Cultural aspects of motivational psychotherapy for patients with alcohol dependence: problem statement

Relevance. Cultural influences are not only an important factor in the genesis of mental disorders, but also significant in the development of any psychotherapeutic models and technologies. However, the dependence of the latter on cultural influences is poorly taken into account during their implementation and dissemination. The request from routine narcological practice and somatic medicine for motivational psychotherapy targeting patients who use psychoactive substances (PAS) determines the practical significance of the problem. The aim of the authors of the article was to substantiate the need to modify motivational psychotherapy proposed for patients with alcohol dependence, taking into account cultural influences that are significant when it is carried out in modern Russia. Hypothesis. It was assumed that through a structured survey of expert narcologists, it would be possible to identify aspects of the stated problem that are significant for further study and practical use: the presence of cultural influences that are observed during motivational psychotherapy for a patient with alcohol dependence syndrome. The material for the pilot study was data from a survey of 20 Russian expert narcologists, conducted using authors’ questionnaires described in the text of the article. Results. A survey of addiction experts identified anti-therapeutic attitudes and beliefs frequently observed in patients with alcohol dependence. These beliefs reflect the patient's view of alcohol usage as a primary form of recreation, a means of relaxation and pastime, and the conviction that external circumstances are the cause of alcoholism. A lack of understanding of chemical dependence as a serious disorder was identified, along with a negative attitude toward addiction treatment and addiction specialists. A belief that others will not accept the patient if they choose a sober lifestyle is present. These attitudes hinder motivation and subsequent treatment. Conclusions. The research perspective is to study the cultural aspects of the use of motivational psychotherapy for people with substances dependence in modern Russia for the subsequent improvement of its technologies.

Culture, Mental Health, and Psychotherapy

In today's complex, globalizing world, awareness of the differences between cultures becomes mandatory, ensuring interethnic and interstate interaction, and creating a favorable atmosphere within any community that includes representatives of different ethnic groups The influence of culture on individuals cannot be overstated. Several cultural aspects can be considered etiological factors contributing to the increase in mental disorders (Neznanov, Kotsyubinsky, Mazo, 2020). This is reflected in multifactorial psychosocial models of mental disorders developed within the biopsychosocial approach, as well as in the emphasis on the macrosocial aspect that determines an individual's emotional well-being (Kholmogorova, 2011). This interpretation logically continues the tradition of studying the cultural mediation of human mental processes, which is widely represented in Russian psychology and builds upon the ideas of Lev Vygotsky's cultural-historical concept.

The founder of cultural-historical psychology, L.S. Vygotsky, wrote about the specificity of the human psyche, highlighting its special instrumental structure and cultural origin (1983, 2007). He emphasized the importance of tools, signs, and language in the formation of higher mental functions, which are based on cultural norms and values, as well as widely accepted attitudes and beliefs. In this approach, the process of personality formation is also interpreted as dependent on the sociocultural situation in which both the individual and their parents, family, and environment find themselves (Vygotsky, 2025). Cultural differences significantly predetermine the attitudes that individuals adopt towards a wide range of things.

Modern psychotherapy, as a powerful psychotechnical concept and highly significant social practice, has incorporated models and techniques proposed in various countries and cultures. It encompasses not just technologies, but also the products of a particular culture that emerged during a specific period of societal development, based on the specific concepts of relevant psychology during that time, reflecting the influence of that era. Moreover, the history of psychotherapy highlights the limited lifespan of many psychotherapeutic practices, as well as the underlying models of mental disorders. Accordingly, in the context of the development of society, psychological science, and social technologies, psychotherapeutic interventions must undergo changes, and it is necessary to adapt them to a different cultural context.

This topic has not yet been seriously addressed in the literature, and there is a lack of attention from psychotherapists or psychologists, and the number of publications is small (Naeem et al., 2019). Rather, the topic is of interest to healthcare administrators, who require the widespread introduction of psychosocial and psychotherapeutic interventions with proven effectiveness into medical or social practice (Escoffery et al., 2019; Movsisyan et al., 2019). It should be noted that the principles of evidence-based medical practice have become a universal requirement in healthcare, but their implementation in relation to psychosocial and psychotherapeutic interventions has proven to be a challenging task. This is particularly relevant in the field of narcology, where the role of psychotherapeutic and psychosocial interventions difficult to overestimate (Krupitsky et al., 2018; Trusova and Klimanova, 2018).

