is about change
•  Conversations usually promote change
•  Language is used to motivate changes in others
•  ...
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 inter...
A double clinical case
When I woke up this morning I decided I would do some jogging just
before dinner. I have good reaso...
Ambivalence as a key concept
•  Is the patient’s ambivalence a different phenomenon to
my hesitation?
•  How would you rat...
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, a...
Righting reflex
Disadvantages of ‘status quo’
Advantages of change
Disadvantages of change
Advantages of ‘status quo’
By exploring his or ...
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 F...
Exploring values
•  You will be presented with a list of values that are
generally relevant for most people. Please rate t...
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 q...
Internal discrepancy. An example.
Tom: Downfall of a Functioning Alcoholic
https://www.youtube.com/watch?v=3_U58eXl0v4;
ht...
Creating internal discrepancy
•  ‘So, you’re saying alcohol makes you feel relaxed and
helps you to cope with your stressf...
Change talk
What is it?
•  ‘Change talk’ is any self-expressed language that is an
argument for change
Why is it important...
Change talk
Amrhein PC, et al. J Consult Clin Psychol. 2003;71:862-78.
Desire
Ability
Reasons
Needs
Commitment
Activation
...
Identifying change talk
•  Can you identify change talk and type of change talk?
Identifying change talk
•  icon indicates change talkCHANGE
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....
Guiding the process of change
Miller WR, Rollnick S. Motivational Interviewing. New York: Guilford Press; 2013.
Planning
E...
Summing up
•  We use conversations to help people change
•  Ambivalence is normal
•  Contact with our deep-seated values i...
Motivating patients with
alcohol problems
Dr Antoni Gual
Barcelona, Spain
THANKS !!!!
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Key Opinion Leaders talk on Alcohol. Thessalonika 2015

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Workshop for Key opinion leaders in the field of alcohol, psychiatrists from Bulgaria, Rumania and Greece. The meeting was held in Thessalonika in march 20, 2015

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Key Opinion Leaders talk on Alcohol. Thessalonika 2015

  1. 1. Antoni Gual Hospital Clínic de Barcelona Barcelona, Spain Motivating patients with alcohol problems
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. Ambivalence as a key concept http://www.youtube.com/watch?v=cgF1fzCqu-k.
  6. 6. 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)?
  7. 7. 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
  8. 8. 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)?
  9. 9. Ambivalence •  Is normal •  Is often mistaken for resistance •  Must be explored, not confronted
  10. 10. 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
  11. 11. Righting reflex
  12. 12. 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
  13. 13. Confrontational or directing style Motivational or guiding style Discord Discord
  14. 14. 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 intentionInform with permission and options
  15. 15. 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).
  16. 16. Exploring values •  Life •  Freedom •  Work •  Security •  Spirituality •  Success •  Power •  Responsibility
  17. 17. 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?’
  18. 18. Internal discrepancy. An example. Tom: Downfall of a Functioning Alcoholic https://www.youtube.com/watch?v=3_U58eXl0v4; http://www.thesecondroad.org.
  19. 19. 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?’
  20. 20. 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.
  21. 21. 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
  22. 22. Identifying change talk •  Can you identify change talk and type of change talk?
  23. 23. Identifying change talk •  icon indicates change talkCHANGE
  24. 24. 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.
  25. 25. Guiding the process of change Miller WR, Rollnick S. Motivational Interviewing. New York: Guilford Press; 2013. Planning Evoking Focusing Engaging
  26. 26. 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
  27. 27. Motivating patients with alcohol problems Dr Antoni Gual Barcelona, Spain THANKS !!!!

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