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Brief Alcohol Intervention in Medical Settings:Concerns from the Consulting Room
Abstract
Brief alcohol intervention is moving with apparent ease from demonstration outcome research to clinical practice. With benefits to public health in mind, nurses and doctors are being encouraged to give advice to all patients drinking above recommended limits. This paper critically examines the impact of this strategy on practitioners and their patients. It is argued that, firstly, practitioners might not be entirely satisfied with the evidence about effectiveness. Secondly, they might have difficulty interpreting the evidence about harmful consumption when talking to patients, particularly those without alcohol-related problems. Thirdly, the recommended framework for intervention, advice-giving, is potentially flawed. A number of possible solutions to these difficulties are raised for discussion. These include the widening of brief intervention to include severely dependent drinkers and the discussion of any health behaviours or concern expressed by the patient. These changes might best be achieved by adopting an intervention framework based on the principles of patient-centred medicine.
... La entrevista motivacional (EM) también ha demostrado ser efectiva en la reducción del consumo de alcohol y en el manejo de la adicción. Conceptualmente la EM se considera, un resultado secundario a una atmósfera conversacional constructiva, acerca de un cambio en el comportamiento, en la cual el terapeuta emplea la escucha empática para la comprensión de la perspectiva del cliente y la reducción de las resistencias 10 . ...
Fundamento: En la actualidad existe un amplio rango de formas de intervención psicológicas que se emplean para el tratamiento del alcoholismo; no obstante, los estudios que documentan la efectividad de estas alternativas hacen énfasis en un grupo de acciones que son más efectivas en el tratamiento del paciente alcohólico. Objetivo: Resumir las principales evidencias sobre la efectividad de los distintos enfoques existentes en el tratamiento de la dependencia alcohólica, a partir de un análisis de las pruebas existentes y diferenciarlas de las alternativas que han demostrado una limitada efectividad. Desarrollo: En los últimos años ha aumentado el interés por conocer la efectividad de las distintas alternativas de intervención en el alcoholismo, en gran parte por el interés marcado que existe en la administración adecuada de recursos de los que se dispone para el enfrentamiento de esta enfermedad. Los estudios sobre efectividad de las intervenciones además de necesarios para los profesionales que prestan ayuda psicoterapéutica, son cruciales para los decisores políticos que manejan los recursos dedicados a la salud, fundamentalmente para la toma de decisiones sobre el destino de los fondos basándose en el análisis de costo-beneficio. Conclusiones: Entre los enfoques interventivos con efectividad documentada se destacan las intervenciones breves, entrevistas motivacionales, entrenamiento en habilidades sociales y de afrontamiento cognitivo-conductual, el reforzamiento comunitario, el contrato conductual, las terapias aversivas y la prevención de las recaídas. Entre las terapias con limitaciones se pueden mencionar la psicoterapia del "insight", consejería confrontacional, el entrenamiento en relajación, consejería y el empleo de recursos educativos.
DeCS: ALCOHÓLICOS/psicología; PSICOTERAPIA; DEPENDENCIA (PSICOLOGÍA); ENTREVISTA PSICOLÓGICA.
Palabras clave: intervención psicológica, paciente alcohólico, efectividad de la intervención, psicoterapia, evidencia empírica.
... Opportunity costs are substantial, as well, because SBI must also compete with other demands on providers' and patients' time, attention, and resources. 111,[124][125][126][127]156,158,[180][181] Many feel that the workload to implement SBI is not balanced by observable clinical or financial benefits. 46,101,158 Neushotz and Fitzpatrick 172 suggest that SBI must show benefits that outweigh its costs to implement and sustain: benefits to patients in improved health and functioning, to clinicians in improved outcomes for their patients and improved clinical interactions, and to the institutions in improved reputation, efficiency, and resources. ...
This report reviews the research literature on the barriers in federally qualified health centers (FQHCs) and primary care and strategies for overcoming those barriers to integrate substance use (SU) care into evolving patient-centered medical/health homes (PCMHs). The literature review is supplemented by extensive interviews with experts and site visits to FQHCs across the country. From these data, several opportunities have been identified that could help FQHCs adopt and sustain SU screening and treatment as a routine part of whole-person care for their patients.
... For example, the brief advice evaluated in the recent Screening and Intervention Programme for Sensible drinking (SIPS) trial [14], which has its origins in the advice evaluated in the WHO cross-national trial conducted more than 20 years ago [2] , provided information on alcohol and national guidelines , and the benefits of cutting down (or stopping in the case of dependent drinkers) and practical tips. This type of content, focused on the risk behaviour itself, does not enquire about, and thus does not address directly, any problems that someone may be having with their drink- ing [15]. This approach contrasts sharply with that of MI [16], where asking the person about their situation, and listening carefully to what they have to say, places their concerns or problems at the heart of the conversation. ...
Background
Brief interventions have well-established small effects on alcohol consumption among hazardous and harmful drinkers in primary care, and national large-scale programmes are being implemented in many countries for public health reasons. Methods
This paper examines data from reviews and draws upon older brief intervention studies and recent developments in the literature on motivational interviewing to consider the capacity of brief interventions to benefit those with problems, including those with severe problems. ResultsEffects on alcohol problems have been shown much less consistently, and evidence cannot be claimed to be strong for any outcomes other than reduced consumption. Combinations of advice and motivational interviewing are a promising target for evaluation in trials, and more detailed studies of the conduct of brief interventions are needed. Conclusions
We propose that brief interventions in primary care may be more effective if they offer appropriate content in a person-centred manner, addressing patient concerns more directly.
... Integrating questions about alcohol with other lifestyle behaviour was also seen as a useful way of avoiding the potential sensitivity of this issue. Thus targeted approaches to the detection of alcohol-related risk, that is neither universal screening of all patients nor restriction to those seeking treatment for alcohol problems, appears to be feasible and acceptable to both patients and health professionals, and may resolve a debate about screening in the research community ( Rollnick et al., 1997;Beich et al., 2002;Kelly, 2002). This targeted approach has also been recommended in the Alcohol Harm Reduction Strategy (Strategy Unit, 2004). ...
Excessive drinking is a global health problem which is responsible for a wide range of both chronic and acute illness, and which costs the UK National Health Service (NHS) £1.7 billion annually. Current health policy aims to reduce alcohol-related problems by promoting early identification of risk followed by brief intervention to facilitate positive changes in drinking level or patterns of consumption. However, practical and philosophical barriers concerning screening and brief alcohol intervention have so far impeded its uptake in routine primary care. This qualitative study aimed to simultaneously explore and compare health professionals’ and patients’ views on the acceptability and feasibility of screening and brief alcohol intervention in primary care. Focus groups were held with (a) four primary care teams, (b) two general practitioner (GP) and two nurse groups and (c) six patient groups in the north-east of England. A thematic framework approach was used to analyse audio-taped data via transcripts. Both health professionals and patients reported that raising and discussing alcohol-related risk was acceptable in primary care, when combined with other lifestyle issues or linked to relevant health conditions. Targeted rather than universal screening was the most acceptable method of identifying alcohol-related risk and would fit well with existing practice. However, there was uncertainty among health professionals about the effectiveness of brief alcohol interventions and some disagreement with patients concerning who was best placed to deliver them. Health professionals felt that nurses were best placed for such work whilst patients reported that they would initially raise the subject with GPs. There was broad acceptance of brief intervention approaches but a lack of support and specific incentives for this work impeded its delivery in routine practice.
... Such strategies could involve the development of educational packages, discussion workshops, booklets, and promotional materials that engage people within organisations in thinking about the issues. As with assisting people in behavioural change, the opportunities for reflection need to be engaging, matter-of-fact, and nonjudgemental (Rollnick, Butler, & Hodgson, 1997). ...
This paper outlines the ethical and organisational risks for community and other public good organisations of accepting funding from gambling industry sources. Aspects of this moral jeopardy include the ethics of benefiting from the suffering of others as well as impacts on an organisation's reputation, governance, and internal relationships. After 50 years of unethical practice by tobacco manufacturers, community agencies involved with tobacco control are now actively challenging organisations that continue to pursue these links. This readiness to question has not yet been extended to gambling, but with efforts at improving ethical awareness, people in key agencies can be assisted in challenging these relationships. The different arrangements for dispersing charitable funds from gambling are examined and we conclude that none of them are free from moral jeopardy. The paper finishes with recommendations on ways organisations might participate in promoting low moral jeopardy environments.
