Psychosocial interventions

Staff training

The psychosocial interventions should be provided by staff with qualifications in psychology, social work or other healthcare disciplines. There should be a clear separation between these staff, and staff who are employed to provide security for the closed setting.

Accept that different people have different treatment needs

Most people who use drugs do not experience any negative consequences. Not everyone who is in a closed setting is going to be dependent on drugs. Some patients will be dependent, but others will not. Patients who are not drug dependent do not need the same intensity or type of intervention as those who are.

Don't tell the patient what to do

It is not the purpose of psychosocial interventions to tell the patient what to do. Only the patient can decide what is best for him or her. Your role is to help the patient develop skills to think about and modify their behaviour.

Often patients will ask a question such as “What would you do?” or “What do you think I should do?”. In instances such as these, gently redirect the conversation back to the patient by saying something like “It doesn't matter what I would do, because I'm not you. Only you can determine what's best for you”.

Maintain a respectful, non-judgmental attitude

Patients may have been involved in activities that you disapprove of, including crime, sex work and illegal drug use. It is essential to remember that it is the activity you disapprove of, not the patient. You should always demonstrate respect for the patient. Avoid using words that insult or label the patient, like ‘addict’, ‘criminal’ or ‘prostitute’. Shaming or upsetting a patient will not help them.

Encourage the patient to talk

Many of the treatment sessions in the psychosocial interventions involve the patient talking about their problems. Generally, you should talk less than the patient. Encourage the patient to talk by asking open-ended questions. These are questions that require more than a ‘yes’ or ‘no’ response. For example:

• Can you tell me about yourself?

• Can you tell me about your drug use?

Listen carefully to how the patient answers these questions and ask follow-up questions.

Acknowledge and praise positive change

Many drug dependent people feel unable to help themselves. An important part of drug treatment is giving the patient confidence and skills to solve their problems. You can do this by focusing on the patient's abilities. Show that you believe they are capable of changing their drug use and encourage the patient to believe the same. Acknowledge positive changes in the patient by using praise and small rewards.

Maintain confidentiality

As discussed previously, confidentiality is essential to ethical and effective treatment. Although sometimes very difficult in closed settings, discussions between a patient and healthcare worker are private and must be kept confidential. A person who has committed a crime or is dependent on drugs is still entitled to privacy and confidentiality.

Objective

To provide patients with accurate information about drugs, drug dependence and treatment.

Rationale for patient

By understanding more about how drugs interfere with the brain, you can get a better understanding of how to cope with cravings for drugs.

Method

There are a number of key concepts to discuss with patients. Don't just say these things to patients – ask the patient what he or she thinks about what you are saying and how it relates to their own experiences.

Discuss the various drug types, both legal and illegal. Describe the way that different drugs affect the central nervous system (see p.6). Mention that many people use drugs and experience no problems. However, some people experience harm when they use drugs, and some people become dependent on drugs. Using drugs or being drug dependent does not mean the patient is a bad or weak person. If a person is drug dependent, they have a medical problem that needs specialised treatment.

Discuss the signs of drug dependence, such as tolerance and withdrawal. Point out that if a person doesn't experience these symptoms, they are probably not dependent on drugs.

Explain that drugs cause temporary changes in the way a person's brain works. For a drug dependent person, this means that he or she may experience cravings for drugs for weeks or even months after they have stopped using them. However, these cravings will get less frequent and less intense over time, and will eventually go away completely.

Sometimes, cravings are very difficult to resist and the person may use drugs again – he or she may relapse. To avoid this, it is important to develop skills and strategies that the patient can use in their daily life. You will discuss some of these skills and strategies with the patient over the remaining sessions of this intervention.

Objective

To provide patients with the self-confidence and skills to assertively refuse offers to use drugs.

Rationale for patient

Explain to the patient that, once released (or even while in the closed setting), they will almost certainly find themselves in a situation where they are offered drugs. It can be hard to say no in some situations, so we are going to help you to develop their confidence and ability to refuse offers of drugs.

Method

Saying “no” assertively isn't just about the words you use – it's also about body language and tone of voice.

We communicate a lot through our body language – how we stand or sit, and whether we make eye contact. One of the most important things to remember when refusing drugs is to look at the person directly when speaking so that they know you are serious about what you are saying.

