Motivational Interviewing Approach for Benzodiazepine Users
For patients using benzodiazepines, motivational interviewing should employ a patient-centered, collaborative approach that emphasizes exploring the patient's own reasons for change while avoiding confrontation or direct persuasion. 1
Core Principles of Motivational Interviewing for BZD Users
1. Establish a Collaborative Relationship
- Create a safe, non-threatening environment with unconditional positive regard for the patient
- Avoid the "righting reflex" (telling patients what to do) which can generate resistance
- Use the "elicit-provide-elicit" technique:
- First elicit what the patient already knows
- Then provide tailored information with permission
- Finally elicit the patient's response to the information 1
2. Explore Ambivalence About BZD Use
- Ask open-ended questions about both benefits and drawbacks of benzodiazepine use
- Example questions:
- "What do you like about using benzodiazepines?"
- "What concerns do you have about your benzodiazepine use?"
- "How does your benzodiazepine use fit with your future goals?" 1
3. Elicit Change Talk
- Listen for and reinforce statements expressing the patient's:
- Desire to change ("I want to stop relying on these pills")
- Ability to change ("I've been able to reduce my dose before")
- Reasons for change ("I'm worried about memory problems")
- Need for change ("I can't keep taking these forever")
- Commitment to change ("I'm ready to try tapering") 1
4. Roll With Resistance
- Avoid direct confrontation when resistance emerges
- Reflect back the patient's concerns without judgment
- Emphasize personal choice and autonomy
- Example: When a patient says "I'm not ready to stop yet," respond with "You'll know when the time is right for you to make changes" 1
Specific Strategies for BZD-Related Motivational Interviewing
Assessment Phase
- Assess the patient's pattern of BZD use, including:
- Duration of use (short-term vs. long-term)
- Dosage and frequency
- Reasons for use (anxiety, insomnia, etc.)
- Previous attempts to reduce or discontinue 1
Goal-Setting Phase
- Help patients identify inconsistencies between their BZD use and their personal values/goals
- Discuss potential risks of long-term BZD use in a non-threatening manner:
Planning Phase
- For patients ready to change, assist in developing a concrete plan:
- Set a realistic timeline for tapering (usually over months)
- Identify potential barriers and solutions
- Discuss alternative strategies for managing underlying conditions
- Arrange appropriate follow-up 1
Special Considerations
For Patients with BZD Dependence
- Acknowledge that physical dependence can occur even with prescribed use
- Emphasize that a slow taper (usually over months) is the safest approach
- Discuss potential withdrawal symptoms in advance
- Consider referral to specialists for patients with:
- History of withdrawal seizures
- Unstable medical comorbidities
- Concurrent alcohol or other substance use 1
For Patients with Concurrent Mental Health Conditions
- Address underlying anxiety or insomnia with evidence-based alternatives
- Discuss non-pharmacological approaches (CBT, relaxation techniques)
- Consider appropriate alternative medications when indicated 3
Common Pitfalls to Avoid
- Confrontational approaches - These typically increase resistance rather than motivation
- Rushing the process - Change often requires multiple conversations over time
- Focusing only on risks - Acknowledge benefits the patient perceives from BZDs
- Neglecting underlying conditions - Address the reasons for BZD use, not just the use itself
- Setting unrealistic goals - For long-term users, gradual reduction may be more realistic than complete discontinuation 1, 2
By applying these motivational interviewing principles specifically to benzodiazepine use, clinicians can help patients explore their ambivalence about BZD use and develop intrinsic motivation for appropriate changes, ultimately improving outcomes related to morbidity, mortality, and quality of life.