Why Motivational Interviewing?

The need to address the issue mentioned in the title has arisen due to the growing demand for the use of psychotherapeutic techniques in providing assistance to individuals who use psychoactive substances, including those with alcohol addiction. This demand is evident in routine narcological practice and, to a lesser extent, in the field of somatic medicine. For example, in emergency medical settings, many patients in trauma, cardiology, and neurosurgery departments are admitted while intoxicated, which is a significant etiological factor in various pathological conditions. Data from toxicology centers confirms the presence of legal and illegal psychoactive substances in the structure of acute poisoning, especially in frequently hospitalized patients. This leads to a demand for technologies that motivate patients to seek specialized care and algorithms for patient routing. The absence of such technologies and algorithms inevitably leads to a portion of discharged patients returning to the use of psychoactive substances, resulting in repeated hospitalizations, worsening of clinical conditions, and an increase in the number of fatalities.

Short-term interventions to motivate patients with chemical addictions (or with episodic substance use) to seek specialized care were created based on several approaches (Prochaska, DiClemente, Norcross, 1992; Miller, Rollnick, 2002). This type of intervention is well-known to specialists, so we will not describe it in detail. It is important to note that their effectiveness has been studied and confirmed repeatedly, including in the context of emergency departments (Bogenschutz et al., 2011; Tait et al., 2016; Cimini, Martin, 2020). An important argument in favor of their use in emergency departments is that they reach patients who do not typically seek medical attention and are therefore inaccessible to treatment for their substance use problems (Neighbors et al., 2010). However, given the short-term stay of the patient in the emergency department, the severity of the patient population — low-motivated, often antisocial, with a high level of resistance to exposure — highly technological interventions are needed, precisely tailored to the target group.

What is important to consider when creating a motivational interviewing algorithm for patients using psychoactive substances in modern Russia?

The first point that requires attention is based on the theory of cultural-historical psychology as a scientific system relevant to any human-centered practices. This is L.S. Vygotsky's proposition that all higher mental functions have a social nature. The norms and patterns of activity accepted in society are assimilated and “ingrowed” into the individual's psyche, and appropriated by them. In accordance with cultural-historical theory, the sociogenic layer of the psyche constitutes the person's "personality", their "self." As L.S. Vygotsky wrote, "The Self is the social in us" (Vygotsky, 2025, p. 112). This thesis is insufficiently taken into account in the planning and implementation of psychotherapeutic interventions. It appears that modern psychotherapy theory has yet to rethink it, for example, taking into account the well-known division of modern cultures into individualistic ("Western") and collectivist ("Eastern") cultures. When organizing psychotherapeutic assistance, it is impossible to ignore the role of the cultural and social context, the influence of this context on the social attitudes and values that the subject has internalized, and the processes of goal-setting and understanding reality.

The second point concerns the role of cultural context in the planning and implementation of psychotherapeutic interventions. This topic has only been addressed at the professional community level in the current century and has sparked significant controversy. Starting with the call "...to be aware of oneself and others from the point of view of culture" (APA, 2003), it was developed in the call for the formation of special "multicultural" competencies, involving going beyond judgments "... based on limited knowledge of individuals and communities" (Sorenson, Harrell, 2021). The question remains open as to how universal the multiculturalism approach is. Does it resolve all the contradictions of using psychotherapy models and technologies in different societies? Does it help to promote the widespread adoption of practices that are closely related to cultural differences? Is it possible to achieve high efficiency in psychotherapeutic technologies only through the development of specific competencies in specialists? Does this eliminate the need for "adjustment" and adaptation of psychotherapeutic techniques to the cultural context? It seems that at least some psychotherapeutic practices require evaluation of their ecological validity in a particular society, followed by modification based on the cultural context.

The third consideration is that there is a gap in the principles of organizing assistance to individuals with substance use disorders, as used by domestic and foreign specialists. This gap is related to fundamental differences in the organization of services. For example, in Western countries, the practice of substitution therapy and harm reduction programs is widespread, but these approaches have not been adopted in Russia. Recently, the gap has been exacerbated by the trend towards the legalization of drugs in many Western countries, which has not been supported in Russia. These (and other) differences require a well-founded, selective transfer of assistance practices widely used in Western countries. Interestingly, motivational psychotherapy technologies are not considered universal, and work on their adaptation to the cultural context has begun (Rimal et al., 2021; Self et al., 2023). Such work has not been conducted in our country.

