Screening of Persons With Substance Dependence

7/31/2019 Screening of Persons With Substance Dependence

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SCREENING OF PERSONS WITH SUBSTANCE

DEPENDENCE

Drinking is an accepted behaviour in our society, & alcohol isprojected as an essential art of good life.

For 2 out of 10 people who drink, alcohol use slowly deviates

from harmless to harmful activity.

Majority of substance abusers go unnoticed for a long time.Screening is a basic & important part of evaluation.


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SCREENING OF PERSONS WITH SUBSTANCE

DEPENDENCE (contd.)

For screening of alcohol dependence, the following scales areavailable:

CAGE (oldest & briefest instrument available) MICHIGAN ALCOHOL SCREENING TEST (2 forms- one

having 10 items & the other having 25 items)

Few scales are available for assessing the severity of alcoholdependence syndrome. They are:

Addiction Severity Index

Alcohol Dependence Scale Severity of Alcohol Dependence Short Alcohol Dependence Data


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ASSESSMENTPsychiatric assessment:

Delirium & amnesticdisorders

Psychotic symptom Affective disorder

Sexual function

Psychosocial assessment:Family

WorkSocialLegalAssessment of relapse


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ASSESSMENT (contd.)

Personalityassessment:

Developmental history,

with focus on childhooddisruptions Educational achievement Employment history Marital & sexual history Locus of control Using tools of personality

assessment in order toassess pre-morbidfunctioning

Physical examination &investigations:

General appearanceAbdomenCardiovascular systemRespiratory systemNervous system

Lab investigations


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ASSESSMENT OF MOTIVATION

Motivation, here, refers to the desire to change ones owndysfunctional behaviour. It may be assessed based onfollowing factors:

o Accepting that there is a problem with chemicalso Asking for help

o Reporting for treatment without coercion

o Compliance with the terms laid down by thetherapist

o Past history of abstinenceo Internal locus of control


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MOTIVATIONAL INTERVIEWING Concept evolved from experience in the treatment ofproblem drinkers.

First described by Miller (1983) in an article published inBehavioural Psychotherapy and later developed bypsychologists William R Miller and Stephen Rollnick.

Semi-directive, client-centered counseling style that isnon-judgmental, non-confrontational and non-adversarial,for eliciting behaviour change by helping clients to exploreand resolve ambivalence.

It attempts to increase client's awareness of the

potential consequences & risks that may arise as a resultof the behavior in question.

Focusses on the present, and entails working with a clientto access motivation to change a particular behavior, thatis not consistent with a client's personal value or goal.


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MOTIVATIONAL ENHANCEMENT THERAPY Designed as a standardized four-session counsellor

approach in Project MATCH (Matching AlcoholTreatments to Client Heterogeneity), a clinical trial ofpatient-treatment matching sponsored by the NationalInstitute of Alcohol Abuse and Alcoholism (NIAAA).

Based on principles of motivational psychology, and isdesigned to produce rapid, internally-motivated change.

MET approach founded on the assumptions thatcounselees have the capacity and responsibility forchange and that it is the counsellors task to create

conditions that enhance clients motivation for andcommitment to change.

Seeks to support intrinsic motivation for change, whichleads the counselee to initiate, persist in, and complywith behaviour change efforts.


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BASIC MOTIVATIONAL PRINCIPLES

Expression of empathy counsellor communicates respect for thecounselee and listens rather than tells;

Assisting the counselee in perceiving discrepancy counsellor helpsthe counselee perceive a discrepancy between where he or she isand where he or she wants to be;

Avoiding argumentation

Rolling with resistance counsellor does not meet resistance headon, but rather rolls with the momentum, with a goal of shiftingcounsellees perceptions in the process;

Ambivalence is viewed as normal and openly discussed- thecounsellor elicits solutions from the counselee

Support of self-efficacy the counselor works to enhance thecounsellees sense of self-efficacy, or ability to achieve goals.


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STAGES OF CHANGE

PRECONTEMPLATION- Individuals who are not consideringchange in their problem behaviour.

CONTEMPLATION- Here, the person begins to considerboth the existence of a problem and the feasibility and costsof changing the problem behaviour.

DETERMINATION This is the stage where the decision ismade to take action and change.

ACTION- Once the individual begins to modify the problembehavior, he or she enters the action stage, which normallycontinues for 3-6 months.

MAINTENANCE After successfully negotiating the actionstage, the individual moves to this stage where he sustainsthe changes in his behaviour.

RELAPSE Relapse occurs if these efforts fail & theindividual begins another cycle.


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STRATEGIES IN PHASE-I

Eliciting self-motivational statements-

Based on cognitive-dissonance theory. Words spoken by the person himself more persuasive than

words spoken by another. (If I say it, and no one has forcedme to say it, then I must believe it!)

Thus, ME therapist elicit statements from client including

those of:1. being open to input about drug use and effects2. acknowledging real or potential problems related to drug use3. expressing a need, desire, or willingness to change4. expressing optimism about the possibility of change.

Listening with empathy-

In this style, the therapist listens carefully to what the clientis saying, then reflects it back to the client, often in a slightlymodified or reframed form. Acknowledgment of the client'sexpressed or implicit feeling state may also be included.


