ENCOURAGING GP ALCOHOL INTERVENTION: PILOT STUDY OF CHANGE-ORIENTATED REFLECTIVE LISTENING (CORL)

Jim McCambridge*, Simon Platts, David Whooley and John Strang

National Addiction Centre (The Maudsley/Institute of Psychiatry), London, UK

* Author to whom correspondence should be addressed at: National Addiction Centre (The Maudsley/Institute of Psychiatry), Addiction Sciences Building, 4 Windsor Walk, Denmark Hill, London SE5 8AF, UK. E-mail: j.mccambridge{at}iop.kcl.ac.uk

(Received 15 August 2003; first review notified 2 October 2003; in revised form 5 November 2003; accepted 30 November 2003)


    ABSTRACT
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 APPENDIX 1: INTERVIEW SCHEDULE
 REFERENCES
 
Aims: To test the feasibility of delivery and potential value of a brief motivational enhancement intervention targeting GPs in relation to alcohol as a public health issue, and to compare data obtained with similar attempts to influence GP intervention with drug users. Method: 21 GPs who were not involved in the treatment of drug dependence received a telephone-administered ‘change-orientated reflective listening’ (CORL) intervention, based on Motivational Interviewing, with an informational adjunct. Assessments were made at baseline and at 2–3 months of activity and willingness to deliver specified alcohol-related interventions, plus overall therapeutic commitment and motivation. Qualitative data was obtained. Results: There was no change over time in the sample as a whole, with very modest evidence of benefit among individual practitioners. Comparisons with cannabis and drug misuse intervention targets suggest that it may be more difficult to alter views on intervening with drinkers. Conclusions: Further attempts are needed to influence practitioner motivation, based on improved understanding of GP views on the delivery of alcohol interventions.


    INTRODUCTION
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 APPENDIX 1: INTERVIEW SCHEDULE
 REFERENCES
 
General practitioners in the UK have been encouraged to screen for, and intervene with, hazardous and harmful drinking for the last quarter of a century (Department of Health and Social Services, 1978Go). The effectiveness of brief interventions with those not seeking alcohol treatment has been repeatedly demonstrated in meta-analyses (see Moyer et al., 2002Go). However, national survey data reveal that, on average, only 3.2 patients are identified as hazardous drinkers each month in general practice, with only a minority of these patients identified by practitioner activity (Deehan et al., 1998Go). Attempts to encourage GPs to avail themselves of training and to become more involved in this area of work have included personal and social marketing, though results have been disappointing (Kaner et al., 1999Go). Changing practitioner behaviour in other areas, for example, to deliver more patient-centred care, has also been found to be far from straightforward (Lewin et al., 2003Go).

Throughout the entire period of encouragement of GP alcohol intervention, barriers to such activity have been studied. Role legitimacy, adequacy, support and attitudinal components have been identified as important, and measured. Substantial motivational elements and situational constraints have also been considered (Shaw et al., 1978Go; Cartwright, 1980Go; Lightfoot and Orford, 1986Go). GPs need to have a clear sense that this activity is consistent with their role and manageable in practice, that they are proficient, and that there is support available should it be needed, if they are to be motivated to intervene in this area.

Motivational Interviewing is primarily concerned with the resolution of ambivalence about change, and for which the evidence base in different applications is accumulating (Miller and Rollnick, 2002Go). It is an approach which might be applied to changing the professional behaviours of health practitioners themselves. For these reasons, we decided to test the feasibility and potential value of a brief practitioner-targeted intervention based on the principles of Motivational Interviewing. In addition, we sought to compare preliminary data on influencing practitioner behaviour and attitudes for alcohol interventions with that for drug misuse interventions.


