Psychosocial Interventionfor

substance users

Dr Manoj Kr Sharma

Assistant Professor

Department of Mental Health &Social Psychology

NIMHANS,Bangalore

Substance dependence

• Medico Psychosocial Problem

• Psychosocial intervention an umbrella term

Goals of Psychosocial intervention

• Achieving sustained drug free status.• Develop/enhance motivation; work toward resolving

ambivalence• Teach coping skills (drug use is overgeneralized)• Prevent relapse• Change of life style• Improvement of Quality of life• Develop means of address Adverse consequences• Improve interpersonal functioning/social support• Foster compliance with pharmaco-therapy

Stages of Change Model(Prochaska & DiClemente, 1992)

Precontemplation No intent to change

More pros than cons to using

Contemplation Thinking about changing

Seeking information

Preparation Ready to change (attitude and behavior)

May begin self-regulation

Action Actively modifying problem behaviors; learning skills to prevent relapse

Maintenance Long-term strategies for maintaining the changes that have been accomplished

Stages of Change

• Why consider stage of change? – Presumably matching treatment approach to

stage would yield better outcomes

Precontemplation

• Defensive• No awareness of problem• Resistant to suggestions of problems associated

with alcohol/drug use• Uncommitted to treatment• Consciously or unconsciously avoiding steps to

change behavior• May seek treatment because of others’ pressure• May feel coerced by significant others

Contemplation

• Seeking to evaluate and understand their behavior

• May experience some level of distress• May be thinking about making changes• Have not taken action and are not prepared

to do so• May have made previous attempts to

change

Preparation

• Have intention to change behavior

• Exhibit readiness to change both in attitude and behavior

• Engaged in the change process and are on the verge of taking action

• Decision to change has been made and they are ready to commit to the actions involved

Action

• Firm decision to initiate change; this has been verbalized or somehow committed to.

• Taking action to change behavior and environment

• Patient exhibits motivation

• Willing to follow suggested strategies and activities

Maintenance

• Working to sustain changes

• Attention focused on avoiding relapses

• May express fear/anxiety about facing high-risk situations

• Less frequent but still intense cravings to use substance, particularly in response to various stressors

Motivation

• Motivation– Is a stable trait, consistent across situations, not

modifiable because it lies within the patient– Clinician’s behavior is irrelevant to patient’s

motivation– Denial is standard defense mechanism for

people with addictions– Resistance is the patient’s problem

Motivation

• Motivation– Is a process that happens between a patient and

a clinician– Is a fluid state that changes across situations, in

different environments, and is at least partially determined by interpersonal interactions

– Resistance is a “therapist skill challenge”

Motivation

• People with substance use disorders often– Terminate treatment early– Continue to use during treatment– Are noncompliant with treatment

Motivation Motivational Interviewing (Miller, 1983)

• Developed in early 80’s; originally designed to be a prelude to treatment and increase patient compliance with help.

• Good evidence to show that treatment outcomes are enhanced by adding initial motivational interview (Bien et al., 1993; Brown & Miller, 1993; Saunders et al., 1995).

• .

Motivation Motivational Interviewing

2. Develop Discrepancy– Help patient to become more aware of the discrepancy

between their addictive behaviors and their more deeply-held values and goals.

– Part of this is helping patient to recognize and articulate negative consequences of use. More effective if the patient does this, not the clinician.

– Explore values and life goals and then ask patient to reflect on how their addictive behavior fits into them.

Motivation Motivational Interviewing

3. Avoid Argumentation– In general, it is unhelpful to argue with patients.

Confrontation elicits defensiveness, which predicts a lack of change.

– Particularly countertherapeutic for clinician to argue that there is a problem while patient argues that there is not.

Motivation Motivational Interviewing

4. Roll with Resistance– Seemingly resistant responses from patients are met not

with opposition but with acceptance and an invitation to try new perspectives.

Motivation Motivational Interviewing

5. Support Self-efficacy– Clinician must support the patient’s belief that they can

change.

– A realistically optimistic belief in the possibility of change can be a powerful instigator and motivator of change.

– Ultimately, patient is responsible, but the sense of hope that the clinician can generate is very important.

Brief intervention

• Consistently, controlled trials of brief interventions with problem drinkers show significant reductions in drinking compared to control groups

• Some of these interventions are as brief as 1 or 2 sessions, for only 10 or 15 minutes

• Brief intervention (4 session MET) reduced drinking as much as longer (12 weeks of CBT or 12-Step oriented tx) interventions (i.e. Project MATCH, 1993).

B.I Common Elements

• Miller & Sanchez (1994) – FRAMES– 6 ingredients frequently present in brief

interventions:• Feedback• Responsibility• Advice • Menu• Empathy• Self-efficacy

FRAMES

• Feedback – refers to personalized feedback or health-relevant information based on careful assessment (not educational material about harmful effects of alcohol/drugs)

• Personal feedback may include: results of lab tests, calendar recording days of use, measures of motivation, etc.

Responsibilityconveying individual is responsible for change or no

change

FRAMES

• Advice– Have to be careful with this one-it can be a

roadblock to listening and developing rapport.– Clear and respectful advice appears to be

important component in enhancing motivation to change harmful lifestyles.

FRAMES

• Menu of Options– Advice about changing more likely to be

carried out if patient has a variety of options to choose from.

– Can be helpful to offer menu of change goals, as well as change methods.

FRAMES

• Empathy– May be the most crucial of the FRAMES

elements.– Creates environment conducive to change,

instills sense of safety, of being understood and accepted, and reduces defensiveness.

FRAMES

• Empathy– Rogers (1959) – skillful reflective listening that

clarifies and amplifies the patient’s own experience and meaning, without imposing the clinician’s material.

FRAMES

• Self-efficacy– Can be conceptualized as a specific form of

optimism, a “can-do” belief in one’s ability to accomplish a particular task or change.

– Part of this is the clinician believing in the patient’s ability to change.

Prevention and Management of Relapse

• Lapse Vs Relapse

• Common reasons: Stress, -VE emotional status,Conflict,Social Pressure,Craving, Cues

Self Help groups

Alcoholic Anonymous,Narcotic Anonymous,Ttherpeutic

Communities

Spiritual intervention

Sobriety The goal

Psycho education

Informed Individuals

Family members

THANK YOU

• Time to ease out