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STRATEGIES IN PHASE-I (contd.)

Questioning-

The MET style does include some purposeful questioningas an important therapist response.

Rather than tellingthe client how he/she should feel, orwhat to do, the therapist asksthe client about

his/her own feelings, ideas, concerns, and plans.

Presenting personal feedback-

First MET session should always include feedback to theclient from the pretreatment assessment.

Done in a structured way, providing clients with awritten report of their results ("Personal FeedbackReport"), and comparing these with normative ranges.

A very important part of this process is the therapistsmonitoring of and responding to the client during thefeedback.


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Affirming the client- Therapist seeks opportunities to affirm, compliment, and reinforcethe client sincerely.

Such affirmations beneficial in a number of ways, including:o Strengthening the working relationship,o Enhancing the attitude of self-responsibility and empowerment,o Reinforcing effort and self-motivational statements, and

o Supporting client self-esteem.

Handling resistance- Resistance- Failure to comply with a therapist's instructions, and

resistant behaviors within treatment sessions (e.g., arguing,interrupting, denying a problem)

Important goal in MET is to avoid evoking client resistance (anti-

motivational statements). Few ways of deflecting resistance:o Simple reflectiono Rolling Witho Shifting Focuso Reflection with amplification


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Reframing- Strategy whereby the therapist invites the client to examine

his or her perceptions in a new light, or a reorganized form To place the problem behavior in a more positive light, but to

do so in a way that causes the person to take action to changethe problem.

In developing the reframe it is important to use the client'sown views, words, and perceptions about drug use.

Summarizing- It is useful to summarize periodically during a session, and

particularly toward the end of a session.

It is especially useful to repeat and summarize the client'sself-motivational statements. serves the function of allowing the client to hear his or her

own self-motivational statements yet a third time, after theinitial statement and your reflection of it.


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TRANSITION FROM PHASE-I TO PHASE-II

Timing is a key issue - knowing whento begin moving toward acommitment to action.

Within the Prochaska/DiClemente model, this is the stage ofdetermination

Such a shift is not irreversible. If the transition to action is

delayed too long, determination can be lost. These are some changes the therapist might observe (Miller &

Rollnick, 1991): The client stops resisting and raising objections The client asks fewer questions The client appears more settled, resolved, unburdened, or

peaceful The client makes self-motivational statements indicating adecision (or openness) to change

The client begins imagining how life might be after a change


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STRATEGIES IN PHASE-II (contd.)

Communicating Free Choice An important and consistent message throughout MET

is the client's responsibility and freedom of choice. Reminders of this theme should be included during the

commitment-strengthening process.

Consequences of action & inaction A useful strategy is to ask the client to anticipate what

the result would be if the client continued using asbefore.

Similarly, the anticipated benefits of change can begenerated by the client.

A formal "decisional balance" sheet maybe constructedby having the client generate (and writing down) thepros and cons of change options.


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Information & advice Often clients will ask for key information, as important input

for their decisional process. Clients may also ask the therapist for advice. It is quite appropriate to provide the therapists personal views

in this circumstance, with a few limitations.

The therapist could provide his best advice on issues such aso changes to be made in clients drug use,o need for the client and significant other to work togethero general kinds of changes that the client might need to make in

order to support changes in drug use (e.g., find new ways tospend time that don't involve drugs)

However, on issues pertaining to how to bring about thechanges, strategies should be elicited from the client himself/herself.


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Abstinence and Harm Reduction Not all clients choose, as their goal, to abstain totally from all

psychotropic drugs. The goal of change is, in fact, a choicethat each client must and does make. Within an MET style, itis not up to you to "permit" or "let" or "allow" clients to make

choices. However, the therapist might choose to provide somepersuasive reasons to consider drug abstention, citingavoidance of health problems, legal issues etc.

Harm reduction" perspective in drug abuse treatment positsthat any step in the right direction is a step in the rightdirection, such as, moving to a safer method of drug intake,

changing from a more dangerous drug to a lesser dangerousdrug, reducing the frequency, trying periods of abstinence etc.

Handling Resistance


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The Change Plan Worksheet (CPW) to help in specifying the client's action plan. It should cover the following aspects:o The changes he wants to make

o The most important reasons why he wants tomake these changes

o The steps he plans to take in changingo The ways other people can help himo The benefits he expects out of this plan

o The hindrances perceived in the plan Recapitulating

Asking for commitment


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INVOLVING A SIGNIFICANT OTHER

Involvement of a concerned significant other (SO)can enhance motivational discrepancy & commitmentto change.

Emphasis on need for collaborative work

Goals include

rapport establishment,

raising awareness,

strengthening SOs belief,

eliciting feedback from SO


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FRAMES

Six core active ingredients that induce changein problem drinkers (Miller and Sanchez , 1994)have been summarized by the acronymFRAMES. They are:

FEEDBACKof personal risk or impairment Emphasis on personal RESPONSIBILITY for

change Clear ADVICEto change A MENU of alternative change options

Therapist EMPATHY Facilitation of client SELF-EFFICACY oroptimism


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Screening of Persons With Substance Dependence