Assignment 1 – Alcohol Vignette

Case Formulation: Cassidy is a 40 year old female with evidence of a moderate alcohol misuse disorder. She has a history of alcohol use first starting at the age of 16, with regular drinking for the past seven years consisting of 2-3L of wine per week. Cassidy also has elements suggestive of a depressive disorder evidenced by her mood such as her becoming ‘snappy’ with her children and finding it difficult to get up in the morning suggesting amotivation. Cassidy also has many social stressors including being a single parent of two young children, stressful occupation and limited social supports.

Motivational interviewing (MI) would be an appropriate treatment for this patient. MI is used to enhance intrinsic motivations to change behaviours via facilitating exploration and resolution of ambivalence to change (1). The principles of MI include expressing empathy through reflective listening, helping the patient to identify discrepancies between their problematic behaviours and broader personal values, rolling with resistance and supporting self-efficacy (2, 3). The fundamental process of MI to achieve these principles include engaging the patient using appropriate communication strategies, guiding the patient via agenda setting and providing information, evoking the patient’s own motivations to change and then aiding in planning to enact change (2).

The basic skills of MI used in engaging the patient are commonly referred to as the OARS skills. OARS is an acronym for open ended questions, affirmations, reflections and summaries (2, 4). Asking open ended questions ensures that the patient does most of the talking and allows the practitioner to learn more about the patient’s values and goals. Affirmations help to build rapport and validate and support the patient during the stressful period of change. Reflections are used to rephrase and capture the meaning of what the patient is saying in addition to encouraging further personal exploration to better understand their own motivations. Summarising is used to ensure mutual understanding as well as highlighting discrepancies (2, 4).

The fifth skill used in MI is eliciting change talk which aims to resolve ambivalence and enables the patient to present arguments for change (5). Ultimately, MI does not make attempts to confront irrational or maladaptive beliefs, but rather attempts to guide patients in a supported way to allow them to self-detect discrepancies between their current actions and behaviours and who they ideally want to be (5).

There is extensive evidence supporting the use of MI. MI was chosen for this patient as they are in either the pre-contemplation or contemplation stage of change and can therefore aid the patient in identifying and resolving any ambivalence they may have to change. A study of 215 women demonstrated reductions in alcohol with intensive MI at 2 months with further reductions demonstrated at 6 months (6). A further reason for the selection of MI in this patient is that there is evidence to support the use of MI in alcohol use disorders with comorbid depression. A study of 104 participants demonstrated reductions in hazardous drinking in patients with depression (7). Another study in 2016 supported the use of MI in reducing hazardous drinking in patients with depression (8). A meta-analysis of 15 randomised control trials demonstrated that MI is an effective treatment for reducing alcohol consumption (9). Furthermore, a sub-analysis of 9 studies showed that MI was more efficacious in managing alcohol problems than a range of other treatments (9). In addition, to optimise this patient’s care, additional psychotherapies should be used in conjunction with MI (10).

Relapse prevention (RP) is a cognitive-behavioural approach focussing on identifying and managing high risk situations for relapse (11). RP aims to train patients in coping skills and also use cognitive restructuring to modify maladaptive beliefs and expectancies and improve perceived self-efficacy (12). Appropriate RP skills for this patient would include assertiveness training, communication skills to cope with social pressures and arousal reduction strategies such as relaxation skills to manage anxiety. Cassidy would also benefit from cognitive reframing of lapses, coping imagery for cravings and introduction of lifestyle interventions such as physical activity and other activity scheduling to help manage cravings which will also help with her depression.

References

1. Hettema J, Steele J, Miller WR. Motivational interviewing. Annual review of clinical psychology. 2005;1:91-111.

2. Miller WR, Rollnick S, Rollnick SP, Proquest EBook Central. Motivational Interviewing : Helping People Change. 3rd ed2013. 1 online resource (498 pages) p.

3. Jhanjee S. Evidence based psychosocial interventions in substance use. Indian J Psychol Med. 2014;36(2):112-8.

4. Hall K, Gibbie T, Lubman DI. Motivational interviewing techniques – facilitating behaviour change in the general practice setting. Aust Fam Physician. 2012;41(9):660-7.

5. Resnicow K, McMaster F. Motivational Interviewing: moving from why to how with autonomy support. Int J Behav Nutr Phys Act. 2012;9:19-.

6. Polcin DL, Nayak MB, Korcha R, Pugh S, Witbrodt J, Salinardi M, et al. Heavy Drinking among Women Receiving Intensive Motivational Interviewing: 6-Month Outcomes. J Psychoactive Drugs. 2019:1-10.

7. Satre DD, Delucchi K, Lichtmacher J, Sterling SA, Weisner C. Motivational interviewing to reduce hazardous drinking and drug use among depression patients. Journal of substance abuse treatment. 2013;44(3):323-9.

8. Satre DD, Leibowitz A, Sterling SA, Lu Y, Travis A, Weisner C. A randomized clinical trial of Motivational Interviewing to reduce alcohol and drug use among patients with depression. Journal of Consulting and Clinical Psychology. 2016;84(7):571-9.

9. Vasilaki EI, Hosier SG, Cox WM. The efficacy of Motivational Interviewing as a brief intervention for excess drinking: A meta-analytic review. Alcohol and Alcoholism. 2006;41(3):328-35.

10. Drug and Alcohol Psychosocial Interventions Professional Practice Guidelines. NSW Health Centre for Population Health; 2008.

11. McHugh RK, Hearon BA, Otto MW. Cognitive behavioral therapy for substance use disorders. Psychiatr Clin North Am. 2010;33(3):511-25.

12. Sudhir PM. Cognitive behavioural interventions in addictive disorders. Indian J Psychiatry. 2018;60(Suppl 4):S479-S84.