Motivation and emotion/Book/2020/Brief motivational interventions for problematic alcohol use

Overview
Brief motivational interventions are regularly used to elicit individual behaviour change (McNally et al., 2005). The focus of these interventions is to educate individuals about negative consequences of problematic behaviour and to provide strategies to cope with environments that may lead to the problem behaviours (Borsari et al., 2009). Commonly, brief motivational interventions are used for health behaviour problems such as alcohol misuse (McNally et al., 2005; Borsari et al., 2009; Carey et al., 2006; Magil et al., 2017). The academic literature in this area suggests the demographics at highest risk of heavy drinking patterns and associated harms are individuals aged from 17 to 25 years who are typically in tertiary education (Magil et al., 2017; Dunn et al., 2019). The literature proposes that motivational interviewing, alcohol education and awareness, and readiness for change strategies all have promising components for promoting behaviour change, although there are also criticisms about these interventions (Nyamathi et al., 2010; Michael et al., 2006; Carey et al., 2006; Barnett et al., 2006; Borsari et al., 2009; Dunn et al., 2019).


 * Focus questions:
 * 1) What are brief motivational interventions?
 * 2) What constitutes problematic alcohol use and their associated harms?
 * 3) What are the motivational interventions used for problematic alcohol use?

Jack is a 20-year-old, full-time university student, studying a Bachelor of Design. Jack has a part-time job at a café near his house and spends most of his time with friends from school and some he has made at university. Often the suggestion is made to go to the local university pub, or out to the city on student nights. Jack typically engages in frequent heavy drinking in the presence of his friends and as a result he often makes reckless decisions, becomes aggressive, and engages in unsafe casual sex. Jack recognises that his behaviour can be dangerous, but reassures himself that everyone drinks heavily, so why should he change?
 * Case study (part one)

What are brief motivational interventions?
Motivational interventions have proven to be effective for behaviour change in both short and long-term contexts (McNally et al., 2005). Brief motivational interventions are designed to reduce problematic behaviour and have the participant recognise their behaviour and its consequences (Borsari et al., 2009). Commonly, brief motivational interventions are structured in two parts: assessment and motivational strategies (Carey et al., 2006):
 * 1) The first component, assessment, is effective at producing behaviour changes, providing education and awareness for the consequences of engaging in problematic behaviours (Carey et al., 2006).
 * 2) The second component, motivation strategies, are most effective if more than one is used, these also vary depending on the behaviour (Carey et al., 2006).

The literature highlights the importance of initial intervention, with follow-up assessments varying from six weeks to three months after the initial intervention (Borsari et al., 2009; Magil et al., 2017; Dunn et al., 2019).

Motivational interventions are particularly important in the correlation between behaviour change and problematic alcohol use (McNally et al., 2005; Borsari et al., 2009; Carey et al., 2006; Magil et al., 2017). Changing problematic alcohol use takes on the components that are reflective of motivational interventions, including awareness of consequences, developing motivational strategies and typically involves a population not seeking treatment (McNally et al., 2005; Borsari et al., 2009; Carey et al., 2006; Magil et al., 2017). Types of motivational interventions in the literature involve motivational interviewing, education and awareness, and readiness for change programs (McNally et al., 2005; Borsari et al., 2009; Carey et al., 2006; Magil et al., 2017; Dunn et al., 2019).

Motivational interviewing is the most commonly used motivational intervention technique for problematic alcohol use (Carey et al., 2006). Typically, students of clinical and counselling psychology are used to administer motivational interviewing techniques focusing on regular drinking patterns, education and awareness measures (Carey et al., 2006). Education is regularly used alongside motivational interviewing, emphasising the importance of adequate knowledge about why a behaviour could be problematic, and understanding the consequences of these behaviours (Carey et al., 2006). Readiness for change techniques encourage behaviour change and are administered in a questionnaire form, which aims to uncover patterns of problematic behaviour (Borsari et al., 2009). There are conflicting findings with readiness for change measures because the effectiveness of motivational interventions stems from the target population of non-treatment seeking individuals (Magil et al., 2017). Readiness for change is dependent on an individual’s willingness and likelihood to make a behavioural change (Borsari et al., 2009). Non-treatment seeking populations are often the target for brief motivational interventions, although individuals aged 17 to 25 years, who are typically in tertiary education, are important populations for these kinds of interventions (McNally et al., 2005; Borsari et al., 2009; Carey et al., 2006; Magil et al., 2017; Dunn et al., 2019).

