Alcohol and Other Drugs

Prevention and Intervention

Prevention

• Most efforts directed at young people• Rates of alcohol and tobacco use are very

high in this group• National “Drug-free” policies don’t include

alcohol and tobacco, widely considered gateway drugs

• Related to politics not best practice

Prevention

• Harm Reduction: when it is assumed that SA cannot be eliminated

• Types:– Needle exchange– Sobriety check points– Designated drivers– Tobacco Stings

Prevention

• Supply Vs. Demand• 1.7 Billion for war on drugs in 87’• 1.2 was for supply reduction• 1990 committee revealed little evidence that

supply reduction worked• 1997 67% for supply reduction, 33%

divided between prevention,Tx, research

Prevention

• Legalization– Extremely controversial– Which drugs, how much, for who, where?– Legalization vs. decriminalization

• Some drugs are legal (ETOH, Nicotine, RX drugs)

• Making drugs legal and unrestricted as opposed to removing penalties for certain drug related offenses

Prevention

• Public Health Model (PHM)• Focus on epidemiology

– SA is conceptualized as an interaction between host (the substance abuser), the agent ( the substance used), and the environment

– Prevention activities are conceptualized as primary, secondary and tertiary

Prevention

• Primary Prevention– Attempts to dissuade individuals from initiating

use• Secondary Prevention

– Early intervention, designed to halt progression in individuals identified as users

• Tertiary Prevention– Treatment aimed at substance abusers and

substance dependent

Prevention

• Prevention Efforts– Universal

• Directed at entire population (national media campaign)

– Selected• targeted at risk groups (ACOAs)

– Indicated• Similar to secondary prevention

Prevention

• Prevention Strategies– Information dissemination– Education– Alternatives– Problem identification and referral– Community based processes– Environmental approaches

Prevention

• Few of these prevention strategies have been proven to impact SA

• Environmental approaches (deterrence laws, sobriety checkpoints, bartender training) have proven effectiveness. Usually rely on community coalitions to implement these strategies

• Education works up to three years

Intervention

• Why is intervening with SA so challenging?• Denial- a psychological defense, response

to assault on ego integrity• Fear- of abandoning a relationship that,

while harmful, is at least familiar. The addict may be immobilized by fear of life without drugs

Intervention

• Intervention (according to Anderson) is the process of stopping someone who is experiencing the harmful effects of AOD

• Johnson Intervention- Based on the disease model asserts that forcefulness is needed to counter the “almost impenetrable defenses of the victims…which are organized into highly efficient denial systems.”

Intervention

• Johnson Intervention– “It is a myth that alcoholics have some spontaneous

insight and then seek treatment. Victims of this disease do not submit to treatment out of spontaneous insight-typically, in our experience they come to their recognition...through a buildup of crises that crash through their almost impenetrable defense systems. They are forced to seek help; and when they don’t, they perish miserably.”

Intervention

• Johnson Intervention– Raise the bottom– Serves to precipitate a crisis that is not life

threatening or seriously damaging– Presents “reality” in opposition to “denial”– Objective, unequivocal and caring– Attacks defenses, not the victim

Intervention

• Johnson Intervention Process– 2 or more people– Sometimes not the closest people– Be prepared for client refusal– Rehearse– Get professional help– Have options arranged!!!– Emotionally charged!!!

Intervention

• Effectiveness of Coercive Treatment– Has a higher cure rate (Matuschka,85’)– 97% of the time successful (Royce,

89’)– 50% of the time successful (authors)

Intervention

• Motivational Interviewing (William Miller and Stephen Rollinick)– “is a process for assessing a client’s readiness to

change and it uses procedures based on this readiness to enhance the probability of change. In Motivational Interviewing it is acknowledged that the client may not be ready to benefit from a direct attack on his or her use of AOD.”

Intervention

• Motivational Interviewing (MI)– Confrontational strategies are not supported by

outcome studies. No persuasive evidence that aggressive tactics are even helpful let alone superior.

– Understandable and predictable reactions and resistance to change cause many counselors to jump to the conclusion that clients are in denial. This stance elicits further resistance and denial.

Intervention

• Stages of Change (Prochaska and DiClemente)– Precontemplation– Contemplation– Determination– Action – Maintenance– Relapse

Intervention

• Stage 1 or 2-contraindicated for use of aggressive interventions as clients may react with increased resistance

• Stage 3 or 4-appropriate for aggressive intervention as client is in a position to react positively

• Stage 5 or 6- MHP focus on creating an environment where client can safely discuss difficulties with behavior change

Intervention

• MHP should recognize that the stages of change exist on a continuum and that clients may cycle through them several times

• Working through ambivalence- Create an environment of

empathy, respect, warmth, concreteness, congruence, genuineness, and authenticity

Intervention

• Traps to Avoid• Confrontation- can result in a “yes you are no I’m not”

struggle• Question answer trap- avoid closed ended questions• Expert trap- MHP takes role of expert, client avoids

having to make choices• Labeling- client may resist diagnosis• Premature focus- focus on AOD before client is ready• Blaming-client feels blamed by MHP

Intervention

• Strategies for Resolving Ambivalence– Open ended questions– reflective listening– affirming– supportive statements– summarization

Intervention

• The elicitation of self-motivational statements is the “guiding strategy to help clients resolve their ambivalence. In MI it is the client who presents argument for change. It is the counselor’s task to facilitate the client’s expression of these self-motivational statements.

Intervention

• Self-motivational Statements– Client describes the pros and cons of SA– Asking client “what worries you about SA”– “How has SA been a problem for you?”– Paradoxical Techniques

• MHP argues for continued use while client argues against

Intervention

• Rolling with Resistance– Ambivalence does not disappear but diminishes– Assumption is that client resistance is a

therapist problem– Change in resistance is significantly impacted

by therapist attitudes– Categories of resistance

• Arguing, interrupting, denying, ignoring

Intervention

• Rolling with Resistance– Techniques for reducing resistance

• Amplified or double sided reflections• Shifting the focus (redirection)• Emphasize personal control and choice

– Have client explain the consequences of his or her continued SA

• Re-framing – Assist the client in viewing the problem from a different

perspective

Intervention

• Transition From Resistance to Change– MHP will be aware of transition when client

• Reduces questions about the problem• Seems more calm and settled• Makes more self-motivational statements• Asks more questions about change• Talks about life after change• Experiments with change

Intervention

• If the client progresses to the action stage the emphasis should be on – Setting goals– considering options to achieve goals– deciding on a plan– staying aware of issues that indicate a return to

an earlier stage of change