Modifying Client Behavior with Teachable Moments

Introduction

Teachable moments provide opportunities to produce changes in a client’s behavior that would positively impact the health and well being of a client. The motivating philosophy is that people can change. The focus of this dissertation is upon teachable moments in the treatment of alcoholism. Within this introduction, the problem of alcoholism will be explained. Teachable moments will be defined and the importance of teachable moments in the treatment of alcoholism will be explained. The definition will be used to understand teachable moments in the treatment of alcoholism, the circumstances where teachable moments arise, and how practitioners use therapies, such as brief intervention, to provide a framework in which to identify teachable moments in the treatment of alcoholism.

Alcoholism describes a problematic set of behaviors where alcohol is consumed in excess (Bridgeman, Shepherd, Jordan, and Jones, 2012). Guidelines on excess alcohol consumption do not include personal preferences or lifestyle. The guidelines are specifically based upon research evidencing the host of health problems excessive alcohol consumption creates and are clarified by Bridgeman et al. Males should not exceed ten drinks per week with two days abstinence, and females should not drink in excess of five alcoholic beverages per week with two days abstinence. Consuming alcohol in excess, five times the recommended weekly amount, is correlated with a host of health problems, including liver failure, cancer, diseases of the heart, digestive system, cardiovascular disease, and pancreas, as well as more frequent visit to emergency care facilities because of unintentional injuries while intoxicated and injuries associated with increased violent incidences (Bridgeman et al.) Within the treatment of clients suffering from alcoholism, opportunities arise to assist in enabling decreased alcohol consumption for improved health outcomes. The teachable moment in the treatment of alcoholism is a useful therapeutic technique in the treatment of alcoholism. The following is a definition of the teachable moment and its relevance in the treatment of alcoholism. 

McBride, Emmons, and Lipkus (2003) define a teachable moment as: “naturally occurring health events thought to motivate individuals to spontaneously adopt risk-reducing health behaviors” (p. 156). Within the treatment of alcoholism, according to the National Institute on Alcohol Abuse and Alcoholism (2005), teachable moments can arise within a variety of settings and circumstances that will help facilitate change for the client, even when the client is resistant to therapy or acknowledging their substance abuse.

The National Institute on Alcohol Abuse and Alcoholism (2005) described the circumstances under which teachable moments can arise. Opportunities for teachable moments arise specifically from medical emergencies or in the treatment of trauma, most often when brief interventions are used to handle those events, although opportunities for treatment and positive outcomes can arise from regular office visits. As the National Institute on Alcohol Abuse and Alcoholism stated, teachable moments can also arise from the course of routine medical visits. The key for identifying opportunities for teachable moments stated the National Institute on Alcohol Abuse and Alcoholism is using an evidence-based treatment program such as brief intervention. 

The brief intervention incorporates effective screening interview techniques and assessments that help gauge a client’s weekly and daily use of alcohol and their level of acceptance to treatment for alcoholism and has been demonstrated to decrease the amount of short term alcohol consumption. In the following section, the problem statement will be described.

Statement of the Problem

Brief intervention is a blanket term that describes therapy for one to four sessions (The National Institute on Alcohol Abuse and Alcoholism, 2005). Within brief therapy, there have been programs developed expounding upon the window of opportunity of the teachable moment to facilitate a reduction in alcohol consumption and sobriety for a client. For example, the Alcohol Screening and Intervention Program has been demonstrated to reduce alcohol consumption in clients at the outcome of their treatment, at half a year, and at the year mark (Boyd, Milman, Stuart, Dekker, & Flaherty, 2008).

However, within those therapies, there must be adequate and appropriate training provided to produce the promising outcomes of brief interventions. One aspect is the correct identification of a teachable moment that would be most therapeutic for the treatment of alcoholism. An emergency or traumatic situation does not necessarily constitute the most productive time to approach a client with alcoholism. Moreover, there is a limited time frame, according to Boyd et al. (2008), in which intervention is most appropriate, in addition to emergency personnel believing that they might not be the most appropriate health care providers to assess and treat clients for alcoholism. 

It seems the term “teachable moments” is often used, but its role in the treatment of alcoholism is not widely explained or understood. More research is needed to understand the teachable moment in the treatment of alcoholism in order to appropriately train clinicians to identify these windows of opportunities from a therapeutic standpoint so they are not squandered in the treatment of alcoholism.   