Problematic alcohol use and associated harms
Drinking behaviour guidelines vary cross-culturally, by gender and age groups. Several psychological theories and models can explain why heavy drinking patterns occur.

What constitutes problematic alcohol use?
Excessive and long-term drinking of alcohol subjects people to impaired judgement, health risks and alcohol dependency (Australian Institute of Health and Welfare, 2018). The National Health and Medical Research Council identified for adult men and women, the recommended guidelines for alcohol consumption is a maximum of four standard drinks in one day, and a maximum of ten standard drinks each week (National Health and Medical Research Council, n.d.). 1 in 6 individuals have a pattern of excessive drinking, increasing their risk of alcohol-related disease and injuries (Australian Institute of Health and Welfare, 2018). Risky drinking patterns are also linked to violent behaviours, memory problems and mood swings (Dasgupta, 2011). There are several risk factors that constitute problematic alcohol use; demographic, familial, behaviours and biological risk factors are significant to contributing to alcohol patterns (Kramer et al., 2008). High-risk drinking incorporates binge and heavy drinking and as with other abuses of substances, excessive alcohol consumption can lead to prolonged health effects (Li, 2008). Chronic abuse of alcohol leads to several health impacts including liver disease, cancers, and adverse effects on the heart and immune system (Dasgupta, 2011).

High risk ages and population groups


Problematic alcohol use can occur at any age, although there are suggestions that young adults are considered most at risk (Magil et al., 2017; Dunn et al., 2019). The literature on problematic alcohol patterns and interventions focus on individuals in tertiary education environments and the age group these individuals typically make up (Magil et al., 2017; Dunn et al., 2019). Commonly, participants in these studies range from 17 to 25 years old and enrolled in post-secondary education (Magil et al., 2017; Dunn et al., 2019). Young adults in university/college are often subject to risky patterns of drinking behaviour including binge drinking and associated harms and consequences (e.g., violence and unsafe sexual practices) (Dunn et al., 2019). Dangerous drinking patterns for this demographic is associated with poor academic and social outcomes (Dunn et al., 2019; Carey et al., 2006). The definition of problematic alcohol use differs cross-culturally and between genders, with different recommendations for the amount that is acceptable to consume and how often (Kerr-Corrêa et al., 2007). The 2001 National Health and Medical Research Council (as cited by Kerr-Corrêa et al., 2007) recommendations for Australians is up to 28 drinks for men in a week, with the USA guidelines of 1995 (as cited by Kerr-Corrêa et al., 2007) recommending up to 14 drinks for men per week (Kerr-Corrêa et al., 2007). Biological risk factors for developing a poor relationship with alcohol involve deficits in impulse control, where a person is more likely to make risky choices and neglect negative consequences (O’Halloran, et al., 2015). The role of social influences is important in an individual’s drinking pattern, particularly in young adults and university students (Hussong, 2003). Conforming to the drinking patterns of the social group is associated with affiliation and selection which maintains the reciprocal process of friendships in a group (see Figure 1) (Hussong, 2003).

Theories and frameworks
Three theories and frameworks proposed in literature to explain problematic alcohol use.

