Correspondence Address:
Kumar Hemant Saurabh
Department of Psychiatry, Seth GS Medical College and KEM Hospital, Acharya Donde Marg, Parel, Mumbai - 400 012, Maharashtra
India

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Alcohol has been an important part of human civilization, be it major life events, formal celebrations, or just to “endure the operation of life.”[1] As postgraduates dealing with patients of alcohol dependence is an everyday phenomenon in outpatient department (OPD) or emergency settings. Understanding, motivating, and preventing relapse are a further challenge when dealing with patients. Being in an institute with a de-addiction center has helped us, residents, to undertake motivational enhancement therapy (MET).

MET is a systematic person-centered intervention approach based on motivational psychology principles aimed to evoke change in problem drinkers. It was studied in Project MATCH (1993) as an NIAA initiative [1] and is an advancement over Motivational interviewing (1991), developed by Miller and Rollnick.[2]

Prochaska and DiClemente gave a transtheoretical six-stage model of change: precontemplation, contemplation, determination, action, maintenance, and relapse.[3],[4] An individual moves through these stages in the process of modifying problem behaviors, regardless of treatment. My experience says that the majority of the clients are in the precontemplation or contemplation stage, brought to the OPD forcibly by the relatives. Most problem drinkers show failure in action or maintenance stage several times and have to re-enter the process in precontemplation, till they learn successful maintenance. MET encourages the clients to move toward effective maintenance, as quickly as possible.

MET approach assumes that the responsibility for change lies within the client. Mobilization of client's resources for the desired outcome is the key aim. It revolves around five basic motivational principles:

Expressing empathy - the therapist should respect the client, empathize with them and accept them as they are. They should be simultaneously given a friendly and supportive environment in the process of change. The therapist must seek for chances to compliment the client, instead of coercing the client aggressively, which might affect the client's participation. Reflective listening rather than telling is the key skill.

Developing discrepancy – client's awareness of personal consequences of drinking is raised. This would help the clients to perceive the discrepancy between where they lie and where they actually desire to be, and what is keeping them from the attainment of the desired goal.

Avoiding argumentation- in MET, the arguments for change in problem behavior are voiced by the clients, and not the therapist. The therapist only leads the clients to voice these arguments. The discrepancy and ambivalence, if handled poorly, may lead to defensive coping. Any direct argumentation or imposing a diagnostic label may be taken as an impractical offense on their drinking behavior.

Rolling with resistance – confrontation of resistance head-on exacerbates it further. Instead, the therapist should try shifting the client's focus, or simply go along with what the client is saying so that he stays in therapy. Helping the client to see the problem in a new light should be tried later.

Supporting self-efficacy – optimism needs to be ignited by making the clients believe they can accomplish change. Lack of hope may cause rationalization and therapy failure.

MET comprises four individualized, structured, scheduled therapy sessions, with up to 2 emergency sessions, all to be completed within 12 weeks of the initial session, following which the therapist is not permitted to see the client. Sobriety is ensured before each session. An extensive battery of assessment instruments precedes the therapy, and each session begins from the point it was left in the previous session and is finished with a summary and a personal feedback report (PFR) given to the client.

The therapy in these sessions is carried out in three phases. Phase 1 concentrates on building motivation for change. Depth of client's motivation is deciphered. Tipping the motivational balance from status quo toward change is the aim. Self-motivational statements are elicited through open-ended questions, by listening to the client carefully but with empathy, and selectively reflecting it back to reinforce expressed ideas. The client is led to see his own words and perceptions in a new light by reevaluating their problem behavior in a more optimistic frame.

