I worked in a Substance Misuse service for 6 months, using mainly motivational interviewing and Cognitive Behavioural Therapy. This is an example case to illustrate the approach we used. I have shared it with the clients consent and all details have been anonymised.
A homeless man came to the Substance Misuse Service for assessment. He reported struggling with alcohol use, depression and suicidal thoughts.
I completed the assessment, which took about an hour. We discussed why he’d come in, his substance misuse amounts and frequency, previous convictions, social issues and housing, family (especially details of any children who may be at risk), mental health, physical health, prescribed medication, etc. It also involved completing a risk assessment (eg risk of self neglect, suicide, harm to others, etc) and an initial care plan.
It was important to use Motivational Interviewing skills to during this assessment to encourage change. I’ll explain this in more detail later.
At the end of the assessment, he was asked to complete a urine drug screen and breathalyser.
His assessment indicated that he was physically dependent on alcohol. This means that if he stopped suddenly then he would be at risk of having a seizure (and in some cases people have died from this). I therefore advised him to keep drinking, especially if he was starting to experience shakes, and that he would have to reduce the alcohol gradually (generally by 10% every couple of days).
I discussed his assessment with the rest of the multi-disciplinary team (nurses, psychiatrists, social workers, occupational therapists and psychologists) at the allocation meeting. The client was assigned to the alcohol drop in service; this meant that he would come in once a week during drop in hours for motivational interviewing. After a couple of weeks I was then assigned as his keyworker and continued to work with him on a one-to-one basis.
The aim of Motivational Interviewing was to develop a discrepancy between the person’s current situation and where they want to be. By heightening their ambivalence you can encourage change.
One technique I used is the decisional matrix. This involved asking the client to identify the advantages of staying the same, the disadvantages of staying the same, the disadvantages of changing and the advantages of changing. It was helpful for the client to see that there were many more positives to changing, compared to staying the same.
Another technique was to ask the client to rate their current physical/mental health on a numerical scale and then ask them what it would take to increase that rating by 1 or 2 points. This encouraged the client to think of ways of changing. By coming up with the suggestions himself, he was more likely to accept them compared to being told by someone else. For example, he is more likely to accept his own suggestion ‘I guess I would feel better if I quit smoking’ compared to me saying ‘you should quit smoking’.
It was also important to use the elicit-provide-elicit technique when providing information in to avoid resistance. This is where you ask the person what they know about a topic, then ask permission to give them a bit more information about it, then afterwards elicit it again by asking them how they understand what you’ve just told them.
Throughout the session I used summaries to emphasised the reasons he had given me for wanting to change and encourage ‘change talk’. I also used reflections to manage any resistance. For example, when he stated ‘my family keep nagging me about my drinking’, I reframed it by reflecting ‘so you’re family care about you a lot and are concerned about you’. Or when he stated ‘I’ve tried treatment before and it hasn’t worked’, I reframed it as ‘you’re persistent because it means a lot to you’. You can also used amplified reflections, for example if a client stated ‘I don’t want to give up methadone’, you could amplify it by reflecting ‘so you want to stay on methadone for the rest of your life’, in order to get them to acknowledge ‘well, no I guess not’.
Through Motivational Interviewing I was able to support the client to gradually reduce his alcohol use, to the point where we were able to put him on the waiting list for a detox. I explained that the Detox was the easy part and the hard part would be remaining abstinent when he comes back out again, back to the same situations, places and people. It was therefore important to have some Relapse Management sessions (based on Cognitive Behavioural Therapy) before the Detox.
The Relapse Management sessions involved using Socratic dialogue; informational questioning, active listening (using reflections), summaries and analytical questioning. In analytical questioning you ask questions that will help the client come up with the answers themselves eg ‘on the one hand you say that you think alcohol will help but on the other hand you say that you feel depressed afterwards; how do you make sense of that?’ will lead the client to realise ‘I guess it actually doesn’t help’.
We also focused on identifying and adjusting his automatic thoughts, underlying assumptions and core beliefs (see previous blogs on CBT for an explanation of this). I explained to him that his thoughts and evaluative judgements mediate between stimuli and his emotions or behavioural response. It is not the event that makes him feel depressed but his evaluation of the event; for example, thinking that not being able to get him a job makes him a failure.
He was repeatedly asked to rate on continuum scales (see previous blog) and keep a positive data log as homework. We looked at goal setting and problems solving as well as how to manage high risk situation (eg if in situations with alcohol present), crisis plans (for what to do and who to contact if at risk of drinking) and lapse chains (to determine factors contributing to any lapses he has). I also explained to him the difference between lapses (one or two instances of previous behaviour) versus relapses (going completely back to the previous behaviour) and explained that lapses don’t have to lead to relapse.
Along with the one-to-one therapy sessions, I was responsible for completing continual risk assessments, focusing on the suicidal thoughts and any protective factors. I assessed if they were constant or fleeting and whether he had any intent or plans.
I was also responsible for helping him find housing by writing a letter to the council, helping him find employment by referring him to our employment specialist and liaising social services regarding his daughter. We always inform social services if a child is involved. I explained to him that, although many people worry about social services finding out, they will actually see the engagement in treatment as a good sign because you are getting help. They will always work with families to try and help them and only take children away as a last resort.
I also encouraged him to join in with the service’s groups, including the gardening group, so that he could meet other people in recovery and start engaging in pleasurable activities again (people with depression often cut these activities out of their life over time).
After a successful Detox, he went to rehab. When I left the service he had been sober for 3 months, had improved mood, no suicidal thoughts, had found housing and was completing training (to improve the likelihood of employment). I was glad that I was able to see the case through, as often I have to leave the placement half way through working with someone. It was rewarding to see how far he’d come.
Dr Danielle Crane 