Similarly, you need to use a firm tone of voice that communicates you are serious.

Once you have the right body language and tone of voice, there are some simple things that you can say to refuse drugs.

Say no first: A simple, “no thanks”, delivered in a firm tone of voice, is the best thing to say first.

Then, suggest an alternative activity. For example, going for a walk, or playing a game. If you are trying to avoid alcohol, suggest going to get a coffee instead of going to drink beer.

Sometimes, people can be quite persistent in pushing you to take drugs. They might say something like “go on, just like we used to”. You need to be assertive and ask the person to stop encouraging you to use drugs. Say that you can only be friends with the person if they respect your choice not to use drugs.

Changing the subject of conversation is important too. After saying no, ask the person how he/she has been lately, or how their family are.

Finally, avoid excuses and vague answers. In some cultures, it is difficult to be assertive in communicating your needs, but you will probably run out of excuses eventually, and vague answers give people the opportunity to keep pushing you to use drugs. It's better to be direct. Remember, you don't have to make excuses for not using drugs – it's your right to say no. In group therapy sessions, it can be useful to ask patients to get into pairs and take turns at refusing drugs.

Objective

To provide patients with the ability to recognise physical and psychological tension, and how to reduce this tension for improved well-being.

Rationale for patient

Most people experience anxiety, stress or tension at some stage in their lives. Some people use drugs to cope with these negative feelings. Relaxation training is about learning how to recognise when you are tense, and how to reduce tension and maintain psychological well-being without using drugs.

Method

Ask the patient to identify situations or feelings that produce tension or anxiety for him or her. Examples might include relationship or family problems, money difficulties, or negative feelings like boredom, sadness or anger.

It's normal to feel tense or anxious occasionally, but sometimes people let their anxiety overwhelm them, and they may use drugs or alcohol to cope. A more productive way of coping is to practice relaxation.

Ask the patient if he or she already uses any sort of meditation or other psychologically calming practices such as yoga or tai chi. If so, encourage the use of these practices in addition to the relaxation training you will provide. Also encourage the patient to practice relaxation regularly – at least once a day. This will mean finding a quiet place where the person can sit or lie down comfortably, alone, and focus on relaxation.

The technique described below is called progressive muscle relaxation. It takes around 15-20 minutes. Use the following script as a guide for what to say to the patient. Speak slower than you would in normal conversation and use a gentle, quiet, soothing voice. The * symbol throughout this script represents a pause; pause silently for approximately five seconds per symbol. Pause for 15-20 seconds after each muscle group is relaxed, before moving onto the next muscle group.

“Please take off your shoes and sit (or lie on your back) comfortably. Have your legs uncrossed and arms comfortably by your sides. Now, breathe slowly and deeply through your nose.

I'm going to ask you to tighten particular muscles, then relax them. Tense the muscles for around five seconds, then relax the muscles for about ten seconds.

Start with your feet. Curl your toes downwards and tense your feet muscles for one, two, three, four, five. Now, relax those muscles. Feel the tension slipping away and your breath getting slower. Focus on the sensation of your body relaxing *.

Now tense your lower legs. Pull your toes towards you to stretch the calf muscles for one, two, three, four, five. Now relax your lower legs, feel the tension release from your legs**.

Tighten your thigh muscles *. Relax, focus on the pleasant feeling of relaxation and warmth in your body. **

Squeeze and tense your buttock muscles *. And now relax. Breathe slowly and deeply, feeling more and more relaxed*.

Tense your stomach and chest muscles *. Relax, feeling all the tension drain away from your body **.

Make a fist with each hand and tense the muscles in your forearms *. And relax **.

Tense the muscles in your upper arms. * And relax. **

Next, tense the muscles in your back. Push your shoulder blades together. * Now relax the muscles, feeling all the tension in your back loosen and leave your body **.

Carefully tense your neck *. And relax **.

Tense your jaw *. Now relax, as all the tension in your jaw and neck reduces **.

Squeeze your eyes shut and tense the muscles in your forehead *. Now relax your forehead and eyes **.

Continue breathing slowly and deeply. Tense your whole body and hold for a few seconds. * And now relax your whole body. Lie quietly for a few moments, feeling how relaxed your body is.”

Allow the patient lie quietly in this relaxed state for at least five minutes, longer if possible. Then,

“Now, slowly become aware of your surroundings. Gently move your fingers and toes, arms and legs. Slowly open your eyes and sit up.”