    MATERIALS AND METHODS
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 APPENDIX 1: INTERVIEW SCHEDULE
 REFERENCES
 
Intervention
A brief adaptation of the principles of motivational interviewing was constructed as ‘change-orientated reflective listening’ (CORL). There has been a proliferation of terms used for applications and adaptations of motivational interviewing, some of which may represent questionable dilutions of the parent method (Rollnick et al., 2002Go). It is thus appropriate to make plain our intention to apply Motivational Interviewing, rather than what has been termed ‘behaviour change counselling’ (Rollnick et al., 2002Go). The CORL label takes account of the novel nature of this application, the somewhat unusual device to structure the discussion (a series of questions) and specifies what we regard as the key component in the development of discrepancy and creation of the possibility of change — reflective listening.

In addition to targeting the topic of alcohol, we also separately targeted the topics of cannabis and opiate use in two adjacent Inner London areas (McCambridge et al., 2003Go; Strang et al., 2003Go). Change-orientated reflections were used to guide the conduct of the interview in an exploratory practitioner-centred manner and were selectively employed to reinforce consideration of issues, about which change in attitudes or behaviour was judged to be possible. The discussion took the form of a 15–20-min telephone conversation, in which CORL statements supplemented open questions (see Appendix 1; with specific questions asked when judged helpful, along with supplementary questions). These questions were selected and asked in ways designed to elicit relevant material, tailored within each discussion. The intervention thus comprised a discussion structured by a series of open questions, conducted in the style of Motivational Interviewing.

Approximately half the interventions were delivered by each of the first (J.M.) and third (D.W.) authors. All were audio-recorded and transcribed. A further intervention component was provision of information to all those interested in or willing to receive it. This information included a pack of generally available materials on alcohol, and general guidance on the management of drug misuse and dependence.

Procedures and participants
We targeted primary care physicians in an area of London adjoining that in which the third author (D.W.) was a practitioner. To allow comparisons to be made with other pilot studies, we targeted only those who had not attended local training events in the management of drug misuse and dependence and were not known to be involved in methadone prescribing. The 32 GPs identified by these criteria, out of a total of 45, were offered £40.00 ({euro}60.00) to take part. Ethical approval was obtained.

After receiving invitations to participate, targeted GPs were contacted 1 week later by telephone to arrange a time for interview. Appointments for telephone interviews were made and interventions delivered to 21 (66%) of the 32 GPs targeted, with 11 refusals to participate. No differences were observed between participants and non-participants on available data such as sex or ethnicity.

Outcome measures
Telephone follow-up interviews were conducted 2–3 months after the CORL intervention by the second author (S.P.). The interview was transcribed. In addition to change over time in the sample as a whole on activity and attitudinal measures, decision rules were set a priori for ascertainment of change among individual practitioners — categorical change (from ‘not willing to be involved’, to ‘willing to consider’, to ‘current activity’ in six selected alcohol interventions — see Table 1) or change of one standard deviation or greater on attitudinal measures (change score of four on 10-item SAAPPQ or three on five-item AAPPQ motivational subscale; Anderson and Clement, 1987Go; Cartwright, 1980Go) according to criterion 1. These latter measures assessed change in overall therapeutic commitment and motivation to working with drinkers (on a five-point Likert scale).


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Table 1. Change in general practitioner alcohol interventions at entry and at 2–3 month follow-up (n = 20; some information missing on one subject)

 
Each practitioner was categorized as having ‘changed’ or ‘not changed’ according to this criterion, with positive change being in the direction of increasing involvement or attitudinal positivity. Where there was contradictory evidence of change (in either positive and negative directions) practitioners were categorized according to the balance of change (as evidencing positive, negative, or no overall change).

A second and more stringent criterion for individual level change was also adopted: where there was evidence of change on more than one variable, with no contradictory change (criterion 2). Where change was detected, practitioner views on whether this was attributable to intervention were sought in a semi-structured interview.

The transcribed interviews 2–3 months following intervention were reviewed to compare material following the alcohol intervention with that following the cannabis intervention. Discourse analysis was guided by the concept of the ‘rationale’ as a key technique to facilitate action upon the conduct of others, as developed by Foucault (1967)Go.


