Show and express empathy: This promotes acceptance and facilitates change.
Promote the perception of discrepancies and willingness to change: The patient himself/herself should provide the arguments for change.
Avoid arguments: Neither blame nor labels are constructive. Allegations generate only resistance.
Go along with the resistance of the patient: Accept the resistance of the patient to handle his/her inner conflicts.
Build confidence in self-efficacy: The patient is responsible for the decision to change and its implementation.
Basic Interventions
The task of physicians in independent practices and hospitals is to provide the patient an insight into the disease and to motivate him/her for the withdrawal treatment and the subsequent detoxification treatment. Four stages of readiness to change can be distinguished (Prochaska and DiClemente 1986):
Stage 1: From Precontemplation to Contemplation
Case Study
‘Asking about consumption behaviour’
Doctor: I’ve now completed my examination and I can say that I am presuming gastritis.
Patient: I am sure there is treatment available for it.
Doctor: Yes, there is. I would like to talk to you about possible maintaining factors and about your health behaviour. For example, do you consume alcohol and nicotine?
Patient: I quit smoking 7 years ago, from one day to the next. It was not a problem at all.
Doctor: And Alcohol?
Patient: Yes, I drink now and then. But that’s normal.
Doctor: A lot of people drink regularly, that’s true. How much do you consume?
Patient: About three to four beers in the evening. You have to understand! After work, I am finished. Currently, we are under a lot of pressure, and I’m a little worried of losing my job.
Doctor: That is, you drink to be able to relax better.
Patient: Yes, then I sleep wonderfully.
Doctor: What’s the maximum that you can drink on an evening?
Patient: Well, at the weekend I had half a bottle of cognac. But I don’t feel much, I’m not really drunk.
Doctor: And the next day?
Patient: I feel good, no problem. I can tolerate quite a bit.
Doctor: Have you thought about reducing your alcohol consumption?
Patient: Hmm…my wife keeps making comments.
The diagnosis of alcohol dependence is clearly communicated to the patient without demonization.
Case Study
‘Communicating the diagnosis of addiction’
Doctor: After all that you’ve told me, and together with the results of the blood test, my diagnosis at this stage would be ‘alcohol dependence’.
Patient: Oh, come on! What are you telling me?
Doctor: I can understand your reaction. It sounds like condemnation. But that’s not what it is about. It’s about me telling very clearly what my findings are.
(Pause)
Patient: Yes, what do we do now?
Doctor: That’s the right question. What does the diagnosis imply in terms of changes?
Patient: Less drinking, I can see that, okay.
Doctor: This is also very important to recognize. Alcohol dependence is a disease and not a character flaw. And I advise you very clearly to avoid alcohol completely in the future.
Patient: What do you mean, completely? How can I possibly do that?
Stage 2: From Contemplation Towards Action
Building motivation includes the identification of discrepancies in behaviour and raising awareness of the patient, addressing his/her ambivalent stance on abstinence and coming jointly to a decision.
The patient experiences the dependence in an ambivalent manner: On one hand, he/she realises that it has assumed the form of a disease and that he/she must do something about it. On the other hand, it is the nature of addiction, to protect oneself from unbearable feelings, to balance insurmountable tensions and to create wellbeing. The patient cannot imagine having to give up the comforting companion. The result is a mixture of guilt, fear and servility. Patients develop avoidance strategies regarding a detoxification treatment. This explains why they seem to listen to the consultation patiently and attentively, but internally have long since zoned out. The doctor feels this ambivalence, and should pick it up.
Case Study
‘Promotion of readiness for change’
Patient: Never drinking again, right? I don’t think I can do this.
Doctor: Here, I am more confident than you! If you think about smoking, you were able to do that! I think that you could easily succeed to quit drinking alcohol also.
Patient: You may be right, indeed. But to be honest, I am not sure if I really want to.
Doctor: I have the impression that you are still divided on the inside. One part very clearly recognizes that you are addicted to alcohol and need help. Another part does not want to quit drinking and is fearful what might happen during a possible treatment. You are faced with a decision in which there are reasons for and against.
Stage 3: Action Phase
This includes emphasizing the freedom of choice, to encourage abstinence and to create a plan for change, together with the patient.
Motivation is not seen as something static, rather as a dynamic, process-like procedure, which requires a specific approach for each phase.
Stage 4: Maintenance Phase
Relapse is more a rule than exception, it is not an addiction-specific phenomenon, but is a part of the ‘normal’ course of the disease. Outpatient follow-up (self-help groups, counselling, psychotherapy) prevents and can catch incipient relapses effectively. Recidivists avoid self-help groups more often than abstainers, even though the groups are extremely helpful, especially for them.
How Can We Prevent Individual Relapses?
Early recognition and acceptance of risk situationsRelated posts:
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