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

1. Antoni Gual
Hospital Clínic de Barcelona
Barcelona, Spain
Motivating patients with
alcohol problems

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. 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. 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. Ambivalence as a key concept
http://www.youtube.com/watch?v=cgF1fzCqu-k.

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

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. Righting reflex

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. Confrontational
or directing style
Motivational
or guiding style
Discord
Discord

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

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. Internal discrepancy. An example.
Tom: Downfall of a Functioning Alcoholic
https://www.youtube.com/watch?v=3_U58eXl0v4;
http://www.thesecondroad.org.

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

23. Identifying change talk
• icon indicates change talkCHANGE

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. Guiding the process of change
Miller WR, Rollnick S. Motivational Interviewing. New York: Guilford Press; 2013.
Planning
Evoking
Focusing
Engaging

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. Motivating patients with
alcohol problems
Dr Antoni Gual
Barcelona, Spain
THANKS !!!!