The fourth point concerns the general cultural context in which we work. Potential differences in understanding the problem of alcohol dependence are linked to attitudes, behavior patterns, values, and even myths that are reflected in the minds of both patients and the professionals working with them (representatives of the same culture). Perhaps before achieving changes in patients' perceptions, it is necessary to change the perspectives of specialists: psychiatrists, addiction specialists, psychotherapists, and clinical psychologists. Developing professional thinking and the ability to reflect on the cultural aspects of our work is a new and challenging task. Any distortions in the perspectives of specialists, misconceptions (regarding the psychoactive substance use and permissibility of it, the possibilities of therapy, psychotherapy, and other treatment methods, the potential of rehabilitation programs), prejudices (against psychotherapy methods, self-help communities, and patient stigmatization) inevitably change the context in which psychotherapeutic practices are used and impact their effectiveness.

The fifth point concerns the transtheoretical model of change as the basis for motivational interview, proposed for individual work with persons with substance abuse disorders (Prochaska et al., 1992). According to the model's logic, the process of abandoning psychoactive substances is discrete, and intervention should be tailored to the individual's current stage. This will ensure the effectiveness of the intervention. The transition from one stage to another involves changes in targets, conditions, and intervention techniques. In the real-life practice of an emergency department, it is possible to conduct a limited number of sessions with an unmotivated patient. And if these are patients at the contemplation stage (or even preliminary contemplation), then after the decision to maintain sobriety is made, it is crucial to understand how the patient's support will be organized through the action, support, and potential relapse stages (by whom, in what forms, and for what duration). The organization of support no longer depends on the efforts of the specialist conducting the motivational intervention in an inpatient setting. But who exactly will shoulder the burden of supporting the patient? How exactly will it be organized? In most cases, the question remains open.

Finally, the sixth consideration. It seems that a serious and well-founded cultural adaptation of a psychotherapeutic intervention must take into account a deep understanding of the community for which it is being implemented. This requires not only translating instructions, screening procedures, questions, or supporting materials into another language, but also taking into account linguistic differences, types and rules of interpersonal interaction, therapeutic and anti-therapeutic attitudes, the peculiarities of the emotional experience of representatives of a particular culture, differences in ideas of illness and health, and much more. This is especially important for motivational psychotherapy, which initially assumes not standard algorithmic interventions, but an individualized approach based on carefully monitored transition of the patient from one stage of "decision-making" to another, and adjusting psychotherapeutic techniques to the current stage (Prochaska et al., 1992).

The above considerations require consideration when developing an algorithm for motivational psychotherapy for patients using psychoactive substances in modern Russia (by "modern" we do not mean the period after 1991, which is often referred to as such, but rather the situation in recent years). The goal of the study was to improve the technology of motivational interviews by taking into account the cultural context. At the initial stage of the study, the following research questions were identified as relevant:

— What are the specific features or characteristics of patients with alcohol addiction in modern Russia that professionals providing such assistance note?

— What specific traits of patients should be taken into account when organizing assistance, and how should this be done?

— What specific medical and rehabilitation measures should be created or organized to support patients at all stages of recovery?

Pilot Study Data

The aim of the pilot study was to preliminarily identify aspects of the stated problem that are significant for further study and practical use.

Study Sample

Specialists with a high level of expertise were selected as respondents for this survey. 20 people were interviewed, and they were personally invited to participate in the study, with guaranteed anonymity during the publication of the materials. In addition to regular practical work assisting patients with alcohol dependence, completed training, and proficiency in motivational interviewing (5 people used it regularly, 11 occasionally), the experts were involved in scientific research, possessed the ability to scientifically analyze the problem, and were skilled in reflecting on their own work and the conditions under which it was implemented. Among the surveyed experts, 4 had a Doctor of Science degree, 11 had a Candidate of Science degree, and the rest are involved in ongoing scientific research. Professional affiliation of respondents: 17 people are psychiatrists-narcologists, 2 are psychotherapists, one person is a clinical psychologist.

Data Collection Methods

In the first stage, the " Narcologist Expert Questionnaire-1" was administered. It was completed independently by the experts in writing and included the following open-ended questions.

