CONTENTS

About This Course

Table of Contents

1. Introduction to the Issues
2. Understanding Alcohol Abuse
3. Understanding Violence Against Women
4. Alcohol and Domestic Violence
5. Alcohol, Sexual Assault, and Rape
6. Prevention and Early Intervention
7. Screening and Assessment
8. Diagnosis and Treatment
9. Legal and Ethical Issues

Supplements
Fact Sheets
Videos
Resources

Silence Hurts
Alcohol Abuse and Violence Against Women

Brief Interventions

	Abstinence	Low-Risk Use	At-Risk Use	Problem Use	Abuse/Dependence
Brief Intervention		X	X	X	X

A brief intervention involves one or more counseling sessions. The sessions may include:

• Motivation-for-change strategies
• Patient education
• Assessment and direct feedback
• Contracting and goal setting
• Behavior modification techniques
• Use of written materials, such as self-help manuals¹

Brief intervention techniques have been used to reduce alcohol use in several groups. These include adolescents, adults under age 65 who are nondependent problem drinkers, and most recently, older adults.^2,3 All of these activities can be conducted by trained clinicians, home health care workers, psychologists, social workers, and professional counselors.

Brief intervention strategies range from relatively unstructured counseling and feedback to more formal structured therapy. They rely heavily on concepts and techniques from the motivational psychology and behavioral self-control training literature.^4-7

The goal is to motivate the problem drinker to change behavior, not to assign blame. Therefore, drinking goals should be flexible. The individual should be allowed to choose drinking in moderation or abstinence.

Brief interventions have been shown to be effective in a variety of subjects over the past two decades. Between 10 and 30 percent of nondependent problem drinkers reduce their drinking to moderate levels after a brief intervention by a physician or other clinician.^8-10 Several ongoing studies of brief alcohol interventions are addressing older adults.

Research indicates that confrontation is particularly problematic with older adults and women who have been victimized, who may be experiencing shame and guilt. Furthermore, a confrontational approach is not a necessary aspect of alcohol intervention or treatment. It actually may increase defensiveness, denial, or treatment dropout.

After identifying at-risk or problem drinkers using screening techniques (see Module 7), a semi-structured brief intervention is recommended. Brief interventions may include any of the following steps:

• Provide customized feedback in the form of a health profile related to drinking patterns and other health habits, based on information the drinker has provided.
• Introduce the concept of a standard drink.
• Ask the person to consider changing, quitting, or cutting down.
• Discuss sensible drinking limits and strategies for cutting down or quitting. These include alcohol-free social gatherings and hobbies.
• Get a signed drinking agreement in the form of a prescription or contract to ensure the client is responsible for his or her actions.
• Discuss and develop strategies for coping with risky situations, such as negative family interactions.
• Summarize the session.

Positive change is more likely when the woman is motivated to take action on her own behalf. The following are key to inspiring motivation:

• The clinician's caring style
• Willingness to view the woman as a full partner in her recovery
• The capacity to provide hope and encouragement as the woman progresses through the referral, treatment, and recovery process

Motivational interviewing is a way to help people recognize their problems and increase their motivation to make changes. It is especially useful in resolving ambivalence. It is a supportive, respectful approach that is persuasive without being coercive.

This approach is particularly relevant when working with older persons. Understanding the conditions for persuading people who abuse alcohol to seek treatment and messages people who abuse alcohol can help.

A knowledgeable, positive, determined, hopeful orientation toward alcoholism and its treatment is indispensable in persuading abused and non-abused women to overcome denial and shame and seek help. One useful model for understanding motivation is FRAMES.¹¹

The acronym FRAMES stands for six key elements that have been shown to be effective in assisting persons with at-risk or problem drinking to change their drinking behavior:

• Feedback
• Responsibility
• Advice
• Menu
• Empathy
• Self-efficacy

Motivational interviewing differs in a number of ways from many traditional approaches to modifying problem behaviors. Motivational interviewing:

• De-emphasizes the use of labels such as alcoholic
• Emphasizes personal choice and responsibility for change
• Focuses on eliciting the patient's own concerns
• Understands that the role of the clinician can affect the level of resistance in the patient
• Uses reflection to meet resistance
• Negotiates, rather than prescribing, drinking goals and strategies

Motivational interviewing is an approach that circumvents certain aspects of interpersonal interactions that can sidetrack a discussion or reinforce resistance to change.

One critical aspect of the brief intervention is to elicit motivational statements from a patient. It is the clinician's task to facilitate the patient's expression of her reasons for changing her drinking as well as her resolve to change. Motivational statements tend to fall into four categories:

• Problem recognition
• Expression of concern
• Openness to change
• Optimism

It is important to reinforce statements that indicate a willingness to consider change. Each motivational statement may further help patients realize that the benefits of changing outweigh the costs.

References

1. Fleming, M. F., Barry, K. L., Manwell, L. B., Johnson, K., & London, R. (1997). Brief physician advice for problem alcohol drinkers: A randomized controlled trial in community-based primary care practices. Journal of the American Medical Association, 277, 1039-1045.
2. Blow, F. C. (1998). The spectrum of alcohol interventions for older adults. In E. S. L. Gomberg, A. M. Hegedus, & R. A. and Zucker (Eds.), Alcohol problems and aging, Research Monograph No. 33. NIH Publication No. 98-4163. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.
3. Fleming, M. F., Manwell, L. B., Barry, K. L., et al. (1999). Brief physician advice for alcohol problems in older adults: A randomized community-based trial. Journal of Family Practice, 48(5), 378-384.
4. Miller, W. R., & Taylor, C. A. (1980). Relative effectiveness of bibliotherapy, individual and group self-control training in the treatment of problem drinkers. Addictive Behaviors 5, 13-24.
5. Miller, W. R., & Hester, R. K. (1986). Inpatient alcoholism treatment: Who benefits? American Psychologist, 41, 794-805.
6. Miller, W. R., & Munoz, R. F. (1976). How to control your drinking. Englewood Cliffs, NJ: Prentice-Hall.
7. Miller, W., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.
8. Kristenson, H., Ohlin, H., Hulten-Nosslin, M. B., Trell, E., & Hood, B. (1983). Identification and intervention of heavy drinking in middle-aged men: Results and follow-up of 24-60 months of long-term study with randomized controls. Alcoholism: Clinical and Experimental Research 7(2), 203-209.
9. Wallace, P., Cutler, S., & Haines A. (1988). Randomized controlled trial of general practitioner intervention in patients with excessive alcohol consumption. British Medical Journal, 297(6649), 663-668.
10. Babor, T. F., & Grant, M. (1992). Project on identification and management of alcohol-related problems. Report on phase II: A randomized clinical trial of brief interventions in primary health care. Geneva, Switzerland: World Health Organization.
11. Miller and Rollnick (1991).