Psycho-social interventions

Motivational enhancement is an essential component of any intervention of this kind. Different strategies will be utilised depending on peoples’ level of engagement. In the earlier stages of engagement, the first and second strategies (below) may be more useful. As the engagement deepens and strengthens, the later strategies will become more useful. However, people’s engagement will fluctuate and it is important to ensure the correct strategies are being utilised at the right time. The main motivational enhancement strategies include:

1. Establishing a supportive, caring therapeutic relationship.  Establishing a relationship and developing communication skills is important to enable a conversation about drug use. Effective therapeutic relationship may be strengthened by helping the individual to identify practical needs, problems and priorities. Crisis intervention and stabilisation of acute symptoms may help to strengthen the relationship.
2. Finding topics that motivate interest (motivational hooks). Find out what is important to the individual; what do they want to change in their lives. Explore their relationships and goals to find topics that motivate interest.
3. Enabling conversations which explore and discuss substance use. Why are they using? What do they like about the drug? What role does it have in their life e.g. do they think it helps them to cope with mental health difficulties. Try to remain neutral. People will be more likely to listen to information on the adverse effects of the drug, if they feel they have been listened to. Before providing this information, check their existing knowledge i.e. individuals are often aware of the risks of drug use.
4. Explore the pros and cons of behaviour change. Firstly, explore the pros and cons of their current drug use, then move on to the cons and pros of making the change.
5. Strategies for supporting positive change. Look out for statements of concern or intent to change. Ask readiness to change questions. Rate the importance of each pro and con. Identify and question the positive beliefs around drug use.

Developing control over impulsive behaviour begins with investigating the behaviour itself (e.g. why someone smokes crack cocaine), in addition to what was happening before the drug use, and what the consequences of the drug use were. This process is known as Functional Analysis and it can help an individual to realise that when a trigger occurs, they can use a non-drug using behaviour, resulting in a different set of positive long-term consequences. This is one of the core principles of controlling impulsive behaviour, which involves identifying and managing triggers, coping with cravings, analysing seemingly irrelevant decisions and managing high risk situations.

Identifying and managing triggers

Individuals may not be aware of their triggers, or even that they have them. Identifying triggers enhances control in that it is the first step in learning how to manage triggers. A detailed drug diary may help to identify their triggers (as well as understanding the links between triggers, drug use and consequences; and potentially to develop a better sense of control over their drug use). The Discovering Triggers worksheet can also help, as can asking the following questions:

• Before the individual used the drug, what were they thinking, feeling, doing; where were they, who were they with?
• What was the perceived coping mechanism e.g. did they believe that it improved their feelings of wellbeing or alleviated boredom?
• What were the positive and negative short and long-term consequences?

In terms of managing triggers, the individual should try to remove all of the possible environmental triggers. This will be helped by the Self-Management Plan. For those triggers that cannot be removed, develop a craving plan, using the Coping with Cravings and Urges worksheet. At some point in the future, some environmental triggers may be able to return, as the coping strategies strengthen. It is also important to identify thoughts and feelings which are triggers and develop a coping plan, using the Coping with Thoughts worksheet.

Coping with cravings

The following activities may help individuals to manage their cravings:

1. Distraction involves any activity that diverts their attention from the drug craving and may involve mental, physical or soothing activities. Examples include participating in sports; rediscovering interests such as art, music, film; gaming, doing crosswords, Sudoku, other puzzles, reading, TV etc.
2. In a safe setting, focus on the craving and find ways to cope with the feeling such as urge surfing, mindfulness or recovery meetings.

Again, a drug diary will be helpful in managing cravings.

Seemingly irrelevant decisions and high risk situations

Seemingly irrelevant decisions occur when a series of decisions are made, that increase the risk of lapse or relapse. For example, going to the local shop and meeting an old friend may put the individual at risk of a lapse or relapse. The Seemingly Irrelevant Decisions Worksheet will help individuals gain a broader understanding of these. The individual should be supported in developing an awareness of high risk situations in terms of people, places, thoughts and feelings.

When an individual has mastered many of the skills above and has developed a strong sense of control over their substance use, it is important to support them in developing a more rewarding lifestyle, as this will help strengthen their recovery. Supporting an individual to develop new or existing skills, may help improve motivation, encourage greater stability and ensure they have the commitment and energy to develop holistically. It is important to help someone develop new experiences and explore ways in which they pursue new interests. The exercises and worksheets highlighted below can help to structure the conversation and develop ideas:

1. Set priorities using the Happiness Scale and identify person-centred activities using the Recreational Survey.
2. Set goals using the Goal Setting Worksheet.
3. Monitor progress using the Highlighting Progress Graph and Calendar.

*This guidance has been taken from the NHS Education for Scotland (NES) Core Behavioural and CBT Skills for Relapse Prevention and Recovery Management Course (Laura Freeman, NES, 2011). In order to follow and implement this guidance effectively, it is recommended that workers should have attended Core Skills training. The worksheets mentioned in this guidance are covered in Core Skills training and are available from the website below:

Links: https://turasdashboard.nes.nhs.scot. Please complete the registration process (if you are not already registered) and search “core skills”.