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Dr Barbara HedgeConsultant Clinical Psychologist
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Is there more to risk prevention than MI?Flavour of the month
Relaxation therapyCognitive behaviour therapySolution focused therapyMotivational interviewing
Why recommendedLooks to be effective but cheapNever mind the problem
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NICE guidance 2007
One to one interventions to reduce the transmission of sexually transmitted infections (STIs) including HIV, and to reduce the rate of under 18 conceptions, especially among vulnerable and at risk groups
May 2007
Implementing NICE guidance
NICE public health intervention guidance 3
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Putting therapy into contextSexual health setting
A normal, universally practised behaviourRisk
Probability of danger and/or undesired outcomes Individual Partners and families Society
Undesired outcomes Sexually transmitted infections Pregnancy
Aim to change behaviours to reduce riskIdentify useful psychological therapies
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What factors are associated with risk?Lack of knowledge or understandingResourcesSkills
CommunicationAbility
Conceptualisation of personal riskMotivation to reduce riskLack of care for self or others
Low moodShame
Power differentialCulturalCoercive
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Sexual health expert knows best
AssumptionsPatients are always rational so act on knowledgeThe goals of patients are the same as goals of
sexual health practitionersAll patients want what is best for themselves
UK national guidelines on safer sex adviceBASHH 2011
ConclusionsGiving knowledge is all that is necessaryTelling people what to do is the same as giving
advice
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They just don’t listen!Repeated STIsHIV transmissionUnwanted pregnanciesRepeated requests for PEP
Information is necessary but not sufficient
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Theory of reasoned actionFishbein, 1979
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Which therapy?What, who needs to change?Who wants or doesn’t want to change?What are the risk factorsGoal to be achievedHow to bring about change
Learning theories Skinner’s Operant Conditioning theory Bandura’s Social Learning theory
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Risk reduction
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Behaviour change therapiesCognitive Behaviour TherapySystemic TherapySolution focussed TherapyMotivational InterviewingPeer InfluenceNudge
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Cognitive behaviour theories
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Personal risk cognitionsNot want to transmitNot want to discloseNot want to use a condomNot want to become infectedNot want to think about itNot want to confront
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Self-serving attributionsConstructed narratives that allow
justification of our behavioursBefore and/or after action or non-action
ART means I have no virus to transmit PEP is available if need it If partner is willing to have unprotected sex they
are probably already positive Partner wouldn’t suggest unprotected sex if they
were positive Can trust negotiated safety agreement
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Cognitive behaviour therapyAddresses non-adaptive cognitionsReplaces with adaptive
Can confront the issueCan plan to remain uninfected
Raises moodLowers anxietyIncreases self-esteemAdoption of self affirming behaviours
AssertivenessAcceptance of rejection of the behaviour rather
than of the self
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Learning new behavioursOperant ConditioningReinforcement
Positive repeat of behaviour Great sex with a condom
Remove negative Finally agree to sex when agree to condom
Negative Fail to keep erection with a condom
Remove positive No sex as no condoms
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Nudge theorySuggestion + positive reinforcementAddress one element of behaviour in the
chainIf positively reinforced by others or internally
Repeat behaviourReinforce additional elements in chain
Gradually approach goal of protected sex
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Solution focussed therapyNot concentrating on the problemUses resources patient already has
Encourages trying a course of action (possible solution) Strengths patient already has
AdvantagesQuickCheapPatient generated
Builds self esteem and self efficacyDisadvantages
Failure for complex issuesKey factors may not be identifiedDifficult engagement when depressed
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Cycle of change – Prochaska and Diclemente
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Changing behaviours
“After all, when you seek advice from someone it’s certainly not because you want them to give it. You just want them to be there while you talk to yourself”
Terry Pratchett
Changing behaviours
“After all, when you seek advice from someone it’s certainly not because you want them to give it. You just want them to be there while you talk to yourself”
Terry Pratchett
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Motivational interviewingDirective, client-centred
counselling style to resolve ambivalence (Rollnick & Miller, 1995)
Motivation = Importance + Confidence + Readiness
Aims to elicit and boost these factors
NICEQuickCheapCatch people on first
visitEvidence of
effectivenessA stand alone
interventionPossible service
approach
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Peer interventionsUse of a peer educator
Group leaderIntroduce safer sex into conversationSet up group norm
‘cool to use condoms’ Social learning theory + Nudge + MIEfficacy
Some support? Culturally specific
Review: Simoni et al, AIDS Behav, 2011, 1589-95
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When do I need systemic therapy?Risky sex is rarely an individual practice
What is the influence of the partner?What is the perceived influence of the partnerIs there a power in-balance?
CommunicationNegotiationAgreement between partners to change
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SummaryMotivational interviewing a good place to start
Finding out the whole picturePatient suggests the next step
Moves to action from pre-contemplationMore commitment to meet their own challenge
Ready to address cognitions and beliefs and learn skillsAble to identify when there are greater unmet needs
Pathways for onward referral to meet general needsAppropriate use of therapeutic techniques brings
best results