... The aforementioned themes suggest that road safety planners and injury-prevention researchers should advocate for programs that (1) promote smart driving practices among motorcyclists by identifying and correcting misperceptions about the use of safety helmets, increase their awareness of the danger of impaired driving, inform them about existing laws and the risks of being detected, and enhance their coping skills with the hassles and stresses of everyday living; (2) train pediatricians and emergency physicians to deliver brief motivational intervention (Rollnick et al. 1997) to their young patients to avoid risky behaviors while riding; (3) train traffic enforcement officers to appreciate the value of providing consistent law enforcement services; (4) enhance local efforts to increase number of pathways for motorcyclists and improve the condition of deteriorated roads and other road hazards such as potholes, bumps, and gravel; (5) revise legislation and polices in association with motorcycle ownership among underage and unlicensed individuals; (6) limit an excessive number of passengers (particularly children) and cargo on motorcycles; and (7) identify solutions to reduce car drivers' negative attitudes toward motorcyclists and increase systematic compliance of traffic laws by motorcyclists and car drivers. ...
Injuries caused by motor vehicle crashes in Middle Eastern countries are among the highest in the world. In Iran, road traffic crashes are the second most common cause of mortality. Particularly, motorcycle-related injuries among men are the second most common type of traffic-related crash in this country. This study used qualitative research methods to elicit and explore the personal experiences of Iranian motorcyclists in respect to factors that facilitate their engagement in risk-taking behaviors within the PRECEDE (predisposing, reinforcing, and enabling constructs in educational diagnosis, and evaluation) framework.
Focus groups, in-depth interviews, and field observation were conducted among motorcyclists, pillion passengers, and police officers.
Our data show that being young and single, living in lower socioeconomic conditions, and suffering from poor physical health and daily stress influence risk-taking behaviors. Additionally, lack of defined traffic rules and regulations, the availability and accessibility of motorcycles among unlicensed underaged persons, the cost-effectiveness of motorcycle transportation, unsafe roads and a lack of special pathways for motorcycles, and aggressive car and van/truck drivers are among the enabling factors that provoke risk-taking behavior. Finally, the participants verified that the enjoyment of motorcycling reinforced their decision to continue engaging in risky behaviors, and being penalized for disobeying traffic laws prevented them from further risk-taking behaviors.
Enabling and reinforcing factors to reduce risk-taking behaviors among motorcyclist could include (1) promoting smart driving practices among motorcyclists; (2) training pediatricians and emergency physicians to deliver brief motivational interventions to their young patients to avoid risky behaviors while riding; (3) training traffic enforcement officers to appreciate the value of providing consistent law enforcement services; (4) enhancing local efforts to increase the number of pathways for motorcyclists and improve the condition of deteriorated roads; (5) revising legislation and policies in association with motorcycle ownership among underaged and unlicensed individuals; (6) limiting an excessive number of passengers (particularly children) and cargo on motorcycles; and (7) identifying solutions to reduce the negative attitudes of car drivers toward motorcyclists and increase systematic compliance of traffic laws by motorcyclists and car drivers.
... Overall, this review provides further positive evidence for brief interventions compared to control conditions in opportunistic samples and as typically delivered by health-care professionals. The extent to which healthcare professionals are receptive to, or are qualified for delivering, such interventions effectively has been debated (Roche et al. 1991;Bradley et al. 1995;Rollnick, Butler & Hodgson 1997;Kaner et al. 1999;Andréasson, Hjalmarsson & Rehnmen 2000). However, that such treatments could reach a considerable proportion of individuals with alcohol problems who would not otherwise seek formal help (Rumpf et al. 1998) is not in question. ...
Brief interventions for alcohol use disorders have been the focus of considerable research. In this meta-analytic review, we considered studies comparing brief interventions with either control or extended treatment conditions. We calculated the effect sizes for multiple drinking-related outcomes at multiple follow-up points, and took into account the critical distinction between treatment-seeking and non-treatment-seeking samples. Most investigations fell into one of two types: those comparing brief interventions with control conditions in non-treatment-seeking samples (n = 34) and those comparing brief interventions with extended treatment in treatment-seeking samples (n = 20). For studies of the first type, small to medium aggregate effect sizes in favor of brief interventions emerged across different follow-up points. At follow-up after > 3-6 months, the effect for brief interventions compared to control conditions was significantly larger when individuals with more severe alcohol problems were excluded. For studies of the second type, the effect sizes were largely not significantly different from zero. This review summarizes additional positive evidence for brief interventions compared to control conditions typically delivered by health-care professionals to non-treatment-seeking samples. The results concur with previous reviews that found little difference between brief and extended treatment conditions. Because the evidence regarding brief interventions comes from different types of investigation with different samples, generalizations should be restricted to the populations, treatment characteristics and contexts represented in those studies.
... Since the seminal publication of a brief intervention by Orford et al. (1976) a quarter of a century ago, numerous studies have been published that show that brief interventions are effective in getting alcohol abusers to significantly reduce their alcohol use, whether the intervention is as short as 5 min with a physician (e.g., Fleming and Manwell, 1999; Rollnick et al., 1997 ), a few cognitive/behavioral outpatient sessions (e.g., Breslin et al., 1999; Sobell, 1993a, 1998 ), a correspondence intervention with a selfhelp manual (e.g., Kavanagh et al., 1999; Sitharthan et al., 1996), or bibliotherapy (Miller and Baca, 1983; Miller and Taylor, 1980). The effectiveness of brief interventions suggests that their major function is motivational (i.e., they catalyze a person's own resources to bring about self-change). ...
By using a public health approach to the treatment of alcohol problems, this study analyzed the efficacy and cost analysis of two versions of a community-level mail intervention to promote self-change among alcohol abusers who had never sought help or treatment.
A total of 825 participants who responded to media solicitations were randomly assigned to one of two interventions: (a) for bibliotherapy/drinking guidelines (n = 411), they were given two pamphlets with information about the effects of alcohol and guidelines for low-risk drinking and self-monitoring, and (b) for motivational enhancement/personalized feedback (n = 414), personalized advice/feedback was provided on the basis of the participants' assessment of their drinking and related behaviors.
Although both groups exhibited significant reductions in drinking from 1 year before to 1 year after intervention, there were no significant differences between the two interventions for any variable. This suggests that the materials, irrespective of whether they were personalized, facilitated the reduction of drinking. Cost analysis revealed that a brief mail intervention could reduce drinking at a very low cost per participant (US97).
A brief community-level mail intervention for problem drinkers who had never sought treatment resulted in sizable reductions in alcohol use over the year after the intervention compared with the year before. Furthermore, many of those with poorer outcomes engaged in a natural stepped-care process by seeking help. These results, coupled with the low cost to deliver the intervention, suggest that public health campaigns could have a substantial effect on reducing alcohol problems and associated costs as well as getting some individuals into treatment. Such an approach would represent a shift from the alcohol field's long-standing clinical focus to a broader public health perspective.
... The representativeness of the non-ALSPAC lesbian mothers cannot be determined. However, the process of snowballing is most effective when initiated from a representative sample (Heckathorn, 1997;Rollnick, Butler, & Hodgson, 1997), as was the case with the ALSPAC. Comparisons were carried out between ALSPAC and non-ALSPAC lesbian mothers for all of the study variables to determine the nature and extent of differences between them. ...
Existing research on children with lesbian parents is limited by reliance on volunteer or convenience
samples. The present study examined the quality of parent– child relationships and the socioemotional
and gender development of a community sample of 7-year-old children with lesbian parents. Families
were recruited through the Avon Longitudinal Study of Parents and Children, a geographic population
study of 14,000 mothers and their children. Thirty-nine lesbian-mother families, 74 two-parent heterosexual
families, and 60 families headed by single heterosexual mothers were compared on standardized
interview and questionnaire measures administered to mothers, co-mothers/fathers, children, and teachers.
Findings are in line with those of earlier investigations showing positive mother– child relationships
and well-adjusted children.
... Our data restate some of the previous findings in this field such as clinical pessimism about the effectiveness of treatment interventions, especially in relation to more extreme alcohol problems (Clements, 1986;Strong, 1980) and the importance of a 'supportive working environment' (Anderson et al., 2003) for clinicians carrying out alcohol-related work. Our data also offers empirical evidence that develops previous conceptual discussions about the practical problems GPs can face when raising alcohol problem in consultations (Kelly, 2002;Rollnick, Butler, & Hodgson, 1997). We show how GPs' alcohol-related consultations are deeply shaped by very practical issues like patients presenting with multiple problems, and with their own treatment agendas, alongside broader social, cultural and moral expectations about 'normal' and 'abnormal' alcohol-related practices. ...