Articulation of a concise problem statement is the key to a successful proposal/dissertation manuscript and typically requires many revisions before the proposal is approved.  The problem statement is a brief discussion of a problem or observation succinctly identifying and documenting the need for and importance of the study.  Clearly describe and document the problem that prompted the study. Include appropriate published or relevant primary sources to document the existence of a problem worthy of Ph.D. doctoral-level research.  A lack of research alone is not a compelling problem (many things are not studied but do not necessarily warrant research). Please consider: what perspective is represented? For example, is the problem an individual-level problem, an organizational problem, an industry problem, or a social problem? What is not known that should be known and what are the potential negative consequences to the field of study if the proposed research is never conducted?  These questions can help to identify the problem that needs to be addressed and the theories relevant to predict, explain and understand the problem.

[Text… Present a general issue/observation that is grounded in the research literature and leads to the need for the study (in most cases scholarly citations within the last 5 years are required to document the general and specific problem). Follow with a focused, documented problem that directly reflects and leads to the need for a research response.  Ph.D. dissertation-worthy problems must be relevant and documented beyond any particular study site and have clear theoretical implications in order to make a realistic, but substantive contribution to the field of study.]

Note: Ensure that the concepts presented in the Problem Statement lead to and align directly with the Purpose Statement. Use of a “logic” map is highly recommended in order to ensure direct alignment and avoid “surprises” among the key elements: problem, purpose, research questions, proposed method and design. Note: Clear and precise definitions of key words upon first use and consistent use of key words throughout the paper will also help ensure alignment.

Purpose of the Study 

The purpose statement should be one concise paragraph that describes the intent of the study and it should flow directly from the problem statement. Specifically address the reason for conducting the study and reflect the research questions. Begin the purpose statement with a succinct sentence that indicates the study method and overarching goal.  

[Text…“The purpose of this [quantitative, qualitative, mixed method] study is to...  (describe the study goal that directly reflects and encompasses the research questions).”  Follow with a brief, but clear overview of how, with what instruments/data, with whom and where (as applicable).]

Within the Purpose Statement: 

The research method is identified as qualitative and quantitative or mixed method. The stated purpose reflects the research questions: variables/constructs and/or phenomenon/concept/idea are identified (See the Research Degree Guidebook for additional information). The research design is clearly stated and is aligned with the problem statement.  The participants and/or data sources are identified (See the Research Degree Guidebook for additional information). The geographic location of study is identified (as appropriate).

Before moving forward, ensure that the purpose is a logical, explicit research response to the stated problem. The purpose, research questions, and design must reflect a Ph.D. study goal, which includes theoretical implications and generalizability/transferability. The study results in response to the purpose, research questions and research design must be generalizable or transferable and have theoretical implications relevant beyond any particular study site.

Research Questions

Before listing the research questions, introductory information should be presented in a discussion context.  The research questions are to be distinct and answerable, given the identified constructs/phenomenon and population.  Note: Do not include specific interview or survey question/items here.

Quantitative: Research questions are included and the question list is followed by a corresponding list of proposed hypothesis(es). Ensure the research questions and hypothesis(es) are aligned with Purpose statement.  The research questions and hypotheses must be directly answerable, specific and testable based on the data collected. 

Qualitative: Proposed research questions that are related to the phenomenon are stated. The proposed research questions must be aligned with the purpose statement.  Qualitative research questions should be open-ended and reflect the nature of the qualitative design (avoid yes/no and closed ended questions).

Mixed Method: includes all of the above. Separate and indicate the qualitative and quantitative questions, followed by corresponding quantitative hypotheses.

Hypotheses 

Both null hypotheses and alternative hypotheses must be stated. Each must directly correspond with a research question.  Hypotheses must be stated in testable, potentially negatable, form with each variable operationalized. Note: Each hypothesis represents one distinct testable prediction.  Upon testing, each hypothesis must be entirely supported or entirely negated.

H10.  [Null Hypothesis Text…]

H1a.  [Alternative Hypothesis Text…]

Definition of Key Terms

[Text (optional)… Definitions given represent key operational terms, words or phrases used in a unique way or that are not commonly used or understood.  Definitions might include terms related to the study topic and context that are not commonly known. Definitions should be supported with citations and/or noted as being those of the researcher with corresponding rationale/support. Commonly known terms should not be defined. 

Note: All definitions included in the list should clear, concise, and directly related to the proposed study. Definitions that represent general concepts, constructs, theories, and main ideas related to the research topic should be discussed in other sections of the paper. Clear and precise definitions of key words upon first use and consistent use of key words throughout the paper will also help ensure alignment.

Also Note: It is not necessary or appropriate to define or describe introductory research and statistical concepts such the differences between qualitative and quantitative methods or correlation, t test, ANOVA, multiple regression and so on. Variable/Construct operational definitions are to be located within the Research Method section.]