Cognitive dissonance theory
Festinger’s cognitive dissonance theory can be used to explore motivation to change behaviour, explaining that cognitive dissonance a''Firises when there is incongruence with decisions and attitudes (Harmon-Jones & Mills, 2019). With behaviour change, particularly in substance abuse situations, the proposal is that creating awareness of problematic behaviour will create inconsistencies that propel an individual to changing their behaviour (Miller, 1983). A person is motivated to reduce dissonance, by changing drinking behaviour (see Figure 2) (Miller, 1983). Literature suggests that cognitive dissonance mechanisms may be effective for young adult age groups who manage responsibilities and can be subjective to the discrepancies between alcohol and negative impacts (Magil et al., 2017). A study by Magil et al. (2017) revealed that cognitive dissonance was positively correlated with motivation to change current behaviour and had a negative association with future drinking.''

Self-regulation theory
Self-regulation theory, proposed by Brown (1998, as cited by Carey et al., 2006), relates closely to cognitive dissonance theory, in that an individual recognises their behaviour is not consistent with norms of the society. Self-regulation has been integrated into motivation interventions for drinking behaviour as it is necessary for planning effortful goal behaviours (Hustard et al., 2009). The three main areas of self-regulation include:
 * 1) self-monitoring
 * 2) self-evaluation
 * 3) self-reinforcement (Hustard et al., 2009).

It is proposed that the predictability on whether a person is susceptible to alcohol consequences relates to a low level of self-regulation and preference for immediate gratification (Hustard et al., 2009).

Transtheoretical model


The transtheoretical model of change (see Figure 3) is a widely used motivational intervention for changing behaviour that guides behaviour through a process of five stages (Prochaska et al., 2004):
 * 1) pre-contemplation
 * 2) contemplation
 * 3) preparation
 * 4) action
 * 5) maintenance

Transitioning from a pre-contemplation to contemplation stage involves a readiness to change mentality (Demmel et al., 2004). The literature does criticise this model for focusing heavily on the stages of change and frequent regression through the stages that occur before concrete behaviour change is made (Sutton, 2001). There are also questions about the ability to translate effective results from real life to experimental environments, making it more difficult to determine real life changes this model predicts (Armitage, 2010).

Motivational interventions for problematic alcohol use
Many brief motivational interventions can be used for problematic alcohol use and behaviour change, with three main techniques highlighted most in the literature.

Motivational interviewing
Motivational interviewing involves a session which aims to motivate behaviour change (Nyamathi et al., 2010). Often motivational interviewing is conducted with one participant, although group sessions have also proven to be effective in reducing problematic alcohol patterns (Michael et al., 2006). Questionnaires and other techniques are used in motivational interviewing sessions to assess current and future alcohol patterns, and the reasons as to why an individual engages in these behaviours (Dunn et al., 2019). Importantly, strategies are given to assist with reducing drinking patterns and aiding skills to cope with environments that may subject them to risky drinking behaviours (Carey et al., 2007). Brief group motivational interviewing sessions promote a discussion on alcohol patterns, benefits and negatives of alcohol use (Michael et al., 2006). Allowing participants to engage in a discussion with individuals of a similar age, facilitated by a professional, aids the process of change (Michael et al., 2006). The education component of motivational interviewing, both in a group or individual setting, allows participants to understand the benefits of alcohol but also the genetic predispositions and long-term effects problematic and prolonged alcohol use can cause (Michael et al., 2006).

Although motivational interviewing is a popular and effective technique in eliciting behaviour change with individuals with problematic alcohol patterns, the intervention has limitations (Dunn et al., 2019). This intervention requires a trained professional, both in counselling techniques and alcohol education (Dunn et al., 2019). Although group sessions are effective, the literature argues the most effective outcomes for behaviour change occur when a session is delivered individually (Nyamathi et al., 2010; Carey et al., 2007).

Table 1.