This paper describes general practitioners' (GPs) experiences of detecting and managing alcohol and alcohol-related problems in consultations. We undertook qualitative research in two phases in the North-East of England. Initially, qualitative interviews with 29 GPs explored their everyday work with patients with alcohol-related issues. We then undertook group interviews--two with GPs and one with a primary care team--where they discussed and challenged findings of the interviews. The GPs reported routinely discussing alcohol with patients with a range of alcohol-related problems. GPs believed that this work is important, but felt that until patients were willing to accept that their alcohol consumption was problematic they could achieve very little. They tentatively introduced alcohol as a potential problem, re-introduced the topic periodically, and then waited until the patient decided to change their behaviour. They were aware that they could identify and manage more patients. A lack of time and having to work with the multiple problems that patients brought to consultations were the main factors that stopped GPs managing more risky drinkers. Centrally, we compared the results of our study with [Thom, B., & Tellez, C. (1986). A difficult business-Detecting and managing alcohol-problems in general-practice. British Journal of Addiction, 81, 405-418] seminal study that was undertaken 20 years ago. We show how the intellectual, moral, emotional and practical difficulties that GPs currently face are quite similar to those faced by GPs from 20 years ago. As the definition of what could constitute abnormal alcohol consumption has expanded, so the range of consultations that they may have to negotiate these difficulties in has also expanded.
... To date, relatively few brief motivational interventions have been developed for adolescents [22]. In addition, studies of brief interventions have been criticized for their limited focus primarily on substance abuse, resulting in calls for broadening interventions to address other health behaviors [23]. Moreover, interventions limited to addressing risk behaviors like substance use may be perceived by adolescents as more negative and less interesting than those targeting health-promoting behaviors, and therefore may suffer from lack of interest and participation. ...
This paper describes the Behavior-Image Model (BIM), an emerging and innovative paradigm for planning brief interventions
for adolescents that fuse the prevention of harmful behaviors with the promotion of healthy habits. We discuss the components
of the BIM as a new paradigm for creating multiple behavior health interventions, as well as the empirical and conceptual
underpinnings of the model, and present Project Sport as an illustration of how the BIM may be applied to construct a brief
multi-behavior intervention. The BIM posits that selected salient images of others and ourselves may be used to cast gain-
and loss-framed messages coupling and motivating health-promoting and health-risk behaviors within single interventions. This
content in turn activates prototypes and future self-images through the processes of social and self-comparison, leading to
improvements in risk and protective factors and subsequent change in targeted health-promoting and health-risk behaviors.
Recommendations are offered for conducting future research integrating health-risk and health-promoting behaviors in both
brief and non-brief interventions for adolescents and adults.
This chapter1 aims to bridge a divide in the response to substance misuse, between the addiction experts and primary health care practitioners. Both have considerable experience of substance misuse, the former for obvious reasons, the latter because the presentation of everyday health and social problems are frequently laced with the impact of alcohol and other substance misuse. The focus here will be on everyday clinical practice and how it might be improved, rather than the broader political question of whose responsibility it is to reduce the public health burden of substance misuse.
Brief interventions against excessive alcohol consumption delivered in health care settings have been shown by research to be effective in reducing consumption among excessive drinkers. The widespread and routine implementation of brief interventions in these settings would lead to substantial gains for public health. This paper reviews evidence for the effectiveness of brief interventions in a range of medical settings. Special mention is made of the WHO series of studies on "The Detection and Management of Alcohol-related Problems in Primary Health Care", including the current Phase IV of this project concerned with developing strategies for implementing early identification and brief intervention for excessive drinking in the primary health care systems of participating countries. Attention then turns to the potential of brief interventions for reducing alcohol problems specifically among young people. The relevance to this aim of a range of health care settings -general medical practice, general hospital wards, accident and emergency departments- is reviewed. Particular issues that arise when considering brief alcohol interventions for young people are discussed. The paper ends with a series of conclusions regarding research and policy for brief interventions in general and brief interventions adapted for the needs of young people.
Objective: To explore the suitability of a screening based intervention for excessive alcohol use by describing the experiences of general practitioners who tried such an intervention in their everyday practice.
Design: Qualitative interviews with general practitioners who had participated in a pragmatic study of a combined programme of screening and a brief intervention for excessive alcohol use. Doctors were interviewed either individually or in focus groups. A computer based, descriptive, phenomenological method was used to directly analyse the digitally recorded interviews.
Setting and participants: 24 of 39 general practitioners in four Danish counties who volunteered to take part in the pragmatic study were interviewed.
Results: The doctors were surprised at how difficult it was to establish rapport with the patients who had a positive result on the screening and to ensure compliance with the intervention. Although the doctors considered the doctor-patient relationship robust enough to sustain targeting of alcohol use, they often failed to follow up on initial interventions, and some expressed a lack of confidence in their ability to counsel patients effectively on lifestyle issues. The doctors questioned the rationale of screening in young drinkers who may grow out of excessive drinking behaviour. The programme needed considerable resources, and it interrupted the natural course of consultations and was inflexible. The doctors could not recommend the screening and brief intervention programme, although they thought it important to counsel their patients on drinking.
Conclusions: Screening for excessive alcohol use created more problems than it solved for the participating doctors. The results underline the value of carrying out pragmatic studies on the suitability of seemingly efficacious healthcare programmes.
This sole-authored original academic book [226 pages] looks ahead and asks where the increased reliance on profits from gambling is leading in the long term. It argues that the rapid commercial expansion of gambling through modern Western democracies can be likened to the commercial expansion of other primary exploitative industries such as native forest logging in countries like Indonesia and Brazil. As the chainsaw enabled vast tracts of native forests to fall, so the proliferation of poker machine lures increasing numbers of people into regular use. The profits generated by increased consumption establish and reinforce a network of relationships that are increasingly reliant on these profits. Key recipients include industry employees, government agencies, political bodies, media organisations, community groups, charities, gambling helping organisations and researchers. The book looks closely at how relationships to the profits from gambling create environments that generate conflicts of interest that in the long run discourage active and critical participation in democratic systems.
Aim To obtain a consensus of expert views on how best to implement screening and brief intervention (SBI) for excessive drinkers in a routine and enduring fashion in primary health care throughout England.
Method A Delphi survey of expert opinion in the UK.
Participants Seventy‐nine experts in SBI, of whom 53 (67%) remained in round 3 of the survey. The expert panel included primary health‐care professionals, alcohol‐service workers and researchers/ academics.
Measurements In round 3, 53 panel members (67% of an initial sample of 79) made ratings on a five‐point Likert scale of 157 items developed from responses to open ended questions in round 1 and fed back with group median ratings derived from round 2. Consensus was defined as an interquartile range of ≤1 and attention was mainly directed to items with consensus around median responses of strong agreement or disagreement.
Findings A number of clear conclusions emerged from the survey, including the recommendation of routine screening confined to new patient registrations, general health checks and special types of consultation. The employment of a specialist alcohol worker as a member of the primary health‐care team was strongly supported, but a model of interprofessional cooperation in the delivery of SBI could also be derived from findings. Other conclusions included the importance for the widespread implementation of SBI of a national alcohol strategy.
Reviews the literature and describes the nature and feasibility of brief interventions in the treatment of alcohol use disorders. Attention is given to the promising results of outcome studies, and recommendations are provided for the implementation of brief interventions with a heterogeneous clientele. (Contains 39 references.) (GCP)
Brief interventions involve a time-limited intervention focusing on changing behaviour. They are often motivational in nature using counselling skills to encourage a reduction in alcohol consumption.
To determine whether brief interventions reduce alcohol consumption and improve outcomes for heavy alcohol users admitted to general hospital inpatient units.
We searched the Cochrane Drug and Alcohol Group Register of Trials (March 2011) the Cochrane Central Register of Controlled Trials (The Cochrane Library March 2011), MEDLINE January 1966-March 2011, CINAHL 1982-March 2011, EMBASE 1980-March 2011 and www.clinicaltrials.gov to April 2011 and performed some relevant handsearching.
All prospective randomised controlled trials and controlled clinical trials were eligible for inclusion. Participants were adults and adolescents (16 years or older) admitted to general inpatient hospital care for any reason other than specifically for alcohol treatment and received brief interventions (of up to 3 sessions) compared to no or usual care.
Three reviewers independently selected the studies and extracted data. Where appropriate random effects meta-analysis and sensitivity analysis were performed.
Forteen studies involving 4041 mainly male participants were included. Our results demonstrate that patients receiving brief interventions have a greater reduction in alcohol consumption compared to those in control groups at six month, MD -69.43 (95% CI -128.14 to -10.72) and nine months follow up, MD -182.88 (95% CI -360.00 to -5.76) but this is not maintained at one year. Self reports of reduction of alcohol consumption at 1 year were found in favour of brief interventions, SMD -0.26 (95% CI -0.50 to -0.03). In addition there were significantly fewer deaths in the groups receiving brief interventions than in control groups at 6 months, RR 0.42 (95% CI 0.19 to 0.94) and one year follow up, RR 0.60 (95% CI 0.40 to 0.91). Furthermore screening, asking participants about their drinking patterns, may also have a positive impact on alcohol consumption levels and changes in drinking behaviour.