Theoretical Framework

[Text… Identify and articulate the theoretical foundations of the proposed study based on a review of the relevant literature. 

1.  Discussion should reflect a thorough elaboration of the conceptual and/or theoretical area under which the research falls and how the proposed research fits within other research in the field.  Discussion clearly considers the study theoretical assumptions and principles, and specifically includes important issues, perspectives, and, if appropriate, controversies in the field.  

2.  Discussion should demonstrate knowledge of and familiarity with both the historical and current literature.  The majority of sources must be scholarly and peer-reviewed.

 For a Ph.D. study, the research proposed must make a contribution to the literature and include relevant theories as the foundation of the study and, in this way, it would contribute to theory by adding more support, expanded applications or perhaps demonstrate ways in which the theory may not be as explanatory as originally presumed for the given study context. Theories provide a “lens” with which to observe, understand and explain the study topic. It is acceptable to discuss more than one relevant theory that help to predict, explain or understand the study topic, but it should be clear why the theory is included rather than simply listing several disparate theoretical frameworks.

The theories identified must be explicit as there are many different lenses, such as psychological theories, social theories, organizational theories and economic theories, which may be used to predict and explain concepts, topics or phenomena. The theoretical framework must be appropriate, aligned with the topic, well-articulated and sourced.] 

Brief Review of the Literature

Note: When the proposal is eventually developed, this section of the Concept Paper should be incorporated into the Background section in Chapter 1 and/or the Literature Review of Chapter 2 as appropriate. 

[Text… The discussion should have depth and present an integrated critical analysis and synthesis of the scholarly, peer-reviewed literature that provides a foundation and context for the dissertation study.  The discussion should be comprehensive, organized, and flow logically. The brief review of literature should not be a list of one article summary after another or an annotated bibliography. Use themes and/or subtopics as headings.  Identify the themes or sub-topics around which the literature review has been organized into a coherent narrative discussion.  In the review, at least 7 to 10 of the most important works or studies that touch upon the dissertation topic or problem should be discussed.  Be sure to include works that provide alternate or opposing perspectives on the proposed topic area to demonstrate unbiased research.  Focus particularly on those works that address main ideas in the field, describe areas of controversy, and indicate areas of incomplete knowledge and relate them to the envisioned study problem, purpose, and research questions.  Include historical and germinal works as well as current works (within the last 5 years). Continue to expand and update the literature review until the final dissertation is submitted.

Note: Emphasize key findings and interpretations to build a coherent narrative of the current state of the literature rather than focus on researchers/authors (other than seminal authors in the field) and specific study designs (i.e., unless the author, specific design, analytics, sample size or geographic location are directly relevant, it is usually not necessary to describe them). Review the Background and Literature Review sections of published, peer-reviewed journal articles for examples of academic writing. Please note the literature review will contain several headings specific to the topic.  With the exception of key, seminal authors, the majority of references should be scholarly, peer-reviewed and published within the last 5 years.

Research Method

Because the research plan is in the concept paper stage, a highly detailed research design is not expected.  The concept paper, however, provides a foundation for the next step in the dissertation process, the development of each milestone document.  A well-conceived, well written and well researched concept paper serves as a foundation for the remainder of dissertation work. Dissertation research is an iterative and often recursive process. Students should expect to revise numerous times before the proposal is finalized. Although not required at this stage, students and faculty may find it useful to review the Dissertation Proposal template to begin to consider what will be required at the proposal stage, for example, design details and ethical considerations.

Note: If students wish to provide additional subheadings to organize the content of the discussion in this section, the Dissertation Proposal template Ch. 3 subheading wording/organization/format should be followed rather than developing unique subheadings.  

[Text… Discuss the proposed research method (quantitative, qualitative, or mixed).  At the Ph.D. level quantitative studies must demonstrate both internal and external validity (e.g., large, random samples, statistical power and representativeness). Qualitative studies must demonstrate validity within the context of the specific qualitative design (e.g., credibility, dependability, transferability, trustworthiness). Replication studies are not permitted.

A clear rationale behind the chosen questions for study, the particular data gathering techniques, and data analyses should be provided. Clear decision paths should be provided based on the associated research method/design. Qualitative studies must demonstrate validity within the context of the specific qualitative design. 

In this section In this section, describe and substantiate the appropriateness of the method and design to respond to the stated problem, purpose and research questions. The discussion should not simply be a listing and description of research designs; rather, elaboration demonstrates how the proposed method and design accomplish the study goals, why the design is the optimum choice for the proposed research, and how the method aligns with the purpose and research questions.  Provide appropriate foundational research method support for the proposed study design; for example, refer to Moustakas and other appropriate authors to describe a phenomenological design and Yin to describe the appropriate application of a case study design. This description of the proposed method and design based on primary research authors should be followed by a detailed discussion of how the chosen design will be applied within the Measurement section below.