1. We believe that there are characteristics or specific traits that distinguish the clinical group of patients with alcohol dependence living in modern Russia and that are significant when organizing care for such patients. If you agree with this statement, please indicate which of these characteristics or patient attitudes you are aware of and consider most significant (you can list an unlimited number of items). 
2. We believe that the characteristics you identified (and others) that characterize the clinical group of patients with alcohol dependence living in modern Russia determine specific principles for organizing care for such patients, as well as treatment and rehabilitation measures. Please indicate which of these characteristics you consider fundamentally important. 

Later, the same experts were presented with the "Narcologist Expert Questionnaire-2". It contained a list of items selected based on the analysis of 20 completed Questionnaire-1s. In total, the Questionnaire-2 included 25 items. The answers to the Questionnaire-2 items were provided using a Likert scale, ranging from 0 (false) to 4 (true), depending on the degree of agreement with the item. The number of selections for each answer option on the Questionnaire-2 items was counted. Since the study was pilot-based, we do not provide the full text of the questionnaire. It should be noted that some of the items in the Questionnaire-2 were not identified by the experts as reflecting significant differences in the Russian sample of patients with alcohol addiction. Therefore, the analysis focused on evaluating and interpreting the responses to items that were either agreed upon by the expert respondents or had significant discrepancies in their assessments.

In the Questionnaire-1, in a number of cases, addiction specialists provided examples of formulations that reflect the anti-therapeutic attitudes of Russian patients. These attitudes appear to be related to the existing social practice of alcohol consumption and may be considered to have a cultural significance. These formulations were also analyzed, and some of them are discussed below in the results section.

Frequency Analysis Results and Expert Agreement

Of particular interest are the questionnaire items most frequently accepted by the experts, i.e., those for which expert agreement is high (3, 6, 7, 8, 17, 20, 22, 24, 25, and 12). Also of interest are items for which divergence in expert opinion was noted (5, 13, 18) (see table).

Since the results of the survey among addiction specialists are preliminary, the data analysis is presented more in terms of formulating hypotheses that require testing in subsequent studies.

Analysis and Interpretation of Results 

Table

Frequencies of selection/rejection of Questionnaire 2 item by expert respondents (N=20)

As can be seen from the data presented in the table, the most frequently cited characteristic of patients with alcohol dependence observed in Russia is the statement that "drinking alcohol is the main form of entertainment long before the development of alcohol dependence." This statement, in our view, reflects the widespread use of alcohol as a form of recreation, relaxation, and leisure, and also indicates the paucity of alternative forms of entertainment among some of the population. Among the attitudes cited by the experts as typical for the target group of patients were: "I drink in a civilized manner and rarely relapse," "I drink like everyone else. At funerals or weddings, everyone has to drink," and "Not drinking at a birthday party is disrespectful" (these statements are typically encountered by patients during the preliminary consideration stage). The experts also cited patients' beliefs such as, "I'm not an alcoholic, I drink like everyone else, I don't just hang out on the streets," and "I have a drinking problem, but how can I not drink? How to communicate with friends then?" (These attitudes are observed during the contemplation phase of change). 

Some attitudes reflected in the expert questionnaires reveal widespread misconceptions among Russian patients regarding alcohol dependence disorder. For example, patients are poorly informed about the logic and stages of disorder development, risks, and symptoms. They are convinced that "the risks associated with alcoholism are greatly exaggerated" because "everyone drinks and nothing happens"; they believe that "it is possible to quit drinking without the participation of a doctor" and "by force of will" (see items 12 and 22 in the table). Responses to Questionnaire 1 include statements such as: "I would go to treatment, but what about 100 grams for appetite?" (more likely expected at the dec sion-making stage), "I'm ready to treat my liver, but I don't have a drinking problem, so I don't need an addiction specialist" (at the action stage). These statements reflect a lack of understanding of substance dependence as a serious disorder, which clearly reduces the demand for specialist help.

According to experts, Russian patients are convinced that external circumstances are the cause of their alcoholism: "an unfair or difficult social life," "serious external causes, and the person is a victim of circumstances" (see points 8, 20 in the table). The strategy of self-justification (and simultaneously blaming others, attributing responsibility for their alcoholism to them) is an anti-therapeutic attitude that must be taken into account when providing assistance to patients. It is important to note that this attitude is difficult to overcome, as it requires a radical change in patients' attitudes towards the events and circumstances of their own lives. This requires serious psychotherapeutic or psychosocial interventions beyond motivational psychotherapy. Therefore, such assistance must be organized.