    RESULTS
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 APPENDIX 1: INTERVIEW SCHEDULE
 REFERENCES
 
Baseline data
Practitioners ranged in age from 33 to 62 (mean 47) years and had worked as GPs for between 7 and 30 (mean 17) years. Ten of the 21 were women and eight were Asian or Black. One practitioner worked single-handed and one worked for five or fewer sessions per week in general practice.

In the previous 4 weeks, one practitioner reported seeing no patients drinking above 30 units of alcohol for men and 20 units for women. Eleven practitioners reported seeing between one and five such patients, and seven reported seeing 10 or more hazardous or problem drinkers (mean number of 6.6). Alcohol interventions reported at study entry, and at follow-up, are presented in Table 1.

Overall change in the study population
Follow-up interviews with all 21 participants were conducted 63–91 (mean 76) days after the CORL interview. In the sample as a whole, at follow-up there was a greater level of detection of patients drinking more than the previously specified levels, though this was not a statistically significant increase (from 6.6 to 9.1). Overall therapeutic commitment (mean scores 35.9 to 35.8) and motivation (18.8 to 18.2) did not change following intervention. There was thus no evidence of change over time in the study population as a whole.

Change among individual practitioners
Most change was observed in relation to shared care with specialist services (see Table 1). Four practitioners moved from not being willing to consider this provision to a position of consideration, and four others moved from consideration to current activity. In the opposite direction, two practitioners moved from willingness to unwillingness to consider shared care.

The numbers of individuals who were categorized as changers in either attitudes, willingness or activity in alcohol interventions according to both criteria used are presented in Table 2. Data are presented as proportions of those who were both originally targeted and of those who actually received intervention. One of the five negative changers attributed this change to receipt of the intervention — having the opportunity to reflect led to an unintended effect. Five of the nine positive changers according to criterion 1 attributed this change to the intervention, as did one of the three changers according to criterion 2.


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Table 2. Extent of change by 2–3 months

 
Comparisons with other intervention targets (alcohol vs. cannabis vs. opiate)
Different methods of negotiating access to practitioners were associated with different extents of successful intervention delivery — 66% (21/32) in this study was obtained via a close working relationship with the Primary Care Trust, which is the local administration employing the practitioners. This compared to 43% (29/68) for opiate misuse and 53% (20/38) for cannabis use, where access was facilitated by other service providers or commissioners.

For both the targeted illicit drug use categories, change over time in the study population as a whole was observed in relation to overall therapeutic commitment, and a change in actual activity was observed for cannabis use.

Among individuals and according to both criteria for change, a lower proportion were categorized as being positive changers for alcohol than both other targets. According to criterion 1, 43% (9/21) for alcohol, 52% (14/27) for opiate misuse and 68% (13/19) for cannabis changed in a positive direction. According to the more stringent criterion 2, only 14% (3/21) of individuals were positive changers in the case of alcohol, compared to 33% (9/27) for drug misuse and 32% (6/19) for cannabis use. Neither of these differences were statistically significant.

Qualitative data (alcohol vs. cannabis)
The GPs in the alcohol study all described asking patients about their drinking. Generally GPs were selective in asking patients who have what they considered to be alcohol-related presentations. The selective nature of these enquiries was overtly related to resource management (their own time), with alcohol being seen as in competition with other priorities. Their accounts of alcohol interventions with patients varied from using purely directive comments about the need to stop, to eliciting the patient's views on alcohol and trying to change them appropriately.

The alcohol study interventions failed to develop discrepancy between current practice and the benefits of increasing intervention for alcohol problems. These attempts to develop discrepancy generally led to discussions of resource use, whereas in the case of cannabis much of the discussion focused on whether this activity might be a helpful addition to current practice.


