Dr Barbara Hedge Consultant Clinical Psychologist

Is there more to risk prevention than MI? Flavour of the month Relaxation therapy Cognitive behaviour therapy Solution focused therapy Motivational interviewing Why recommended Looks to be effective but cheap Never mind the problem

NICE guidance 2007

Putting therapy into context Sexual health setting A normal, universally practised behaviour Risk Probability of danger and/or undesired outcomes Individual Partners and families Society Undesired outcomes Sexually transmitted infections Pregnancy Aim to change behaviours to reduce risk Identify useful psychological therapies

What factors are associated with risk? Lack of knowledge or understanding Resources Skills Communication Ability Conceptualisation of personal risk Motivation to reduce risk Lack of care for self or others Low mood Shame Power differential Cultural Coercive

Sexual health expert knows best Assumptions Patients are always rational so act on knowledge The goals of patients are the same as goals of sexual health practitioners All patients want what is best for themselves UK national guidelines on safer sex advice BASHH 2011 Conclusions Giving knowledge is all that is necessary Telling people what to do is the same as giving advice

They just don’t listen! Repeated STIs HIV transmission Unwanted pregnancies Repeated requests for PEP Information is necessary but not sufficient

Theory of reasoned action Fishbein, 1979

Which therapy? What, who needs to change? Who wants or doesn’t want to change? What are the risk factors Goal to be achieved How to bring about change Learning theories Skinner’s Operant Conditioning theory Bandura’s Social Learning theory

Risk reduction Interventions Provision of information Skills acquisition Motivation to reduce risk behaviours Change of perspective Identification of risk BehavioursThoughtsAssumptionsSkills

Behaviour change therapies Cognitive Behaviour Therapy Systemic Therapy Solution focussed Therapy Motivational Interviewing Peer Influence Nudge

Cognitive behaviour theories CognitionsBehavioursEmotions

Personal risk cognitions Not want to transmit Not want to disclose Not want to use a condom Not want to become infected Not want to think about it Not want to confront

Self-serving attributions Constructed narratives that allow justification of our behaviours Before and/or after action or non-action ART means I have no virus to transmit PEP is available if need it If partner is willing to have unprotected sex they are probably already positive Partner wouldn’t suggest unprotected sex if they were positive Can trust negotiated safety agreement

Cognitive behaviour therapy Addresses non-adaptive cognitions Replaces with adaptive Can confront the issue Can plan to remain uninfected Raises mood Lowers anxiety Increases self-esteem Adoption of self affirming behaviours Assertiveness Acceptance of rejection of the behaviour rather than of the self

Learning new behaviours Operant Conditioning Reinforcement Positive  repeat of behaviour Great sex with a condom Remove negative  Finally agree to sex when agree to condom Negative  Fail to keep erection with a condom Remove positive  No sex as no condoms

Chains of behaviour Develop a chain of behaviours that lead to the outcome Anticipate sex Think about protection Acquire a condom Introduce the condom Correct use of condom Protected sex

Nudge theory Suggestion + positive reinforcement Address one element of behaviour in the chain If positively reinforced by others or internally Repeat behaviour Reinforce additional elements in chain Gradually approach goal of protected sex

Solution focussed therapy Not concentrating on the problem Uses resources patient already has Encourages trying a course of action (possible solution) Strengths patient already has Advantages Quick Cheap Patient generated Builds self esteem and self efficacy Disadvantages Failure for complex issues Key factors may not be identified Difficult engagement when depressed

Cycle of change – Prochaska and Diclemente

Motivational interviewing Directive, client-centred counselling style to resolve ambivalence (Rollnick & Miller, 1995) Motivation = Importance + Confidence + Readiness Aims to elicit and boost these factors NICE Quick Cheap Catch people on first visit Evidence of effectiveness A stand alone intervention Possible service approach

Peer interventions Use of a peer educator Group leader Introduce safer sex into conversation Set up group norm ‘cool to use condoms’ Social learning theory + Nudge + MI Efficacy Some support ? Culturally specific Review: Simoni et al, AIDS Behav, 2011,

When do I need systemic therapy? Risky sex is rarely an individual practice What is the influence of the partner? What is the perceived influence of the partner Is there a power in-balance? Communication Negotiation Agreement between partners to change

Summary Motivational interviewing a good place to start Finding out the whole picture Patient suggests the next step Moves to action from pre-contemplation More commitment to meet their own challenge Ready to address cognitions and beliefs and learn skills Able to identify when there are greater unmet needs Pathways for onward referral to meet general needs Appropriate use of therapeutic techniques brings best results