BRIEF MOTIVATIONAL INTERVENTIONS
Ideal for use in primary care, and aimed more at the problem substance misuser than the dependent substance misuser, brief (between one and several short sessions of a few minutes) interventions are more of an interviewing style than a counselling intervention. The FRAMES acronym described by Miller et al (1991) encapsulates the essential elements of such interventions:
- Feedback of personal risk of impairment (through sharing of results of assessments such as cognitive testing, liver function tests).
- Emphasis on personal Responsibility.
- Clear Advice to change.
- A Menu of alternative change options.
- Therapist Empathy.
- Facilitation of client Self-efficacy or optimism.
Such empathic and positive approaches have been demonstrated to be associated with better outcomes than more traditional 'confrontation of denial' approaches; this may be associated with their increased propensity to foster internal rather than external motivation.
Based on Classical Conditioning Theory (Pavlov's dogs), Childress et al (1993) recognised that repeated pairings of substance use with particular settings, individuals, affect states, paraphernalia and so on could lead to substantial conditioned craving. They demonstrated 'cue reactivity' including both physiologic (changes in skin temperature) and subjective (withdrawal-like symptoms, craving) responses in both opiate and cocaine abusers exposed to drug-related stimuli, such as handling drug paraphernalia etc.. They then demonstrated that repeated exposure to these stimuli in laboratory settings was associated with extinction of some conditioned responses, particularly decreases in craving. However, such approaches have yet to be demonstrated as enhancing effectiveness of treatment in the clinical setting.
Based on Operant Conditioning Theory, contingency management approaches use positive reinforcement (or negative reinforcement) to promote desired behaviours. Examples of reinforcers of demonstrated efficacy include take-home methadone doses (as opposed to on-site consumption), and voucher schemes. The use of positive reinforcers is generally believed to be more effective than the use of negative reinforcement (removal of a positive reinforcer) (Stitzer et al, 1986). The context in which such programmes are run is also probably important in determining their success. The rationale of the clinic must be a supportive one, and punitive elements must be avoided; behaviours to be rewarded or otherwise must be detected and reinforced swiftly; chosen behaviours should probably be central (e.g. drug-free urine provision, absence of fresh injecting sites) rather than distal (e.g. group attendance); the reinforcers should themselves promote desired behaviours associated with a drug-free life-style (e.g. cinema tickets, vouchers for sporting goods) (Higgins et al, 1993).
CBT is based on Social Learning Theory where substance misuse is seen as functionally related to other major problems in a client's life. From this perspective, clients who misuse substances are perceived as not having the skills to cope with other problems and thus misuse substances as a coping strategy. Emphasis is placed on overcoming skill deficits and increasing the ability to cope with difficult situations. Therefore, the main benefit of this approach is to equip clients with coping strategies and resources to fundamentally prevent relapse. Most such treatment approaches touch on the relationship between high-risk situations and substance use to some extent. CBT should also be considered for clients presenting with a dual diagnosis as it is an effective counselling technique for the management of anxiety disorders such as post traumatic distress, obsessive compulsive disorder and phobias, acute or chronic depression and personality disorders.
Many intervention packages have been devised over the years, but all CBT approaches employ some form of coping skills training to address cognitive and behavioural coping deficits. A standard set of techniques are used to teach coping skills that include identification of specific situations where coping inadequacies occur, and the use of instruction, modeling, role-plays and behavioural rehearsal. Exposure to stressful situations is gradually increased as adaptive mastery occurs. Often referred to as 'relapse prevention', skills training is typically offered in the following areas:
- Reducing exposure to substances.
- Motivating by exploring positive and negative consequences of continued use.
- Self-monitoring to identify situations, settings, or states associated with higher risk for substance use.
- Recognition of conditioned craving and development of strategies for coping with craving.
- Identification of thought processes that can increase risk for relapse.
- Preparation for emergencies and coping with relapse to substance misuse.
- Homework assignments.
Comprehensive reviews of treatments for alcohol problems rank CBT packages as having high evidence of effectiveness in treating alcohol dependence (Finney & Monahan, 1996), and social skills training (one form of coping skills training) emerged as the treatment rated with most evidence for effectiveness to treat alcohol dependence across all reviews. Some report that CBT is the now the dominant form of psychological intervention for the treatment of substance misuse (Morgenstern & Longabaugh, 2000).
A comparative analysis of CBT and inter-personal therapy approaches found that the outcomes from CBT were significantly higher for severely dependent substance misusers. However, inter-personal therapy (IPT) (see over) approaches were reported to be more effective than CBT for clients presenting with a lower dependency. The findings of this study also showed that the outcomes for severely dependent substance misusers were further improved for clients who remained in therapy for longer durations (Carroll, 1996).
In summary it would appear that both CBT and IPT approaches have a role to play in helping clients achieve positive health changes, although counsellors do need to tailor the type of approach used to the aims of the client to maximise treatment outcomes.
Research has indicated that brief counselling interventions are more effective than no intervention and often as efficacious as more extensive long-term counselling (Miller & Rollnick; Harris 2001). The most common brief counselling intervention applied in substance misuse is motivational interviewing. It is based on the premise that the main obstacle to changing drug or alcohol use and associated behaviour patterns is a lack of motivation; it follows that if motivation to change can be enhanced then, then behaviour change will be more likely (Baker & Reicher 1998). It is a technique that does not require an in-depth counselling knowledge and it can, therefore, be used by most professionals specialising in substance misuse.