The main results of this review indicate that there are benefits to delivering brief interventions to heavy alcohol users admitted to general hospital wards in terms of reduction in alcohol consumption and death rates. However, these findings are based on studies involving mainly male participants. Further research is required determine the optimal content and treatment exposure of brief interventions within general hospital settings and whether they are likely to be more successful in patients with certain characteristics.
Brief interventions involve a time-limited intervention focusing on changing behaviour. They are often motivational in nature using counselling skills to encourage a reduction in alcohol consumption.
To determine whether brief interventions reduce alcohol consumption and improve outcomes for heavy alcohol users admitted to general hospital inpatient units.
We searched the Cochrane Drug and Alcohol Group Register of Trials (June 2008) the Cochrane Central Register of Controlled Trials (The Cochrane Library 2, 2008), MEDLINE January 1966-June 2008, CINAHL 1982-June 2008, EMBASE 1980-June 2008 using the search strategy developed by the Cochrane Drug and Alcohol Group. We hand searched relevant journals, conference proceedings and contacted experts in the field.
All prospective randomised controlled trials and controlled clinical trials were eligible for inclusion. Participants were adults (16 years or older) admitted to general inpatient hospital care for any reason other than specifically for alcohol treatment and received brief interventions (of up to 3 sessions) compared to no or regular treatment.
Three reviewers independently selected the studies and extracted data. Where appropriate random effects meta-analysis and sensitivity analysis were performed.
Eleven studies involving 2441 participants were included in this review. Three results were non significant and one result was significant mean alcohol consumption per week change scores from baseline (P0.02).
The evidence for brief interventions delivered to heavy alcohol users admitted to general hospital is still inconclusive. From data extracted from two studies it appears that alcohol consumption could be reduced at one year follow up though further research is recommended. Few studies have been retrieved and the results were difficult to combine because of the different measures used to assess alcohol consumption.
The purpose of this paper was to explore how events that counselors endorsed occurring during an emergency department-based screening and brief intervention (SBI) for drinking discriminate patients who reported change in Alcohol Use Disorder Identification Test (AUDIT) domains at follow-up from those who did not.
Patients who scored ">5" on the AUDIT were eligible for SBI. At the end of each intervention, counselors completed the questionnaire indicating which parts of the intervention they just used.
Discriminant function analyses indicated that "Referral made" discriminated for alcohol intake change (Wilks' lambda = 0.993, P < .05); "Did the patient set goals during intervention?" and "Referral made" discriminated for alcohol dependency change (Wilks' lambda = 0.940 and Wilks' lambda = 0.919, P < .05, respectively). "Intention to quit" (Wilks' lambda = 0.984, P < .05) discriminated for alcohol-related harm change.
Making referrals to addiction treatment during motivational intervention discriminated for alcohol intake and dependency change. Working on intention to quit is an important point in changing alcohol-related harm. When conducting the SBI in ED, counselors may be mindful in making appropriate referrals to address alcohol use and examine intention to quit to maximize the efficacy of the harm-reduction approach.
To compare alcohol-related intervention and general interactional skills performance of medical students from a traditional (Sydney) and a non-traditional (Newcastle) medical school, before and after participation in an alcohol education programme about brief intervention.
In two controlled trials, students received either a didactic alcohol education programme or didactic input plus skills-based training. Prior to and after training, all students completed videotaped interviews with simulated patients.
The Faculties of Medicine at the University of Newcastle and the University of Sydney, Australia.
Fifth-year medical students (n=154).
Both alcohol-related intervention and general interactional skills scores of the Newcastle students were significantly higher than those of the Sydney students at pre-test but not after training. Although alcohol-related interactional skills scores improved after training at both universities, they did not reach a satisfactory level. The educational approach used had no effect on post-test scores at either university.
Significant baseline differences in interactional skills scores favouring non-traditional over traditional students were no longer evident after both groups had been involved in an alcohol education programme. Further research is required to develop more effective alcohol intervention training methods.
To explore the suitability of a screening based intervention for excessive alcohol use by describing the experiences of general practitioners who tried such an intervention in their everyday practice.
Qualitative interviews with general practitioners who had participated in a pragmatic study of a combined programme of screening and a brief intervention for excessive alcohol use. Doctors were interviewed either individually or in focus groups. A computer based, descriptive, phenomenological method was used to directly analyse the digitally recorded interviews.
24 of 39 general practitioners in four Danish counties who volunteered to take part in the pragmatic study were interviewed.
The doctors were surprised at how difficult it was to establish rapport with the patients who had a positive result on the screening and to ensure compliance with the intervention. Although the doctors considered the doctor-patient relationship robust enough to sustain targeting of alcohol use, they often failed to follow up on initial interventions, and some expressed a lack of confidence in their ability to counsel patients effectively on lifestyle issues. The doctors questioned the rationale of screening in young drinkers who may grow out of excessive drinking behaviour. The programme needed considerable resources, and it interrupted the natural course of consultations and was inflexible. The doctors could not recommend the screening and brief intervention programme, although they thought it important to counsel their patients on drinking.
Screening for excessive alcohol use created more problems than it solved for the participating doctors. The results underline the value of carrying out pragmatic studies on the suitability of seemingly efficacious healthcare programmes.
Editor—I write as the medical referee to the Wakefield cremation authority about the disposal by cremation of the remains of fetuses of less than 24 weeks' gestation.
Although I understand the emotive reasons for hospital authorities wishing to find a more sensitive way of disposing of fetuses of less than 24 weeks' gestation, it is important to recognise that currently such disposals are outside the scope of the law as it relates to cremation. I therefore find it difficult to understand how a cremation authority can legally undertake cremation of fetuses, which are, and will remain until the law is changed, clinical waste, however distasteful this fact is.
Hospital authorities are currently seeking an extension to this practice to include the disposal by cremation of social terminations (abortions) and the contents of fetal sacs, which are also by definition clinical waste. The situation is even more confusing when the policy document of the Institute of Burial and Cremation Authorities that relates to fetal remains contradicts current legislation on cremation and specifically recommends that the medical referee should sign a form F, which is a statutory document.
I am concerned and surprised that cremation authorities and the Institute of Burial and Cremation Authorities, in attempting to respond to these emotive issues are placing themselves and medical referees in an invidious position. Other than for quasi-legal reasons there seems to be no requirement for the involvement of a medical referee or the production of a statutory form F in these cases.
Should cremation authorities and the Institute of Burial and Cremation Authorities still deem it appropriate to obtain a medical referee's signature, then an appropriate form, which is not a statutory document, could be designed for this purpose. It is apparent that a variety of working practices currently exist, which differ between cremation authorities—a situation that is totally unsatisfactory. Urgent consideration should be given to redressing these irregular practices to ensure that the reputation and integrity of cremation authorities and medical referees is not compromised.
Editor—Rost et al conducted a randomised controlled trial of ongoing treatment of depression in primary care, and Stroebele in response argued that it would make more sense for a patient to see a psychiatrist once and receive drug treatment if necessary for three or six months.1,2
I do not believe a psychiatrist can make an accurate diagnosis after a single visit. Patients do not start to reveal themselves until a genuine trust and rapport have been established. Information gathered on an initial visit is likely to be extremely superficial and inadequate simply because the patients are depressed. They are not thinking clearly and usually forget to tell their doctors the most important things the doctors need to know.
I have seen too many misdiagnoses and bad prescribing of drug treatments. The pharmaceutical monographs available on drugs are often based on human trials in healthy male participants who are taking no other drugs. Therefore when a new drug enters the market, all its possible interactions, adverse effects, and contraindications have not yet surfaced. Doctors are poor at reporting adverse effects, so they are often never published. Unexpected paradoxical reactions can kill people or make them wish they were dead. This has happened to people I know who were being treated for depression.
It can be difficult to find the correct drug and dosage the first time. People taking any kind of drug, particularly psychoactive drugs, need to be monitored closely and questioned carefully and regularly until the effectiveness of the drug is determined and any adverse side effects have been evaluated.
Finally, many people cannot call on active networks for support, and family doctors have neither the time nor the training to help a person cope with depression.
EDITOR—In their editorial last year Langer and Villar described the promotion of evidence based practice in maternal care.1 Recon Healthcare's model for Bangalore was developed to disseminate knowledge from the World Health Organization's reproductive healthcare library to doctors caring for women's health in India.
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Screening and intervention for alcohol problems can reduce drinking and its consequences but are often not implemented.
To test whether providing physicians with patients' alcohol screening results and simple individualized recommendations would affect the likelihood of a physician's having a discussion with patients about alcohol during a primary care visit and would affect subsequent alcohol use.
Cluster randomized, controlled trial.
Urban academic primary care practice.
41 faculty and resident primary care physicians and 312 patients with hazardous drinking.
