1. Psychosocial Intervention for substance users Dr Manoj Kr Sharma Assistant Professor Department of Mental Health &Social Psychology NIMHANS,Bangalore

2. Substance dependence Medico Psychosocial Problem Psychosocial intervention an umbrella term

3. 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

4. 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

5. Stages of Change Why consider stage of change? –Presumably matching treatment approach to stage would yield better outcomes

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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”

13. Motivation People with substance use disorders often – Terminate treatment early –Continue to use during treatment –Are noncompliant with treatment

14. 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)..

15. 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.

16. 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.

17. 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.

18. 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.

19. 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).

20. B.I Common Elements Miller & Sanchez (1994) – FRAMES –6 ingredients frequently present in brief interventions: Feedback Responsibility Advice Menu Empathy Self-efficacy

21. 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.

22. Responsibility conveying individual is responsible for change or no change

23. 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.

24. 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.

25. 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.

26. FRAMES Empathy –Rogers (1959) – skillful reflective listening that clarifies and amplifies the patient’s own experience and meaning, without imposing the clinician’s material.

27. 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.

28. Prevention and Management of Relapse Lapse Vs Relapse Common reasons: Stress, -VE emotional status,Conflict,Social Pressure,Craving, Cues

29. Self Help groups Alcoholic Anonymous,Narcotic Anonymous,Ttherpeutic Communities Spiritual intervention Sobriety The goal

30. Psycho education Informed Individuals Family members

31. THANK YOU Time to ease out