Note: Avoid introductory research design and analyses descriptions as well as excessive reference to textbook authors such as Creswell and Neuman. General research methods textbooks are not intended to provide the detail needed to implement qualitative research designs. Do not provide detailed descriptions of particular methods or designs that were not chosen.]

Operational Definition of Variables

[Text (optional)… Identify each of the primary constructs associated with the research question(s), and hypotheses.  Include a brief overview of how each will be operationally defined for the proposed study. Operational definitions should be based on published, validated, research and instruments (describe and document how previous authors and/or the proposed instrument operationally defined each variable construct. Note: Operational Definitions are distinct from the Definition of Terms.]

Describe each variable, the level of measurement of the variable (e.g., nominal, ordinal, interval, ratio), how each variable will vary (e.g., the range of scores (1 – 5, 0 – 100) or levels (low, medium, high; male, female) and the data sources (e.g., archival data, survey items, and, if appropriate, how the specific scores (categories, etc.) used in the analysis will be derived from the raw data such as summing or averaging responses to survey items or assessments..  Review the previous, established use of proposed instrument, the nature of the variable data collected and analytics for examples. 

Note: Dissertations are not typically appropriate sources for instruments and operational definitions. Consult the Dissertation Center (Survey and Interview Resources) for guidance on locating pre-existing instruments. Also, review peer-reviewed, published empirical research related to the research topic for potential pre-existing study instruments that may be used as is or adapted with author(s) permission for the purpose of the study.

Consult research design sources (including Dissertation Center resources) and ensure that the measurement level of each variable and the expected distributional characteristics of the data are appropriate to, and meet the assumptions of, the proposed statistical analyses (for example, is it likely that the responses will be normally distributed?)  Become familiar with non-parametric alternatives to parametric tests to account for the possibility that the data do not meet parametric assumptions. See the Dissertation Center for more information.

Measurement

[Text…Expand on how the stated method and design described in the Research Method section above will be applied in order to respond to the stated Purpose, Research Questions and Hypotheses (for quantitative and mixed methods studies). Describe exactly what data will be collected, how, and from what source(s). Describe the proposed data analysis.  Ensure that the proposed data collection and analysis aligns with the stated research method and design and directly responds to the study purpose, research questions and hypotheses. 

Please note that survey self-development should be considered only after an exhaustive search for an existing validated instrument (See the Dissertation Center (Survey and Interview Resources) for guidance on such a search). Also, survey self-development  will require a multi-step development and validation process, including pilot testing.  (See the Dissertation Center (Research Methods Help/Research Workshop) for a tutorial on the multi-step development and validation process for a survey instrument). Review the scholarly literature for examples of how relevant concepts have been measured in the past. Although a highly detailed description is not required at the CP stage, study variables must demonstrate appropriateness to the study purpose and meet the assumptions of the proposed statistical tests.  For qualitative studies, describe the proposed instrument or collection (e.g., interviews, observations), and how concepts will be coded and analyzed as appropriate to the proposed design based on primary qualitative research methods and design authors.  Include appropriate support for the application of the proposed design.  Consult research design and analysis sources including those available in the Dissertation Center for guidance.]

Summary

[Text…Briefly restate the key points, study purpose and proposed research plan.]

References

Boyd, D. R., Milman, K., Stuart, P., Dekker, A. & Flaherty, J. (2008). Alcohol screening and brief intervention (ASBI) program implementation and operations manual. Emergency Services: Office of Clinical and Preventive Services: Indian Health Service. Retrieved from http://www.ihs.gov/nc4/Documents/ASBI_Manual.pdf

Bridgeman, K., Shepherd, J., Jordan, P., & Jones, C. (2012). Brief intervention for alcohol misuse. Nursing Times.net.  Retrieved from http://www.nursingtimes.net/nursing-practice/clinical-zones/public-health/brief-intervention-for-alcohol-misuse/5052916.article

McBride, C. M., Emmons, K. M. & Lipkus, I. M. (2003). Understanding the potential of teachable moments: The case of smoking cessation. Health Education. Research. 18(2), 156-170. doi: 10.1093/her/18.2.156 

National Institute on Alcohol Abuse and Alcoholism. (2005). Alcohol alert: Brief interventions. The Department of Health and Human Services, 66. Retrieved from http://pubs.niaaa.nih.gov/publications/AA66/AA66.html