Providing physicians with alcohol screening results (CAGE questionnaire responses, alcohol consumption, and readiness to change) and recommendations for their patients at a visit.
Patient self-report of discussions about alcohol use immediately after the physician visit and alcohol use 6 months later.
Of 312 patients, 240 visited faculty physicians, 301 (97%) completed the outcome assessment after the office visit, and 236 (76%) were followed for 6 months. Faculty physicians in the intervention group tended to be more likely than faculty physicians in the control group to give patients advice about drinking (adjusted proportion, 64% [95% CI, 47% to 79%] vs. 42% [CI, 33% to 53%]) and to discuss problems associated with alcohol use (74% [CI, 59% to 85%] vs. 51% [CI, 39% to 62%]). Resident physicians' advice and discussions did not differ between groups. Six months later, patients who saw resident physicians in the intervention group had fewer drinks per drinking day (adjusted mean number of drinks, 3.8 [CI, 1.9 to 5.7] versus 11.6 [CI, 5.4 to 17.7]).
Although effects seem to differ by physician level of training, prompting physicians with alcohol screening results and recommendations for action can modestly increase discussions about alcohol use and advice to patients and may decrease alcohol consumption.
This study tests the effect of a brief intervention with emergency department (ED) patients to reduce at-risk drinking.
We enrolled patients aged 18 years or older who screened positive for at-risk drinking in an urban academic ED and used alternative allocation to assign them to control or intervention status. A 20-minute, semiscripted, negotiated interview was conducted with the intervention group in English and Spanish by 3 health promotion advocates (peer educators). The Alcohol Use Identification Test (AUDIT) was administered at baseline and 3 months after enrollment.
Among 1,036 patients screened for at-risk drinking, 295 with CAGE questionnaire score greater than 1 and no alcohol treatment in the past year enrolled in the study and were randomly assigned to the control arm (n=151) or the intervention arm (n=144). Follow-up was achieved with 88 patients in the intervention group and 97 patients in the control group (63% of enrollees). Among the 185 patients followed up, 64% of the intervention group versus 80% of the control group scored greater than 7 on the follow-up AUDIT (scored on a scale of 1 to 40; P<.05, odds ratio [OR] 2.35, 95% confidence interval [CI] 1.21 to 4.55). Multinomial logistic regression analysis demonstrates, after controlling for demographic characteristics and other independent variables, that assignment to intervention status decreased the odds of at-risk (moderate) drinking as defined by AUDIT scores of 7 to 18 (OR 0.42, P<.05, 95% CI 0.19 to 0.91) but did not affect patients with AUDIT scores in the 19 to 40 range.
Brief motivational intervention administered by peer educators to ED patients appears to reduce moderately risky drinking and associated problems.
Tested motivational interviewing (a strategy to increase motivation for change) as a preparation for residential alcoholism treatment. 28 consecutive alcoholism admissions to a psychiatric hospital were assigned alternately to receive or not to receive a 2-session motivational assessment and interview shortly after intake, in addition to standard evaluation and treatment procedures. Patients who received the motivational interview participated more fully in treatment (as evidenced by therapist ratings) and showed significantly lower alcohol consumption at a 3-mo follow-up interview. The beneficial effects of motivational interviewing on outcome were mediated by increased participation in treatment. The extent to which the received treatment outcome conformed to patients' pretreatment expectations was predictive of outcome. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Motivational interviewing is a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. It is most centrally defined not by technique but by its spirit as a facilitative style for interpersonal relationship. This article seeks to define motivational interviewing and to characterize its essential nature, differentiating it from other approaches with which it may be confused. A brief update is also provided regarding (1) evidence for its efficacy and (2) new problem areas and populations to which it is being applied.
In a controlled evaluation of general practitioner (GP)-based brief intervention, 378 excessive drinkers identified opportunistically by screening in 40 group practices in metropolitan Sydney were assigned to groups receiving: (i) a five-session intervention by the GP (the Alcoholscreen Program); (ii) a single session of 5 minutes' advice by the GP plus a self-help manual (minimal intervention); (iii) an alcohol-related assessment but no intervention; (iv) neither intervention nor assessment. Among all patients allocated to receive it, the Alcoholscreen Program did not result in a significantly greater reduction in consumption at follow-up than control conditions but patients offered Alcoholscreen reported a significantly greater reduction in alcohol-related problems in the period to 6 months follow-up. A greater proportion of patients who returned for the second Alcoholscreen visit were drinking below recommended levels at follow-up than in the remainder of the sample. There was no evidence that minimal intervention or alcohol-related assessment were effective in reducing alcohol consumption or problems. Implications for further research into GP-based brief interventions are discussed.
How people intentionally change addictive behaviors with and without treatment is not well understood by behavioral scientists. This article summarizes research on self-initiated and professionally facilitated change of addictive behaviors using the key transtheoretical constructs of stages and processes of change. Modification of addictive behaviors involves progression through five stages—pre-contemplation, contemplation, preparation, action, and maintenance—and individuals typically recycle through these stages several times before termination of the addiction. Multiple studies provide strong support for these stages as well as for a finite and common set of change processes used to progress through the stages. Research to date supports a transtheoretical model of change that systematically integrates the stages with processes of change from diverse theories of psychotherapy.
A postal questionnaire was sent to all 1291 general practitioners in the Oxford region to determine the pattern of preventive care and their beliefs about its effectiveness. Replies were received from 1014 doctors (79%). Doctors' attitudes to their role in prevention and health promotion were very positive and a large majority claimed to discuss health related topics with their patients when indicated. Fewer respondents said they made a point of discussing smoking habits (64%), alcohol intake (26%), diet (12%), or exercise (11%) as a matter of routine with all their adult patients. Most general practitioners said they usually offered simple advice, leaflets, or other aids when they had identified a problem, but few said they would refer these patients to the practice nurse. With the exception of cervical screening (45%), few respondents said they maintained statistics on the distribution of risk factors in their practice population. Despite considerable enthusiasm for their role in preventive health care, before the imposition of the new contact most general practitioners in the Oxford region had not yet embraced the model of prevention which the contract aims to encourage: systematic screening for risk factors and lifestyle advice for all patients.
To determine effectiveness of advice from general practitioners to heavy drinkers to reduce their excessive alcohol consumption (35 U or more a week for men, 21 U or more for women).
Randomised, controlled double blind trial over 12 months with interim assessment at six months.
Group practices (n = 47; list size averaging 10,000) recruited from Medical Research Council's general practice research framework, mostly in rural or small urban settings.
Patients recruited after questionnaire survey. Of total of 2571 (61.2%) of 4203 patients invited for interview who attended, 909 (35.4%) stated that in past seven days they had drunk above the limits set for study and had not received advice; they were randomised to control and treatment groups.
Patients in treatment group were interviewed by general practitioner (who had had a training session) and received advice and information about how to reduce consumption and also given a drinking diary.
Study aimed at detecting a reduction in proportion of men with excessive alcohol consumption of 30% in treatment group and 20% in control group (for women 40% and 20%, respectively) with a power of 90% at 5% level of significance. In addition, corroborative measures such as estimation of gamma-glutamyltransferase activity were included.
At one year a mean reduction in consumption of alcohol of 18.2 (SE 1.5) U/week had occurred in treated men compared with a reduction of 8.1 (1.6) U/week in controls (p less than 0.001). The proportion of men with excessive consumption at interview had dropped by 43.7% in the treatment group compared with 25.5% in controls (p less than 0.001). A mean reduction in weekly consumption of 11.5 (1.6) U occurred in treated women compared with 6.3 (2.0) U in controls (p less than 0.05), with proportionate reductions of excessive drinkers in treatment and control groups of 47.7% and 29.2% respectively. Reduction in consumption increased significantly with number of general practitioner interventions. At one year the mean value for gamma-glutamyltransferase activity had dropped significantly more in treated men (-2.4 (0.9)IU/l) than in controls (+1.1(1.0)IU/l; t = 2.7, p less than 0.01). Reduction in gamma-glutamyltransferase activity tended to increase with number of intervention sessions in men. Changes in gamma-glutamyltransferase activity in women and changes in other indicators in both sexes did not differ significantly between treatment and control groups.
If the results of this study were applied to the United Kingdom intervention by general practitioners could each year reduce to moderate levels the alcohol consumption of some 250000 men and 67500 women who currently drink to excess. General practitioners and other members of the primary health care team should therefore be encouraged to include counselling about alcohol consumption in their preventive activities.