Phase 2 of MET works to strengthen client's commitment to change. The therapist should not be in a haste to enter this phase. It should be ensured that the client has reached the determination stage. Any ambivalence, indecisiveness or guardedness needs to be explored and handled using Phase 1 strategies. At the same time, shift to action phase should not be delayed for too long; else the client might lose determination. The therapist is never supposed to “prescribe” a specific plan. The client needs to be reminded of his responsibility and freedom of choice. Positive and negative consequences of both changing and not changing are elicited, helping clients construct a “decisional balance sheet.” Accurate information and best advice within the general set may be given to help in decision-making. However, unlike in cognitive behavioral therapy, the challenge to plan specific strategies must be turned back to the client. A short-term trial abstinence may have to be recommended if there is reluctance for long-term commitment. A preprinted change plan worksheet is filled by the therapist based on the motivational dialog with the client. This worksheet incorporates the changes which the client wants to make, reasons for the changes, steps to be taken, possible obstacles, the ways others can help him to achieve these changes and the expected benefits. The client signs this worksheet once completed by the therapist.

Phase 3 involves follow-through strategies of reviewing client's progress since the previous session, renewing his motivation, and reaffirming client's commitment, thereby rejuvenating client's self-efficacy and autonomy. MET considers client resistance as therapist's problem. Any kind of argumentation, criticism, warning, dubiety, sarcasm, or confrontation with authority warrants shifting strategies to avoid resistance head-on and prevent its further exacerbation.

An important aspect of MET is the involvement of a significant other (SO), who may be a spouse, family member, or a close friend. Various alcohol-related studies have shown better response to therapy in a family or spouse-involved treatment compared to an individual approach.[5] The therapist enlightens the SO regarding the extent and severity of the problem, so that they work collaboratively with the client on development, implementation, and attainment of treatment goals in the first two sessions. However, at times, the SO may turn out to be an obstacle in motivation. Their indifferent or hostile attitude might worsen the drinking problem. This has also often been encountered by us.

All said about MET; it is obvious for us as postgraduates to yearn for its application and experience it in practice. There is evidence that MET can also be efficacious in eating disorders, problem gambling, and anxiety.[6] However, proper skill and training in MET are required to go along with the therapy in its systematic, recommended manner. There has always been a dearth of dedicated training programs in India when it comes to therapy, and MET is no different. Inadequate skills, if employed in any phase lead to failure of therapy. Identifying potential candidates for therapy is of extreme importance to begin with, apart from knowing when to move toward commitment, which is a challenge. Besides, handling resistance and SO disruptiveness may be difficult for us due to inexperience. Explaining the SO regarding the nature of therapy and their role is a task in itself. PFR and assessment instruments may be difficult in practice considering the educational status of many patients. Involvement of neuropsychologist may delay the therapy as getting early dates may not be feasible.

Time is considered as the biggest constraint, allowing only limited contact with patients. As postgraduates, even if the therapy as a whole is not feasible, utilization of motivational principles and strategies in daily interactions with patients, is the least that can be done. In spite of our busy schedules, MET can definitely be attempted for at least a few patients, as it is structured to be typically brief, with adequate inter-session duration, and rapid change as its focus. It has been seen that MET is particularly effective for individuals who have a strong resistance to change. Initial session of MET can therefore be started even for indoor-patients of alcohol dependence, while scheduling the later sessions after their discharge. Maintaining continuity of therapy through telephonic session reminders or hand-written notes is important but may not be always possible. MET restricts therapy duration to 12 weeks, however, in a government setup, declining a client thereafter for more sessions is difficult in practice.

While conducting an outpatient clinic, due to heavy patient load, especially in a government setup, frustration on seeing treatment failure seems inevitable, unknowingly leading the therapist to a confrontation-of-denial approach. Imposing diagnostic labels reduce personal choice and argumentation exacerbates the problem further. A huge deal of patience is warranted which is challenging undoubtedly but rewarding too in the long run.

Quoting Stephen Covey, “Motivation is a fire from within. If someone else tries to light that fire under you, chances are it will burn very briefly.” Instead, we need to help individuals add spark to that fire inside. As postgraduates, we are the future. If we take up this challenge, it will be a big step not just for de-addiction but for a better life quality of our patients, is what I believe!

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References