Comparison of literature results

Alcohol education and awareness
Education programs are usually the first intervention used but have been criticised in the literature as an intervention that may not have concrete effectiveness (Carey et al., 2006; Barnett et al., 2006). Education about alcohol can increase an individual’s awareness of the impacts of risky alcohol patterns (Carey et al., 2006). The literature criticises that a solely education-based program does not have effective outcomes on behaviours and attitudes on alcohol (Carey et al., 2006). Therefore, education used collectively with other interventions, with a focus on risk reduction and negative consequences is necessary (Barnett et al., 2006). In a study by Barnett et al. (2006), motivational interventions were compared to alcohol education, to test the effectiveness of a single education session. Interestingly, positive outcomes were revealed, with the researchers claiming that alcohol use was reduced in some cases where the participant used the education session to communicate alcohol-related impacts with a professional in a comfortable setting (Barnett et al., 2006). For solely education-based interventions to work, the individuals need to have made a start at changing behaviour or recognise their behaviour has adverse effects as a result of alcohol consumption (Barnett et al., 2006)

Table 2.

Comparison of literature results

Readiness for change
Alcohol-related behaviour change interventions are most effective when the individual is willing to make the change for themselves (Dunn et al., 2019; Prochaska et al., 2004). The transtheoretical model is integrated into this intervention, with the focus on progressing the individual from the pre-contemplation through to the maintenance stage of change (Dunn et al., 2019). Better outcomes are produced when the participant is actively engaged in the intervention (Dunn et al., 2019). Although this intervention has promising results, there are criticisms associated with the cyclical nature of the transtheoretical model which mediates an individual’s readiness for change (Borsari et al., 2009). Behaviour change does occur, although it is difficult to determine the long-term outcomes of readiness for change interventions (Borsari et al., 2009). The assessment of an individual’s readiness for change is determined by a questionnaire defining at what point someone is at and how likely they are to make a positive change (Borsari et al., 2009). Importantly, follow-ups after initial interventions are important in ensuring consistency with behaviour change, with the studies in literature follow-up on participants from four to six weeks post-intervention (Borsari et al., 2009; Dunn et al., 2019). The questionnaires indicating readiness to change problematic behaviour is paired with goal-setting and motivational strategies and developing skills to promote long-term behaviour change (Dunn et al., 2019).

Table 3.

Comparison of literature results

Conclusion
Jack was encouraged to seek out an intervention for his drinking patterns through the university after his grades and attendance started declining. After meeting with the university counsellors, Jack made the decision that motivational interviewing was the option he wanted to take. After a short session, Jack openly spoke about his drinking patterns and negative consequences he experienced and was given information about the long-term effects this continued behaviour could have on his life. Motivational strategies, coping skills and goals were made to help Jack recognise and understand why his behaviour needed to change. Jack was advised to come back for a follow up in six weeks to reassess his situation.
 * Case study (part two)

Brief motivational interventions are techniques used to elicit behaviour change (McNally et al., 2005). Commonly, problematic alcohol use is the subject of many studies on brief motivational interventions (McNally et al., 2005; Borsari et al., 2009; Carey et al., 2006; Magil et al., 2017). Individuals aged 17-25 are at the highest risk of engaging in heavy drinking and experiencing associated harms (Magil et al., 2017; Dunn et al., 2019). Motivational interviewing, education and awareness, and readiness for change interventions are popular (Nyamathi et al., 2010; Michael et al., 2006; Carey et al., 2006; Barnett et al., 2006; Borsari et al., 2009; Dunn et al., 2019). Motivational interviewing seeks the best results amongst the literature, with education and readiness for change models also showing improvements in drinking reduction but prove more effective when integrated into other techniques (Nyamathi et al., 2010; Michael et al., 2006; Carey et al., 2006; Barnett et al., 2006; Borsari et al., 2009; Dunn et al., 2019).

Research lacks long-term follow-ups, making it difficult to determine how effective these interventions are beyond three months (Borsari et al., 2009; Magil et al., 2017; Dunn et al., 2019). There is an emphasis on 17-25 years olds, so it would be interesting to see impacts of these interventions on different age and cultural groups (Magil et al., 2017; Dunn et al., 2019).

What can be taken away from this chapter is the emphasis on interventions for young adults and risky drinking patterns consistent with this age group. Many of the interventions mentioned are effective in their own rights individually, but components of each working in an integrated approach would see more impactful results.