Sixteen general practitioners participated in a controlled trial of the Scottish Health Education Group's DRAMS (drinking reasonably and moderately with self-control) scheme. The scheme was evaluated by randomly assigning 104 heavy or problem drinkers to three groups - a group participating in the DRAMS scheme (n = 34), a group given simple advice only (n = 32) and a non-intervention control group (n = 38). Six month follow-up information was obtained for 91 subjects (87.5% of initial sample). There were no significant differences between the groups in reduction in alcohol consumption, but patients in the DRAMS group showed a significantly greater reduction in a logarithmic measure of serum gamma-glutamyl-transpeptidase than patients in the group receiving advice only. Only 14 patients in the DRAMS group completed the full DRAMS procedure. For the sample as a whole, there was a significant reduction in alcohol consumption, a significant improvement on a measure of physical health and well-being, and significant reductions in the logarithmic measure of serum gamma-glutamyl transpeptidase and in mean corpuscular volume. The implications of these findings for future research into controlled drinking minimal interventions in general practice are discussed.
Following the development of the Readiness to Change Questionnaire described by Rollnick et al., this article reports on the predictive validity of the questionnaire among a sample of 174 male excessive drinkers identified by screening on wards of general hospitals. Relationships between patients' "stage of change" derived from questionnaires administered prior to discharge from hospital and changes in drinking behaviour at 8 weeks and 6 months follow-up are analysed. Allocated stage of change provided statistically significant relationships with drinking outcome. Multiple regression analysis showed that stage of change remained a significant predictor of changes in alcohol consumption when other possible predictors were taken into account. Two methods for allocating stage of change on the basis of questionnaire responses for use in different circumstances, a "quick" and a "refined" method, are described.
Despite a high level of support for the importance of clinical prevention, physician delivery of preventive services falls well below recommended levels. Competing demands faced by physicians during the medical encounter present a major barrier to the provision of specific preventive services to patients. These demands include acute care, patient requests, chronic illnesses, psychosocial problems, screening for asymptomatic disease, counseling for behavior change, other preventive services, and administration and management of care. This paper outlines how competing demands affect physician delivery of clinical preventive services and provides a model designed to help practicing physicians improve the delivery of preventive services. This model can be helpful in the planning of preventive interventions in primary care settings and can facilitate a better understanding of physician behavior.
To investigate the impact of counselor style, a 2-session motivational checkup was offered to 42 problem drinkers (18 women and 24 men) who were randomly assigned to 3 groups: (a) immediate checkup with directive-confrontational counseling, (b) immediate checkup with client-centered counseling, or (c) delayed checkup (waiting-list control). Overall, the intervention resulted in a 57% reduction in drinking within 6 weeks, which was maintained at 1 year. Clients receiving immediate checkup showed significant reduction in drinking relative to controls. The 2 counseling styles were discriminable on therapist behaviors coded from audiotapes. The directive-confrontational style yielded significantly more resistance from clients, which in turn predicted poorer outcomes at 1 year. Therapist styles did not differ in overall impact on drinking, but a single therapist behavior was predictive (r = .65) of 1-year outcome such that the more the therapist confronted, the more the client drank.
Helping patients to change behaviour concemed with eating, drinking, smoking, exercise, or taking medication is a common task in medical consultations. In both hospital and primary care the care of chronically ill people often entails encouraging them to change behaviour. With the emphasis now placed on health promotion in primary care this activity has been given high priority.' 2 Yet health care practitioners are given little or no training in how to promote behaviour change. We examine the limitations of using the approach of giving advice and identify new concepts and methods which offer the promise of improving the quality and effectiveness of consultations about behaviour change.
To explore general practitioners' reasons for recent changes in their prescribing behaviour.
Qualitative analysis of semistructured interviews.
General practice in south east London.
A heterogeneous sample of 18 general practitioners.
Interviewees were able to identify between two and five specific changes that had occurred in their prescribing in the preceding six months. The most frequently mentioned changes related to fluoxetine, angiotensin converting enzyme inhibitors, and the antibiotic treatment of Helicobacter pylori. Three models of change were identified: an accumulation model, in which the volume and authority of evidence were important; a challenge model, in which behaviour change followed a dramatic or conflictual clinical event; and a continuity model, in which change took place against a background of willingness to change, modulated by other factors such as cost pressures and the comprehensible therapeutic action of a drug. Behaviour change was reinforced and sustained by experiences with individual patients.
Multiple factors are involved in general practitioners' decisions to change their prescribing habits. Three models of change can be identified which have important implications for the design and evaluation of interventions aimed at behaviour change.
The development of a method to facilitate clinical negotiation with diabetic patients is described. The principles of the method incorporate patient centredness, an assessment of readiness to change and some elements of motivational interviewing. A simple low cost technology is part of the innovative method. Details of the method and its application are published before the results of a randomized controlled trial to ensure that the techniques are in the public domain before the outcome of the trial is known.
INTRODUCTION
When a person leaves the culture in which he was born and raised and migrates to another, he usually experiences his new social setting as something strange—and in some ways threatening—and he is stimulated to master it by conscious efforts at understanding. To some extent every immigrant to the United States reacts in this manner to the American scene. Similarly, the American tourist in Europe or South America "scrutinizes" the social setting which is taken for granted by the natives. To scrutinize—and criticize—the pattern of other peoples' lives is obviously both common and easy. It also happens, however, that people exposed to cross cultural experiences turn their attention to the very customs which formed the social matrix of their lives in the past. Lastly, to study the "customs" which shape and govern one's day-to-day life is most difficult of all.1In many ways the psychoanalyst is like a
Primary care interventions directed at drinking and alcohol problems today constitute a highly important issue for service development, training and research. WHO has clone much to encourage work in this area, and in this journal feature we publish a summary by Thomas Babor, Marcus Grant et al. of a WHO multi-national clinical trial on the treatment of alcohol problems in the primary care setting. This summary is followed by comments from, Canada, Australia, Scotland, Norway, Denmark and Sweden and a reply from THomas Babor. We are grateful to the WHO investigators and the expert group of commentators, and to Robert West who took responsibility for organizing this series of contributions
In 1984, a group of researchers, theorists, and therapists gathered at an international conference in Scotland to contribute to the development of a more comprehensive model of change for the treatment of addictive behaviors. The conference and this book that grew out of the conference are signs of the Zeitgeist; they are part of a new attempt to integrate diverse systems of psychotherapy (Prochaska, 1984). In his classic call for a rapproachment across competing systems of therapy, Goldfried (1980) signaled that it is time to move beyond parochial approaches to treatment. It is time to move toward more comprehensive models of change.
Client ambivalence is a key stumbling block to therapeutic efforts toward constructive change. Motivational interviewing—a nonauthoritative approach to helping people to free up their own motivations and resources—is a powerful technique for overcoming ambivalence and helping clients to get "unstuck." The first full presentation of this powerful technique for practitioners, this volume is written by the psychologists who introduced and have been developing motivational interviewing since the early 1980s.
In Part I, the authors review the conceptual and research background from which motivational interviewing was derived. The concept of ambivalence, or dilemma of change, is examined and the critical conditions necessary for change are delineated. Other features include concise summaries of research on successful strategies for motivating change and on the impact of brief but well-executed interventions for addictive behaviors.
Part II constitutes a practical introduction to the what, why, and how of motivational interviewing. . . . Chapters define the guiding principles of motivational interviewing and examine specific strategies for building motivation and strengthening commitment for change.
Rounding out the volume, Part III brings together contributions from international experts describing their work with motivational interviewing in a broad range of populations from general medical patients, couples, and young people, to heroin addicts, alcoholics, sex offenders, and people at risk for HIV [human immunodeficiency virus] infection. Their programs span the spectrum from community prevention to the treatment of chronic dependence.
All professionals whose work involves therapeutic engagement with such individuals—psychologists, addictions counselors, social workers, probations officers, physicians, and nurses—will find both enlightenment and proven strategies for effecting therapeutic change. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Miller's (1983) system of ‘motivational interviewing’ is elaborated by providing a theoretical context for understanding its impact, with a summary of research on motivational interventions. An extension of this approach, the Drinker's Check-up (DCU), is described as a potential intervention for health screening, treatment selection and matching, cleint self-assessment, and research. Initial data from a sample of 42 problem drinkers receiving the DCU suggest that this intervention may increase help-seeking and modestly suppress alcohol consumption. This approach is interpreted within the broader context of research on minimal interventions for problem drinkers.
Outpatients from a V.A. outpatient substance abuse treatment program (N = 32) were assigned at random either to receive or not receive a brief motivational intervention in addition to standard outpatient treatment. The additional intervention consisted of two additional hours of assessment and a one-hour motivational interview. Control subjects received the same additional assessment, but with an attention-placebo interview in place of the motivational interview. Those assigned to receive the additional intervention demonstrated superior clinical outcome at three month follow-up on a composite variable composed of three individual variables: (1) total standard drinks, (2) peak blood alcohol level, and (3) percent days abstinent. These results were substantially corroborated by reports of significant others. By six month follow-up, the superiority of the treatment group was modest, and no longer significant. These findings support the utility of this approach for use with clinically severe alcohol populations on at least a time-limited basis.
