Transcript Day 4: Models of Treatment and Change

Day 4: Models of Treatment
and Change
Liz Hughes
Objectives
 To be able to plan and coordinate care in collaboration with person
with combined mental health and substance use, their carers, and
other professionals (12)
 Be able to utilise knowledge and skills to deliver evidence-based
interventions including brief interventions, motivational interviewing,
relapse prevention and cognitive behaviour therapy to people with
combined mental health problems within own limits and capacity
and remit of ones own organisation. To know where else a service
use can access appropriate specialist care and facilitate that
access. To be able to access support and supervision to perform
such interventions (13).
 To be able to collaboratively review and evaluate care provided with
service user, carers and other professionals. To be flexible in
changing plans if they are not meeting the needs of the service user
(14).
 Be able to accept the person as a unique individual and respect
their choices and lifestyle (3)
Timetable
9.30 Recap on homework
10.00 Cycle of change
10.30 Break
10.45 Models of Treatment
12.00 Motivational Interviewing principals
12.30 Lunch
1.30 Motivational skills
2.30 Break
2.45 Role-play “readiness to change”
3.45 summary, homework
4.00 End
How people change
They undergo a series of cognitive and
behavioural processes
• Involves belief in own ability to change
(self-efficacy)
• Self-esteem- I am worth changing for
• Own rationale for change (the benefits
outweigh the cost or loss)
Cycle of Change (Prochaska and
Diclemente, 1996)
PreContemplation
Contemplation
Lapse/ relapse
Determination
Action
Stages of Change
• Pre-contemplation: lack of acknowledgement that what
they are doing is a problem; in fact it is often seen as a
solution (“in denial”).
• Contemplation: beginning to think about change, but
not quite ready. Characterised by AMBIVALENCE; the
weighing up of the pros and cons of problem and
solution.
• Preparation: Individuals are formulating a plan of action
• Action The individual puts the plans devised in the
previous stage into practice (ready, willing and able)
• Maintenance- This is a period of continued change that
is being maintained by active strategies.
• Relapse: normal, predictable stage in the process of
change. Exploring relapse can be a useful learning
experience.
Integrated Treatment Model
(Drake et al, 2001)
• Comprehensive service- this group has complex needs and the
service needs to be able to recognise and address these needs.
• Stage wise- people come into treatment at various stages of
change (levels of motivation).
• Long term view- Making changes is a slow process so the service
should be expecting to work with someone with a dual diagnosis
over months and years rather than weeks
• Assertive Outreach- This group are typically hard to engage in
treatment.
• Shared Agreement- The service user should be as actively
involved in decisions about their care as possible. It is also
important to include any other significant people in care planning
and decision making.
• Medication management- People with dual diagnosis are more
likely to be non-adherent to medication, and if they do take it, are
more likely to suffer from side-effects. Therefore medication issues
need to be addressed.
Psychosocial Interventions Trials
• Barrowclough (2001)
– MI CBT and FW up to 40 sessions!!
– Improvement in general functioning; reduction in
positive symptoms, increase of % days abstinent from
substances
• Bellack (2006) BSTAS
– Group programme- twice weekly, social skills, MI, PS,
urine contingency
– Increased clean urines, survival in treatment,
attendance, QoL
Evidence
• Cochrane review Ley and Jeffreys 2000- 4 RCts
integrated treatment- no evidence
• Cochrane review 2008- psychosocial interventions 25
RCTs- no compelling evidence that one approach better
than standard care
– Main support for approaches:
• Engagement
• MI more participants abstained from alcohol
• MI and CBT together improved mental state, life satisfaction and
social functioning
The Four Stage Model of Dual Diagnosis
Treatment (Osher and Kofoed, 1989)
•
•
•
•
•
Defines what should be happening in treatment at
different levels of engagement and motivation:
Stage 1:Engagement- sees the importance of
collaborative relationship before starting work on
substance use
Stage 2: Persuasion- also called “building readiness to
change” working on ambivalence
Stage 3: Active treatment- ready to change therefore
focused interventions
Stage 4: Relapse prevention- protecting abstinence or
reduction
May spend many years in first two stages
People can slip between stages at any point; the
worker’s approach is guided by the service user.
Four Stage Model and Cycle of
Change
TREATMENT
• ENGAGEMENT
• PERSUASION
• ACTIVE TREATMENT
• RELAPSE PREVENTION
•
•
•
•
•
•
INDIVIDUAL
MOTIVATION
PRE-CONTEMPLATION
CONTEMPLATION
PREPARATION
ACTION
MAINTAINANCE
RELAPSE/ ABSTINENCE
Staged Activities
Stage
• Engagement
• Persuasion
• Active Treatment
• Relapse Prevention
Focus of Activity
Building relationship,
stabilisation of acute problems,
medication management
Developing reasons for thinking
about changing substance use
using motivational interviewing
techniques, social support,
stabilisation of social situation,
develop meaningful activities,
psychoeducation
Focused counselling and treatment,
group and individual work, family work,
work and activities
Maintaining stability of lifestyle, using
relapse prevention strategies,
developing alternative life including
new peer groups.