    DISCUSSION
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 APPENDIX 1: INTERVIEW SCHEDULE
 REFERENCES
 
There was no change over time in the group as a whole, and although nine individuals changed positively according to criterion 1, five actually changed negatively, becoming less willing or active in alcohol interventions. According to the more stringent criterion 2, three individuals changed positively during the period of study, though only one of these attributed this change directly to the intervention.

The intervention targeting alcohol was less promising than the opiate and, particularly, the cannabis interventions (McCambridge et al., 2003Go; Strang et al., 2003Go). It may be significant that the cannabis interventions were conducted face to face instead of by telephone.

One difference, however, may be that practitioners tend to already accept that alcohol consumption may be a problem that is worth detecting and seeking to influence, while the cannabis interventions were mostly discussions about whether GPs should ask about cannabis use at all. There was a comparative absence of pre-existing rationales for screening for, and seeking to influence cannabis use. Change was possible in the case of cannabis through the development of discussions that supported the case for intervention, particularly through the known health consequences associated with tobacco use.

The uncontrolled design, small sample size, variations in data collection methods before and after intervention (self-completion and telephone interview), and the absence of corroboration of self-reported data are major limitations of the study. We have also deliberately piloted different modes of delivery of the intervention, which must be borne in mind in evaluating the comparative data.

Alcohol is a subject about which many GPs have firmly held views, given the longstanding encouragement of activity on public health grounds. This may result in views which are less amenable to change following a brief motivational intervention of the type investigated here. This suggestion is supported by comparison with the cannabis-orientated intervention. For cannabis, although the public health case for intervention for cannabis is similar, brief intervention has not previously been promoted. This may allow more scope for interventions that target uncertainty and ambivalence.

The qualitative data identify the importance attached by GPs to resources, especially their own time. GPs remain to be persuaded of the relative importance of alcohol-specific interventions within existing resources, Thus interventions need to be minimal (Heather, 1995Go), or incorporated into multi-purpose interventions or consulting styles that rapidly survey a number of possible areas of risk (Reid et al., 2001Go).

Further studies require randomized, controlled designs to identify effectiveness rather than feasibility. This study is perhaps a ‘proof of concept’. Practitioners were not only willing to discuss and consider change in role and activities, but many reported this as a valuable opportunity for reflection on these issues. In seeking to further develop the intervention, we are minded to be as flexible as possible in pursuit of addiction-related benefit. Rather than seeking to discuss a single addiction or other target subject, we are intrigued by the prospect of briefly surveying possible areas for discussion and then pursuing foci for which change seems most likely.

Difficulties in persuading GPs to deliver brief interventions in routine practice have been noted by Beich et al (2002)Go. It is certainly not intended that interventions examined here should operate in isolation from other attempts to encourage GP practice development. Encouragement of training uptake would be one example of how interventions of this type may be integrated with other measures to effect practitioner behaviour change.


    APPENDIX 1: INTERVIEW SCHEDULE
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 APPENDIX 1: INTERVIEW SCHEDULE
 REFERENCES
 

How important do you see alcohol as an issue affecting the health of your patients?
What do you see as your own role in relation to alcohol?
How does alcohol usually crop up in consultations for you?
Could you describe a typical consultation of this type?
How does your alcohol-related practice compare with your approach to cigarette smoking?
Are there benefits to the local community arising out of GP activity in this area?
What, if anything, might encourage you to do more alcohol-related work?
Could your practice in this area be improved?
Would you like to receive a copy of the training materials?
Do you think this discussion has had any impact on your views on this subject?


    ACKNOWLEDGEMENTS
 
This project was funded by the London Region of the NHS Executive as part of a London-wide General Practitioner Training Initiative in the management of Drug Misuse and Dependence. David Whooley is a member of STaRNet London, a primary care research network funded by the NHS Directorate of Health and Social Care for London. We are grateful to Dr Jane Fryer, Director of Clinical Leadership and Quality (Medical), Southwark Primary Care Trust, for assistance.