Motivational interviewing is an approach based upon principles of experimental social psychology, applying processes such as attribution, cognitive dissonance, and self-efficacy. Motivation is conceptualized not as a personality trait but as an interpersonal process. The model deemphasizes labeling and places heavy emphasis on individual responsibility and internal attribution of change. Cognitive dissonance is created by contrasting the ongoing problem behavior with salient awareness of the behavior's negative consequences. Empathic processes from the methods of Carl Rogers, social psychological principles of motivation, and objective assessment feedback are employed to channel this dissonance toward a behavior change solution, avoiding the “short circuits” of low self-esteem, low self-efficacy, and denial. This motivational process is understood within a larger developmental model of change in which contemplation and determination are important early steps which can be influenced by therapist interventions. A schematic diagram of the motivational process and a six-step sequence for implementing motivational interviewing are suggested.(Received December 1982)
The objective of the study was to determine the effectiveness of advice from general practitioners to heavy drinking men (consuming 350–1050 grammes of alcohol per week) to reduce their alcohol consumption. One hundred and fifty-four men recruited from eight general practices were allocated randomly to treatment and control groups. Men in the treatment group received advice from their own general practitioner. At one year follow-up, when analyzed according to intention to treat, the treatment group had reduced their consumption by an excess of 65 grammes of alcohol per week when compared with the control group (p < 0.05). General practitioners should be recommended to screen for alcohol consumption amongst their patients and to give advice to those found to be at risk because of their drinking.
This paper reviews conceptual issues and research findings relevant to the secondary prevention of alcohol-related problems in the primary care setting. A discussion of public health concepts and recent epidemiological studies is followed by a review of screening procedures developed to identify individuals at risk. Representative programmes designed to reduce alcohol misuse and treat harmful drinking are summarized. The results of several systematic programme evaluations suggest that modest but reliable effects on drinking behaviour and related problems can follow from brief interventions, especially with the less serious type of problem drinker. The basic elements of these interventions include information giving, brief advice, self-help manuals, self-help groups and periodic monitoring of progress by the health worker. It is concluded that low intensity, brief interventions have much to recommend as the first approach to the problem drinker in the primary care setting.
In a continuing screening and intervention programme in Malmó, elevated serum‐yglutamyltransferase (GGT) values were used for selection of heavy drinkers. The study population consisted of 585 individuals born 1926–1933 with two consecutive GGT values in the upper decile of the GGT distribution, randomly allocated either to an intervention group of to a control group. The subjects in the intervention group were further investigated and 75% of them were judged to have elevated GGT values caused by alcohol consumption. These individuals were repeatedly encouraged to lower their overall alcohol consumption and GGT measurements were used as biofeedback method in the treatment program. The controls were informed by letter to be restrictive with their alcohol consumption and that they should receive new invitations for measurements of their liver enzymes after 2, 4, and 6 years. The intervention and control groups were well matched and followed over a 2–6‐year period.
Two and 4 years after the screening investigation, the GGT values in both groups were significantly decreased. There were differences, however, between the two groups with regard to sick absenteeism, hospitalization, and mortality. A significant reduction was found in sick absence during 4 years by 80%, in hospital days during 5 years by 60%, and in mortality during 6 years by 50% in the intervention group compared with the control group. Thus, the intervention program was effective in preventing medico‐social consequences of heavy drinking.
Physicians working at the General Medical Clinic of the Johns Hopkins Hospital entered into tutorials to improve their effectiveness as managers and educators of patients with essential hypertension. After exposure to a single teaching session, tutored physicians allocated a greater percent of clinic-visit time to patient teaching than did control physicians, achieving increased patient knowledge and more appropriate patient beliefs regarding hypertension and its therapy. Patients of tutored physicians were more compliant with drug regimens and had better control of blood pressure than patients of untutored physicians. The personal physician, if he is provided with strategies for identifying the noncompliant patient and for intervening in that behavior, can apply a stimulus to his patients that results in improved compliance and better control of hypertension.
How people intentionally change addictive behaviors with and without treatment is not well understood by behavioral scientists. This article summarizes research on self-initiated and professionally facilitated change of addictive behaviors using the key trans-theoretical constructs of stages and processes of change. Modification of addictive behaviors involves progression through five stages--pre-contemplation, contemplation, preparation, action, and maintenance--and individuals typically recycle through these stages several times before termination of the addiction. Multiple studies provide strong support for these stages as well as for a finite and common set of change processes used to progress through the stages. Research to date supports a trans-theoretical model of change that systematically integrates the stages with processes of change from diverse theories of psychotherapy.
The objective of the study was to determine the effectiveness of advice from general practitioners to heavy drinking men (consuming 350-1050 grams of alcohol per week) to reduce their alcohol consumption. One hundred and fifty-four men recruited from eight general practices were allocated randomly to treatment and control groups. Men in the treatment group received advice from their own general practitioner. At one year follow-up, when analyzed according to intention to treat, the treatment group had reduced their consumption by an excess of 65 grams of alcohol per week when compared with the control group (p less than 0.05). General practitioners should be recommended to screen for alcohol consumption amongst their patients and to give advice to those found to be at risk because of their drinking.
An interview survey of GPs working within one district health authority was cartied out in order to examine their views on the prevention of lifestyle-related disease. The 48 doctors (89%) who took part considered that prevention was an important part of their work, but were cautious about their effectiveness and over achieving change in many of their patients. Many expresed considerable concern about their ability to cope with the anticipated workload and the conflict with curative work, particularly when considering numbers of staff that could be made available.
The views of the doctors in this study reflect uncertainty about their ability to carry out effective prevention of lifestyle-related disease for the general population. This uncertainty is not unexpected given that the important risk factors are widely distributed in the population, and greatly influenced by social norms. This has important implications for the planning of health promotion activities. Although additional resources and skills for the orhanization and conduct of health education work are also required, this need must be dealt with alongside the concerns expressed by the doctors in the study. These problems might be addressed by a coordinated district strategy for the prevention of lifestyle-related disease, developed in conjunction with other agencies responsible for public health, and with community groups.
Stott N C H and Pill R M. ‘Advise yes, dictate no’. Patients' views on health promotion in the consultation. Family Practice 1990; 7: 125–131.
Interviews with 130 mothers of lower social class provided the basis for studying their views on the desirability of general practitioner intervention in their lifestyle habits; the study used both quantitative (questionnaire) and qualitative (interview) techniques. The majority of women were in favour of counselling on specific topics by the general practitioner but the qualitative data also revealed that most respondents expected the issues to be relevant to their presenting problem. Moreover they were keen to assert their right to accept or reject the advice given. The same picture was obtained whether specific or general approaches were used. The results highlight the need for qualitative methods to amplify and clarify the results of quantitative techniques when views or attitudes are being explored. The practical implications of the conclusions touch on both the ethical and clinical dimensions of health promotion.
Growing interest in the doctor-patient relationship focuses attention on the specific elements of that relationship that affect patients' health outcomes. Data are presented for four clinical trials conducted in varied practice settings among chronically ill patients differing markedly in sociodemographic characteristics. These trials demonstrated that "better health" measured physiologically (blood pressure or blood sugar), behaviorally (functional status), or more subjectively (evaluations of overall health status) was consistently related to specific aspects of physician-patient communication. We conclude that the physician-patient relationship may be an important influence on patients' health outcomes and must be taken into account in light of current changes in the health care delivery system that may place this relationship at risk.
In this article, a discussion of the definition and description of brief interventions is followed by broad reviews of their effectiveness in the cigarette smoking and alcohol fields. It is then argued that brief interventions should not be justified only in terms of early intervention; that there is at present insufficient evidence to warrant the abandonment of conventional outpatient treatment for clinic attenders; and that the relative contribution of motivational and active behaviour-change components of brief interventions is an important area for research.
This paper reviews conceptual issues and research findings relevant to the secondary prevention of alcohol-related problems in the primary care setting. A discussion of public health concepts and recent epidemiological studies is followed by a review of screening procedures developed to identify individuals at risk. Representative programmes designed to reduce alcohol misuse and treat harmful drinking are summarized. The results of several systematic programme evaluations suggest that modest but reliable effects on drinking behaviour and related problems can follow from brief interventions, especially with the less serious type of problem drinker. The basic elements of these interventions include information giving, brief advice, self-help manuals, self-help groups and periodic monitoring of progress by the health worker. It is concluded that low intensity, brief interventions have much to recommend as the first approach to the problem drinker in the primary care setting.