Kofoed’s
Transtheoretical Model
Osher and
Stages
Four
Pre-contemplation
Engagement/early persuasion
Contemplation
Early persuasion
Preparation
Late persuasion
Action
Active Treatment
Maintenance
Relapse prevention
Engagement Stage defined as:
• Lack of working alliance between worker
and client.
• Sporadic/chaotic use of services.
• Lack of trust (from service user and
worker).
• High levels of resistance.
• Non-adherence to treatment proposed.
• Treatment failure.
Interventions for Engagement
•
•
•
•
•
•
•
•
•
•
Outreach.
Befriending/ low key.
Creative and flexible approach
Therapeutic optimism.
Practical assistance and crisis intervention- be perceived
as helpful.
Stabilisation of psychiatric symptoms (? admission to
hospital; medication management)
Sensitivity to client’s life, choices and viewpoint.
Typically not addressing substance use.
Utilise strategies to reduce resistance.
Support and exploring alternate social networks.
Exercise
In your experience….
• What things hinder engagement process
• What things aid engagement process
Discuss small groups: 15 minutes
Persuasion
• Enters this stage once engaged in a therapeutic
alliance.
• Still not necessarily acknowledging problem with
substances
• Considered behaviourally unmotivated- not
showing any signs of reducing substance use
(but may be talking about it).
• Still expect sporadic attendance; be flexible.
• Worker acknowledges that motivation to change
must be generated internally or will fail.
Examples of Interventions For
Persuasion
•
•
•
•
•
•
•
Individual and family psycho-education.
Motivational Interviewing.
Peer (“persuasion”) groups.
Social skills training.
Structured activity.
Safe/stable housing.
Medication Management.
What Is MI?
Client centred, directive method for
enhancing intrinsic motivation to change
by exploring and resolving ambivalence.
– (Miller and Rollnick, 2002 2nd ed)
“Skillful guiding” not directing or following
-(Rollnick, Miller, Butler, 2008)
Key Ideas
• Worker style powerful determinant of both resistance
and change
• Ambivalence is normal and to be expected
• Resolving ambivalence is a key to change
• Self-efficacy is related to outcome
• Labelling is not essential
• empathy, non-judgemental, and genuineness
• “Spirit”- collaboration, evocation, autonomy
• Detachment from outcomes (not absence of caring)
You can inform, advise, warn but ultimately the
individual decides whether to change or not
RULE
R resist the righting reflex
U understand their motivations
L listen
E Empower
Change Talk
• Ability to recognise this!!
– Guiding through change talk- walking through
a forest, lots of overgrowth, weeds etc but
every so often a flower
– Pick the flowers and present to the client as a
bouquet!
Traps (how not to…)
• Expert/ prescriptive: “ As an experienced nurse, I think
you should….”
• Question-answer: “have you taken your tablets?” “yes I
have”
• Premature focus “I’d like to talk more about your
drinking” “but I am really worried about losing my
tenancy.”
• Labelling: “schizophrenic, alcoholic…etc”
• Blaming: “The reason you end up back in hospital is
because you use cannabis”
• Taking sides “It seems clear to me that you have a
serious drink problem” “but a lot of people drink like me”
OARS (skills)
• O pen-ended
• A ffirming
• R eflecting
• S ummarising
Some key techniques
•
•
•
•
•
•
•
•
•
A “typical day”
Readiness to change
Timeline-looking back
Goals and roadblocks- looking forwards
Exploring the good and less good (pros and
cons)
Evocative questions
Raising discrepancies
Problem solving
Offering choices
Examples of evocative questions
• What worries you about your current
situation?
• How would you like things to be different?
• What encourages you that you could
change if you want to?
• I can see you are feeling stuck; what is
going to have to change?
• What would be the advantages of making
this change?
A Typical Day
• Helps people reflect on processes that are
usually automatic
• Identify maybe some of the less good
aspects of the behaviour as well as the
good
• Helps worker get a picture of the
behaviour
• Get a sense of motivational state
Adapting MI for Dual Diagnosis
(Bellack and Diclemente, 1999)
• Spend extra time engaging in therapeutic
relationship
• Use of repetition and rehearsal
• Being concrete and simple in setting tasks
and discussions.
• Being realistic about goals.
• Small doses (10-20 minutes)
• Flexibility.
Readiness to Change
(Rollnick, Mason and Butler, 1999)
Readiness to change ruler:
NOT READY……......UNSURE…………….READY
0……………………………………………….10
• Importance of change: 0----------10 (willing)
• Confidence in ones own ability to make the
change: 0-------------10 (able)
Readiness to change
• Increasing importance
• A valid reason for change
• Benefits outweigh costs
• Information about possible risks
• Confidence
• Small achievable goals
• Reminder of past successes
• Affirming and empathy
Key Questions
• Can you tell me why you placed yourself there
on the scale (readiness to
change/importance/confidence)
• What would have to be different for you to move
a bit further forward?
• Can you tell me a bit more about that….
• Is there anything else that’s important that we
haven’t discussed yet?