We consider the negative beliefs of Russian patients about narcology and narcologists to be very disturbing: “The patient believes that narcologists are primarily concerned with controlling patients,” “The patient believes that narcologists seek to limit his rights” (see items 24 and 25 in the table). They also expect a negative attitude from others towards themselves as potential patients of a narcologist: “The patient believes that he will always have to hide the fact of treatment from a narcologist, as he will be condemned for it” (see item 7 in the table). These attitudes reflect a widespread distrust, devaluation, and negative attitude towards specialized medical care, which prevents patients from seeking professional help. As a result, patients do not seek a competent doctor and disagree with the statement that "the success of alcohol dependence treatment depends primarily on the competence of the specialist." The possibilities for overcoming these negative attitudes are beyond the scope of this article, but they should not be ignored by the professional community.

The experts' belief that patients "can return to normal alcohol consumption" (drinking "like everyone else") after a considerable period of sober lifestyle appears unjustifiably optimistic. In our opinion, this attitude also reflects an underestimation of the problem and a desire to continue drinking rather than stop. Patients' statements about the fact that they cannot give up alcohol because "I don't want to change my friends" also deserve attention. Patients thus emphasize that others will not support their desire for sobriety.

According to the expert survey data, the ability to motivate patients with alcohol addiction through multiple sessions is limited due to existing anti-therapeutic attitudes and beliefs. Following a stages of change model can help the patient’s transition from the "contemplation" stage to the "decision-making" or "action" stage through multiple sessions. However, the mechanisms underlying behavior change vary depending on the stage and require specific techniques to support the change process. Finding such technologies, taking into account the characteristics of modern patients, is an important task that requires further research in the context of therapeutic and anti-therapeutic factors. We assume that in order to promote the desired changes in patients' behavior, it is necessary to create a social network, develop serious support programs, including the use of resources from both in-person and online events, computerized forms of support, a virtual community, remote chatbots, and other tools. It cannot be ruled out that in some cases, it is necessary to abandon overly ambitious plans to achieve complete sobriety in patients and rather promote a strategy of reducing alcohol consumption (Agibalova et al., 2015). There is evidence in the literature that such a strategic goal is effective, at least for young people, if it is properly managed in the long term (Walton et al., 2017).

A significant number of interventions exist that address the need for long-term patient support to maintain sobriety. These are such controversial practices as the method of situational control of consumption through the use of rewards ("Contingency Management for Substance Abuse Treatment") (Petry, 2011); and Relapse Prevention (Marlatt, Gordon, 2005); and directed self-change ("Self-change from addictive behaviors") (Klingemann and Sobell, 2007). The use of support programs in Alcoholics Anonymous and other 12-step programs deserves special attention. Their analysis should take into account the cultural context and carefully assess the possibility of their application in modern Russia. This is an important perspective and task for the fields of addiction medicine and psychotherapy.

Conclusions

In foreign studies, the idea of modifying psychotherapeutic technologies, even such well-known ones as motivational intervention for individuals with chemical addiction, is reflected and serves as a subject of interest and study. Unfortunately, this topic is not adequately covered in the works of Russian authors, although as the social situation and patient population change with the passage of time and the generation shift, psychotherapeutic technologies must evolve to remain effective and suitable for a wide range of individuals in need of assistance.

A small pilot study conducted with expert addiction specialists allowed us to outline ways for further study of significant aspects of the use of motivational interventions for individuals with alcohol dependence. In the future, we plan to improve this technique and develop an algorithm for its use in emergency departments, where problematic patients who do not seek medical attention are admitted. Assisting these patients in abstaining from substance use or reducing their alcohol consumption will require the development of specific tools and strategies to support their efforts, which is also a promising area of this study.

Limitations. This article presents the results of a pilot study. The study sample includes 20 expert narcologists with experience in motivational psychotherapy techniques. The questionnaires used for the expert survey are also proprietary, created specifically for this study, and therefore do not possess the psychometric characteristics required for psychological tests. The article is problem-oriented and outlines ways for further study of the problem.

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