1. Day 4: Models of Treatment and Change Liz Hughes

2. 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)

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

4. 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)

5. Cycle of Change (Prochaska and Diclemente, 1996)

6. 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.

7. 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.

8. 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

9. 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

10. 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.

11. Four Stage Model and Cycle of Change TREATMENT ENGAGEMENT PERSUASION ACTIVE TREATMENT RELAPSE PREVENTION INDIVIDUAL MOTIVATION PRE-CONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTAINANCE RELAPSE/ ABSTINENCE

12. Staged Activities StageFocus of Activity EngagementBuilding relationship, stabilisation of acute problems, medication management PersuasionDeveloping reasons for thinking about changing substance use using motivational interviewing techniques, social support, stabilisation of social situation, develop meaningful activities, psychoeducation Active TreatmentFocused counselling and treatment, group and individual work, family work, work and activities Relapse PreventionMaintaining stability of lifestyle, using relapse prevention strategies, developing alternative life including new peer groups.

13. Transtheoretical ModelOsher and Kofoed’s Four Stages Pre-contemplationEngagement/early persuasion ContemplationEarly persuasion PreparationLate persuasion ActionActive Treatment MaintenanceRelapse prevention

14. 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.

15. 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.

16. Exercise In your experience…. What things hinder engagement process What things aid engagement process Discuss small groups: 15 minutes

17. 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.

18. 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.

19. What Is MI? Client centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. –(Miller and Rollnick, 2002 2 nd ed) “Skillful guiding” not directing or following -(Rollnick, Miller, Butler, 2008)

20. 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

21. RULE R resist the righting reflex U understand their motivations L listen E Empower

22. 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!

24. 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”

25. OARS (skills) Open-ended Affirming Reflecting Summarising

26. 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

27. 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?

28. 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

29. 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.

30. 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)

31. 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

32. 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?