A 24-year-old man comes to the office because of mood changes. He has felt depressed, irritable, and anxious nearly every day for 2 months. The patient has difficulty getting out of bed in the mornings and staying focused at work. He has no medical conditions and takes no medications. The patient drinks 3 or 4 beers daily and more on weekends. The physician provides education about the link between alcohol and mood changes. The patient responds, "But it really helps me to unwind and relax after a long workday and makes it easier to fall asleep. It's also how I hang out with my friends on weekends. I can't see quitting." Which of the following is the most appropriate statement by the physician at this time?

Question

A 24-year-old man comes to the office because of mood changes.  He has felt depressed, irritable, and anxious nearly every day for 2 months.  The patient has difficulty getting out of bed in the mornings and staying focused at work.  He has no medical conditions and takes no medications.  The patient drinks 3 or 4 beers daily and more on weekends.  The physician provides education about the link between alcohol and mood changes.  The patient responds, "But it really helps me to unwind and relax after a long workday and makes it easier to fall asleep.  It's also how I hang out with my friends on weekends.  I can't see quitting." Which of the following is the most appropriate statement by the physician at this time?

Quizplus · Accepted Answer

11ec160b_3666_c9ec_9249_dd5b733f560e_MD0001_00 This patient believes that alcohol plays a beneficial role in his life (helping with relaxation, sleep, and socialization) and explicitly states that he does not want to quit. Motivational interviewing is a patient-centered approach to help change maladaptive behaviors; it matches strategies to the patient's stage of readiness to make a change. The goal is to develop the patient's own intrinsic motivation to change, rather than using pressure to motivate change. This patient should be educated about the link between mood and alcohol to help him see the discrepancy between continued alcohol use and his goal of not being depressed. However, direct confrontation of his resistance to change (eg, advising the patient not to drink, dwelling on adverse consequences of alcohol use) is likely to make him feel misunderstood, attacked, or criticized and may lead to conflict or defensiveness. It is more productive to acknowledge the patient's resistance to change as a starting point. This involves reflecting the patient's view that alcohol helps him relax and then encouraging discussion of any downsides to drinking from his perspective. In this way, the patient is encouraged to identify ambivalent feelings about drinking that can help him begin to make his own arguments for change. (Choice A) This statement focuses on the negative aspects of alcohol use and insists that it be addressed, which may lead to defensiveness rather than change. Instead, the patient's resistance should be respected, and his internal motivation encouraged. (Choice B) Although this response initially acknowledges the patient's perspective, it then makes an assumption that may be experienced as judgmental. It would be better to encourage an open-ended discussion about how the patient himself understands his alcohol use. (Choice D) This approach prematurely focuses on alternative behaviors without first developing the patient's ambivalence about drinking and intrinsic motivation to make a change. The patient should be encouraged to come up with possible alternative behaviors himself rather than forcing suggestions on him. (Choice E) Although this statement accurately reflects the patient's current lack of readiness to make a change, it does not encourage discussion and prematurely terminates any efforts to facilitate change. Educational objective: Motivational interviewing is a patient-centered approach to help change maladaptive behaviors; it matches strategies to the patient's stage of readiness to make a change. This includes acknowledging the patient's resistance and developing the patient's own motivation to change.

A 24-Year-Old Man Comes to the Office Because of Mood