Encourage patients to practice progressive muscle relaxation, or other relaxation techniques, on their own.

Objective

To encourage patients to plan their release from the closed setting in a way that minimises the risk of relapse.

Rationale for patient

Returning to your home and community is a stressful time, and it is common for people to begin using drugs again. One way to avoid this is to carefully plan exactly what you are going to do when you leave – where you will go, what you will do during the day and so on.

Method

To help patients most effectively, the counsellor needs to have a good understanding of local organisations that can help drug users. It is important that you are very familiar with a range of local services:

• Support groups

• Peer-based organisations

• Drop-in centres

• Services for homeless people

• Drug treatment providers, including methadone maintenance treatment providers

• Free or low-cost medical clinics

• Harm reduction services

Ask the patient to consider the practical, everyday issues they will face when they leave the closed setting:

• Where will you live?

• Do other drug users live there? How will this affect you?

• How will you earn money for essentials like food and clothing?

Also encourage patients to think about how they will avoid illicit drug use:

• Boredom is a big problem for many people trying to remain abstinent. What will you do to keep busy?

• What will you do if you become stressed, anxious or angry? What strategies will you use to cope with negative feelings?

• It is important to be able to talk to people who support your abstinence, including other former drug users. Do you know and can you contact any former drug users who are now abstinent? Is there a local meeting of Narcotics Anonymous or other support group that you can attend?

• What drug treatment options can you access once you return to the community? If you are currently on methadone maintenance treatment, have you discussed with your doctor if and how you can transfer to a community-based methadone program?

When discussing these issues, emphasize that it is possible for patients to address these problems and avoid relapse. If you are negative or pessimistic, patients may believe they will be unable to cope with returning to the community.

Assist the patient to write their own release plan. It should include:

• How they will make sure that their essential needs – food, shelter, income – will be met.

• How they will cope with high-risk situations.

• Support services they can access. These may include support groups, peer organisations, methadone maintenance treatment services and other drug treatment services. Provide specific information such as names of doctors or counsellors and contact details such as telephone numbers or addresses. Also provide practical assistance, such as helping patients to contact services before they are released. For example, let patients use a telephone in the closed setting for contacting drug treatment services. If the patient is on methadone maintenance treatment, assist the patient to transfer to a community methadone clinic. This will require liaison between the doctor in the closed setting and a doctor in the community.

• Harm reduction services they can access in case of one-off occasions of drug use or relapse to regular drug use, for example, outreach services and needle and syringe programs. Again, provide contact details. In an ideal world, patients would not need to consider this information. However, it must be remembered that any patient may relapse. If they do, it is essential that they be able to access sterile needles and syringes.

Objective

To increase the patient's motivation to reduce or cease their drug use.

Rationale for patient

It can sometimes be difficult to stop yourself from using drugs, especially if you still enjoy using drugs sometimes. In this session, we're going to talk about some things that will help you to be more aware of how your drug use affects you and the people around you.

Method

In this session, you will guide the patient through a discussion of different aspects of drug use. Encourage the patient to talk freely but keep the discussion focused. Discussing these things can be quite difficult for some patients. Allow plenty of time for the discussion and don't interrupt the patient because you want to move on to the next topic. Allow the conversation to move naturally from one topic to the next.

First, discuss the positives and negatives about using drugs. For example you could ask the patient:

• What are some of the things you enjoy about using drugs?

• What are some of the things that you don't enjoy about using drugs?

• Do you think the good things about using drugs outweigh the things you don't like about using drugs?

The next area of discussion may be the health risks associated with drug use. For example:

• Do you think that drug use has affected your health? In what way/s?

• If the patient is an injecting drug user, discuss some of the risks associated with injecting. As well as HIV infection, this could include discussion of hepatitis C infection, collapsed veins, endocarditis (infection of heart valves) and abscesses.

• Do you think that drug use has affected your mental health? In what way/s?

• Are you concerned that drug use may affect your health?

The financial costs of using drugs can be very high.

• How much money do you spend on drugs?

• Are there things that your money could be better spent on?

An interesting technique is the ‘looking back/looking forward’ discussion.

• Can you tell me a bit about what your life was like before you began using drugs?

• How has your life changed since you started using drugs?