    REFERENCES
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 APPENDIX 1: INTERVIEW SCHEDULE
 REFERENCES
 
Anderson, P. and Clement, S. (1987) The AAPPQ revisited: the measurement of general practitioners' attitudes to alcohol problems. British Journal of Addiction 82, 753–759.[ISI][Medline]

Beich, A. Gannik, D. and Malterud, K. (2002) Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners British Medical Journal 325, 870–872[Abstract/Free Full Text]

Cartwright, A. J. K. (1980) The attitudes of helping agents towards the alcoholic client: the influence of experience, support, training and self-esteem British Journal of Addiction 75, 413–431.[ISI]

Deehan, A., Templeton, L., Taylor, C., Drummond, C. and Strang, J. (1998) Low detection rates, negative attitudes and the failure to meet the ‘Health of the Nation’ alcohol targets: findings from a national survey of GPs in England and Wales. Drug and Alcohol Review 17, 249–258.[ISI]

Department of Health and Social Services (1978) The Patterns and Ranges of Services for Problem Drinkers. Report by the Advisory Committee on Alcoholism. HMSO, London.

Foucault, M. (1967) Madness and Civilisation Tavistock, London.

Heather, N. (1995) Brief intervention strategies. In Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 2nd edn, Hester, R. K. and Miller, W. R., eds, pp. 105–122 Allyn and Bacon, London.

Kaner, E. F., Lock, C. A., McAvoy, B. R., Heather, N. and Gilvarry, E. (1999) A RCT of three training and support strategies to encourage implementation of screening and brief alcohol intervention by general practitioners. British Journal of General Practice 49, 699–703.[ISI][Medline]

Lewin, S. A., Skea, Z. C., Entwistle, V., Zwarenstein, M. and Dick, J. (2003) Interventions for providers to promote a patient-centred approach in clinical consultations (Cochrane Review). The Cochrane Library 1, 2003. (Update Software, Oxford.)

Lightfoot, P. and Orford, J. (1986) Helping agents' attitudes towards alcohol-related problems: situations vacant? A test and elaboration of a model. British Journal of Addiction 81, 749–756.[ISI][Medline]

McCambridge, J., Strang, J., Platts, S. and Witton, J. (2003) The GP and cannabis use: pilot study of a brief motivational intervention to increase clinical enquiry by GPs. British Journal of General Practice 53, 637–639.[ISI][Medline]

Miller, W. R. and Rollnick, S. (2002) Motivational Interviewing: Preparing People for Change, 2nd edn. Guilford Press, New York.

Moyer, A., Finney, J. W., Swearingen, C. E. and Vergun, P. (2002) Brief interventions for alcohol problems: a meta analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 97, 279–292.[CrossRef][ISI][Medline]

Reid, S., Whooley D., Crayford, T. and Hotopf, M. (2001) Medically unexplained symptoms — GPs' attitudes towards their cause and management. Family Practice 18, 519–523.[Abstract/Free Full Text]

Rollnick, S., Allison, J., Ballasiotes, S., Barth, T., Butler, C. C., Rose, G. S. and Rosengren, D. B. (2002) Variations on a theme: motivational interviewing and its adaptations. In Motivational Interviewing: Preparing People for Change, 2nd edn, Miller, W. R. and Rollnick, S., eds, pp. 270–284. Guilford Press, New York.

Shaw, S., Cartwright, A., Spratley, T. and Harwin, J. (1978) Responding to Drinking Problems. Croom Helm, London.

Strang, J., McCambridge, J., Platts, S. and Groves, P. (2003) Engaging the reluctant GP in care of the drug misuser: pilot study of change-orientated reflective listening (CORL).

Walker, A., Maher, J., Coulthard, M., Goddard, E. and Thomas, M. (2001) Living in Britain: Results from the 2000/01 General Household Survey HMSO, London.





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