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Initial post
This week's case describes Dana, 41, referred by her primary care provider for anxiety. In the first session she says she drinks "a bottle of wine most nights to unwind" but that "it's not a problem, I just need help with my nerves." She is ambivalent about her drinking, which makes motivational interviewing (MI) a good fit.
Miller and Rollnick (2023) describe MI as a collaborative, goal-oriented style of conversation that strengthens a person's own motivation for change. It works through four overlapping processes: engaging (building a working relationship), focusing (agreeing on a direction), evoking (drawing out the person's own reasons for change) and planning (developing a commitment and a plan). Its core skills are often summarized as OARS: open questions, affirmations, reflections and summaries.
With Dana, I would start by engaging around what she wants help with, her anxiety, rather than confronting her about alcohol, which would likely provoke defensiveness. When she mentions drinking to unwind, I might reflect, "Wine helps you switch off at night, and you're also wondering whether it's part of why you feel on edge." That double-sided reflection acknowledges both sides of her ambivalence. Then I'd evoke change talk with open questions, such as "What do you notice about your anxiety the morning after you drink?" or "If you drank less, what might be different?" The goal is for Dana, not me, to voice the reasons for change.
If she moves toward change, planning could include a discussion of medication. A meta-analysis of 122 randomized trials found that acamprosate and oral naltrexone both reduced return to drinking, with a number needed to treat of 12 for acamprosate to prevent return to any drinking and 12 for naltrexone to prevent return to heavy drinking (Jonas et al., 2014). As a PMHNP, I could offer these alongside psychotherapy, while also treating her anxiety.
Question for the group: How do you respond when a client's sustain talk ("it's not a problem") is much stronger than their change talk?
Reply to a peer
Thanks, Alex, for your point that MI can feel slow when a client's drinking is risky. I agree that safety comes first: if Dana described withdrawal symptoms or drinking and driving, I'd address that directly. But I think the "righting reflex," our urge to fix the problem by telling the client what to do, often backfires. Miller and Rollnick (2023) suggest that arguing for change tends to make clients argue against it. I've found that asking permission first ("Would it be OK if I shared some information about alcohol and anxiety?") lets me give important information without taking over the conversation.
References
Jonas, D. E., Amick, H. R., Feltner, C., Bobashev, G., Thomas, K., Wines, R., Kim, M. M., Shanahan, E., Gass, C. E., Rowe, C. J., & Garbutt, J. C. (2014). Pharmacotherapy for adults with alcohol use disorders in outpatient settings: A systematic review and meta-analysis. JAMA, 311(18), 1889–1900. https://doi.org/10.1001/jama.2014.3628
Miller, W. R., & Rollnick, S. (2023). Motivational interviewing: Helping people change and grow (4th ed.). Guilford Press.