The appeal to general practitioners in the U.K. to take a more active role in the detection and management of alcohol problems has fallen largely on deaf ears. Yet the reasons general practitioners give for their reluctance to become more deeply involved in this area are often dismissed as mere ‘rationalizations’. This paper reports general practitioners’ perceptions of their experiences of diagnosing alcohol problems; their difficulties in offering the diagnosis to patients and the strategies they employ in attempting to do so; their attempts to offer help within general practice and their use of hospital services. The data are drawn from 33 interviews with general practitioners using an ‘open discussion’ technique. Some suggestions are made on ways of supporting the medical response to alcohol problems but it is argued that, in the long run, medical intervention is influenced by extraneous political and social factors and that changes are needed in public opinion about the use of alcohol.
This study was designed to see whether the offer and prescription of nicotine chewing gum would enhance the efficacy of general practitioners' advice to stop smoking. A sample of 1938 cigarette smokers who attended the surgeries of 34 general practitioners in six group practices were assigned by week of attendance (in a balanced design) to one of three groups: (a) non-intervention controls, (b) advice plus booklet, and (c) advice plus booklet plus the offer of nicotine gum. Follow up was done after four months and one year. The results show a clear advantage for those offered the nicotine gum (p less than 0.001). After correction for those who refused or failed chemical validation and those who switched from cigarettes to a pipe or cigars, the proportions who were abstinent at four months and still abstinent at one year were 3.9%, 4.1%, and 8.8% in the three groups, respectively. These percentages are based on all cigarette smokers who attended the surgeries including those who did not wish to stop and those in the gum group who did not try the gum (47%). The effect of the offer and prescription of gum was to motivate more smokers to try to stop, to increase the success rate among those who tried, and to reduce the relapse rate of those who stopped. The self selected subgroup of 8% who used more than one box of 105 pieces of gum achieved a success rate of 24%. It would be feasible and effective for general practitioners to include the offer of nicotine gum and brief instructions on its use as part of a minimal intervention routine with all cigarette smokers. A general practitioner who adopts such a routine with similar success could expect to achieve about 35-40 long term ex-smokers a year and so save the lives of about 10 of them. If replicated by all general practitioners throughout the country the yield of ex-smokers would be about one million a year.
This article has no abstract; the first 100 words appear below.
Although evidence that people can do much to promote their own health is growing, the role of the primary-care physician in helping patients change their health behavior is still problematic. At least one study has examined what physicians do to promote their own health.¹ Little is known, however, about the extent to which physicians promote the health of their patients, their success in helping patients change their behavior, or the types of training and support services physicians believe they need. This study examined the health-promotion beliefs, attitudes, and practices of a representative sample of primary-care physicians in Massachusetts. Methods The . . .
Source Information
From the Medical Foundation; the University Professors Program, Boston University; and the East Boston Neighborhood Health Center. Address reprint requests to Dr. Wechsler at the Medical Foundation, 29 Commonwealth Ave., Boston, MA 02116.
A 4-category classification of research on elements of provider-patient interaction that appear related to compliance behavior is presented. The first category describes research on pedagogical techniques employed by practitioners to inform patients in detail of the patient behaviors prescribed to deal with the medical problem. This category contains studies of both correlational and experimental design that support the hypothesis that greater provider explicitness regarding needed patient behaviors is associated with better patient follow-through. The second category of research deals with studies that indicate an association between extensive clinician-patient sharing of expectations about appropriate behaviors in the dyad and good patient compliance. In this category, research has not yet proceeded beyond correlational and descriptive research designs to experimental design. The third category contains studies that reveal links between the patient's assumption of responsibility for his own therapy and compliance. In this division the supporting research is both correlational and experimental. The final category contains research linking positive and supportive tone of the clinician-patient interaction with good patient adherence. Research design in this category has not yet reached the experimental level of development.The concepts and results of research in each category are quite promising. Randomize trials of methods of intervention derived from each category seem called for, though favorable results in different settings, with different combinations of treatments are by no means yet assured.
During the 1980s Motivational Interviewing emerged as one of the memes of the addictions field. This occurred despite the lack of scientific evidence supporting its utility. In this paper findings of a controlled trial of a brief motivational intervention with illicit drug users (n = 122) attending a methadone clinic are reported. Clients who met the study's inclusion criteria were randomly allocated to either a motivational (experimental, n = 57) or educational (control, n = 65) procedure. Over the 6-month follow-up period the motivational subjects demonstrated a greater, immediate, commitment to abstention, reported more positive expected outcomes for abstention, reported fewer opiate-related problems, were initially more contemplative of change, complied with the methadone programme longer and relapsed less quickly than the control group. There was, however, no difference in terms of the severity of reported opiate dependence and the control group fared better on reported self-efficacy. It was concluded that motivational interventions of the type investigated are useful adjuncts to methadone programmes.
In a controlled evaluation of general practitioner (GP)-based brief intervention, 378 excessive drinkers identified opportunistically by screening in 40 group practices in metropolitan Sydney were assigned to groups receiving: (i) a five-session intervention by the GP (the Alcoholscreen Program); (ii) a single session of 5 minutes' advice by the GP plus a self-help manual (minimal intervention); (iii) an alcohol-related assessment but no intervention; (iv) neither intervention nor assessment. Among all patients allocated to receive it, the Alcoholscreen Program did not result in a significantly greater reduction in consumption at follow-up than control conditions but patients offered Alcoholscreen reported a significantly greater reduction in alcohol-related problems in the period to 6 months follow-up. A greater proportion of patients who returned for the second Alcoholscreen visit were drinking below recommended levels at follow-up than in the remainder of the sample. There was no evidence that minimal intervention or alcohol-related assessment were effective in reducing alcohol consumption or problems. Implications for further research into GP-based brief interventions are discussed.
Although interest in clinical guidelines has never been greater, uncertainty persists about whether they are effective. The debate has been hampered by the lack of a rigorous overview. We have identified 59 published evaluations of clinical guidelines that met defined criteria for scientific rigour; 24 investigated guidelines for specific clinical conditions, 27 studied preventive care, and 8 looked at guidelines for prescribing or for support services. All but 4 of these studies detected significant improvements in the process of care after the introduction of guidelines and all but 2 of the 11 studies that assessed the outcome of care reported significant improvements. We conclude that explicit guidelines do improve clinical practice, when introduced in the context of rigorous evaluations. However, the size of the improvements in performance varied considerably.
Relatively brief interventions have consistently been found to be effective in reducing alcohol consumption or achieving treatment referral of problem drinkers. To date, the literature includes at least a dozen randomized trials of brief referral or retention procedures, and 32 controlled studies of brief interventions targeting drinking behavior, enrolling over 6000 problem drinkers in both health care and treatment settings across 14 nations. These studies indicate that brief interventions are more effective than no counseling, and often as effective as more extensive treatment. The outcome literature is reviewed, and common motivational elements of effective brief interventions are described. There is encouraging evidence that the course of harmful alcohol use can be effectively altered by well-designed intervention strategies which are feasible within relatively brief-contact contexts such as primary health care settings and employee assistance programs. Implications for future research and practice are considered.
Excellence in caring for the patient has been pursued in better technology and better management structures with multidisciplinary
teams. Excellence is increasingly sought through taking the whole person seriously and in developing better ways of working
with relationships. This paper traces the growth of ideas and their application in a university department of family medicine,
toward a holistic and more patient-centred, three-stage clinical method. This three-stage assessment helps the patient and
the physician to deal holistically with the problem. The biological, the psychological and the environmental systems as well
as their interrelationships are considered as they impact on health and illness. This method of arriving at a ‘best-fit’ understanding
of a person's problem, by the doctor and the patient together, helps to individualize the assessment and management. Excellence
is more likely to be found when we care in an individualized way within a systems understanding.
The practice patterns of individual clinicians are fundamental determinants of the quality, ethical standards, and cost-effectiveness of health services. The uncertainties inherent in medical practice are the direct result of biological variability and an enormous range of interchanges between a host of factors. Until recently the uncertainties have been ignored or obscured, but their implications are now being exposed through changes in health service organisation. The implications for the quality and costs of health care are such that it has become mandatory for clinicians, purchasers, and providers to recognise and understand the nature, importance, and influence of uncertainty in determining patterns of action. Paradoxically, it is becoming recognised that power traditionally vested within the health professions, especially doctors, seems to rest as much on uncertainty as on technical expertise.¹ Uncertainty has been identified as a major factor common to the key controversies being debated in relation to health-care policy determination.2
If general practitioners are to take an active role in the secondary prevention of problems connected with alcohol, they must
be able to discuss the subject in an adequate fashion. Interviews from a trial study showed that the greatest difficulties
were lack of time and fear of spoiling the relationship with the patient. Earlier studies indicate that the latter problem
may have several causes, in part arising from a desire not to infringe upon the integrity of the patient, and partly due to
condemnation of excessive drinkers. In other words, the root cause is often contradictory conceptions of alcohol problems
on the part of the physician. In order to ensure effective alcohol counselling in primary care, such conceptions must be dealt
with in future training courses.