- Brief Motivational Interventions - an interviewing style involving several short sessions of a few minutes aimed at increasing 'internal' motivation - good evidence of effectiveness.
- Cue Exposure - aimed at extinguishing conditioned responses such as craving - limited evidence of effectiveness in the clinical setting.
- Contingency Management - the use of positive reinforcers to increase desired behaviours - limited evidence of effectiveness in the clinical setting.
- Relapse Prevention - a cognitivebehavioural technique centered around the teaching of coping skills - widely used and good evidence of clinical effectiveness.
- Motivational Interviewing - a directive, client-centered style of counselling that helps clients to explore and resolve their ambivalence about changing - widely used and good evidence of clinical effectiveness .
- Person-centered therapy - based on the belief that clients are always engaged in a search to fulfil themselves, to actualise, to become free of problems created by substance misuse. The focus is on the present, the future and the client's own world.
- Psychodynamic therapy - aimed at facilitating the client's insight and understanding of problems through linking the past and present, and through examination of the client-therapist relationship.
- Marital and Family Therapies - examine the role of important 'others' in the addictive process; marital behavioural therapy may be particularly effective.
- Disease Model Approaches (Traditional, Minnesota Model, 12-step-oriented) - grounded in the concept of substance misuse as a spiritual and medical disease. Group work is central to the approach.
- Solution focused therapy - an approach focusing on exceptions to the problem pattern which enables clients to identify their own unique solutions to the problem.
Motivational interviewing incorporates five general principles: empathy; discrepancy; non-confrontation; accepting resistance; and supporting self-efficacy. The role of the professional is to employ these principles in two main phases; the first of which is concerned with building motivation; while the second is aimed at strengthening commitment to change.
A study of alcohol users found that the number of clients motivated to change was increased by 77% when motivational interviewing was used (Miller & Sanchez 1999). While other brief therapy techniques have also been found to be efficacious, those involving advice or instructions were deemed to be less effective than motivational interviewing if the clients presented with little motivation to change in the first instance (Heather et al 1997).
MARITAL AND FAMILY THERAPIES
Several approaches involve family or spouse in treatment including 'family disease models' (which focus on the family's role in enabling the disease process), family systems models (which conceptualise the role of substance misuse in terms of family dynamics and roles), and behavioural models (which evaluate substance misuse in terms of family behaviours which precede or maintain it) (McCrady B & Epstein E, 1996). Marital behavioural therapy in particular and various other combinations of family approaches have demonstrated effectiveness in reducing dropout and relapse rates.
SOLUTION FOCUSED THERAPY
Solution focused work is based on an Ericksonian model of human behaviour. It argues that most interventions focus on pathological or negative aspects of a person's life. This therapy reframes the therapist role to help the client consider exceptions to the problem pattern. By focusing on the client's strengths and successes through a series of future orientated questions, the therapist and client are able to co-construct new solutions to existing problem behaviours.
Inter-Personal Therapy (IPT) is used here to refer to psychodynamic, person-centred, psychosynthesis, gestalt therapy and psychotherapy counselling techniques.
The person-centred approach is theoretically lean. What matters to the counsellor is the theory or model of the world held by the client. The counsellor approaches the client with an attitude of deep respect and acceptance of whatever the client's aims are i.e. abstinence, controlled drinking etc.. The client is offered freedom of expression (content) and experience of feelings. Person-centred counselling is also a processoriented approach. Central is the belief that clients are always engaged in a search to fulfil themselves, to actualise, to become free of problems created by substance misuse. Person-centred counsellors are strongly influenced by existential philosophy. They are very cautious about any attempts to diagnose or categorise clients, as they believe such labels are static and deny growth or movement in the clients' lives. They are aware of using the client's frame of reference (world-view) rather than their own. Person-centred counsellors are adaptable to cultural diversity, show empathy, warmth and flexibility. The past is sometimes considered irrelevant. The focus is on the present and the future.
The psychodynamic counsellor is not only interested in the presenting problem that the client brings but also in the client's life-history. The relationship with the client is central to the work. The therapeutic alliance and relationship between counsellor and client fosters respect, trust, common purpose and commitment. The task of the counsellor is to facilitate the client's insight and understanding of the problems through linking the past and present; to make interpretations of the client's communication, conscious and unconscious; to highlight defence mechanisms and developmental aspects; and to interpret transferences in terms of relationships of the past and present. The psychodynamic counsellor maintains strict boundaries and the focus on the unconscious and underlying anxiety is a key feature of this approach. Dream work and hidden meanings are all explored to create greater insight and understanding for the client.
Among the most commonly cited reasons for relapse are powerful negative affects, and many psychodynamic clinicians have suggested failure of affect regulation is a central dynamic underlying the development of compulsive drug misuse. While psychodynamic treatments tend to emphasise the role of affect in substance misuse treatment, virtually all forms of counselling for substance misuse include a variety of techniques for coping with strong affect.
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The above information is copyright of Dr Bruce Trathen MBBS MRCPsych (2006). ISBN 0-9545164-0-0. The author grants permission for these guidelines to be downloaded, copied and distributed freely, but does not grant permission for their sale.