• How have you changed since you started using drugs?

The aim of this discussion is to encourage the patient to think about reasons for why they might want to change their drug use. The next step is to assist the patient to identify how they might go about changing their drug use.

First, summarise what the patient has talked about during the above conversation, and then provide the patient with an opportunity to state the need for change. For example,

• What do you think you could do about these things we have talked about?

Often, the decision to change drug use can be difficult. The patient may be worried about losing friends, or difficulties they will have to face when they stop using drugs. Explore these worries and provide reassurance. For example,

• Is there anything that scares you or worries you about not using drugs?

Finally for this session, assist the patient to set some goals for behaviour change. Remember, these have to be the patient's goals, not yours. Some patients may wish to be abstinent from all drugs, while others may just want to reduce their drug use to a more manageable level. Either way, it is important that the goals the patient sets are realistic and obtainable. For example,

• What is your overall goal in relation to your drug use?

• Sometimes it helps to set smaller goals that are steps on the way to a bigger goal. What are some of the smaller goals that you could set on the way to achieving your overall goal?

Objective

To provide patients with the skills to

• Recognise negative or unreasonable thought patterns

• Interrupt negative thought patterns and replace them with more realistic thoughts

Rationale for patient

Explain to the patient that thinking influences the way we feel and behave. That is, the way we interpret a situation affects how our emotions and behaviour.

As an example, imagine you have just knocked over a bucket of water. Some people would respond to this by thinking things like “I'm such an idiot” or “I'm totally useless”. This then leads to them feel that sad or angry. So, an event occurred, the person interpreted it and that made them feel upset.

What we will now do is learn how to identify unhelpful thoughts or interpretations of events, and how to challenge and change your thoughts so that you feel better about yourself.

Method

Objective

To teach patients:

• To recognise when problems exist

• To recognise that problems can have multiple solutions

• How to select and enact the most appropriate solution to a problem

• How to evaluate if the solution was effective

Rationale for patient

Everyone faces problems in their daily life, such as difficulties with family relationships or difficulty earning enough money. Sometimes, people take drugs to forget about or avoid their problems. But, this doesn't fix the problem. When you are released, problems like these might be something that leads to you using drugs again. To help prevent that, we're going to discuss a simple method for analysing and solving problems.

Method

Before beginning, provide patients with the handout ‘Six steps of problem solving’ (p. 74).

The first step in problem solving is to define the problem. It is easiest to define the problem in terms of why the problem has occurred, or when the problem occurs. Have patients select a problem situation. It may be related to drug use, or it may be related to other difficulties, such as employment, friends, family or finances. If the patient is having trouble identifying a problem, prompt him/her by asking about situations when they feel uncomfortable or negative – this is a good sign that there is a problem.

Have patients define their problem in the appropriate section of the handout. If the problem is large, break it down into smaller, more manageable problems and apply the problem solving technique to each. Define exactly what the problem is.

For example, a patient may nominate his or her drug use as a problem. This can be broken down into smaller problems, such as

• I use drugs to cope with anxiety

• I am worried I won't have any friends if I don't use drugs

• Drug use is costing me a lot of money

Once the patient has defined a problem, ask them to ‘brainstorm’ different solutions to the problem. At this stage, there is no criticism of the solutions and no solution is ruled out. Have the patient write down all the potential solutions in the appropriate section of the handout. If the patient is having trouble thinking of solutions, have them think about what they would recommend to a friend with the same problem.

The next step is to choose the most appropriate solution. The patient has to choose the solution that is best for him or her. The patient might choose a different solution to what you would choose. You must let the patient choose the option that they believe is best for them.

Once a solution has been chosen, it's time to develop an action plan. This involves breaking down the solution into small steps. For example, if a patient has decided that “learn how to make traditional crafts” is the solution to their problem, the action plan may be:

• Ask my parents and parent's friends if they know anyone who teaches traditional crafts

• Use the internet to find a place that teaches traditional crafts

• Enrol in a class or ask someone to teach me

• Attend all my classes and practice at home

Get the patient to write their action plan in the appropriate section of the problem-solving handout.

The next step is to undertake the action plan. This may not be practical in a closed setting, but at least the patient has prepared what they may be able to do after release.

The final step of problem solving is to evaluate the solution. Has the problem been resolved? It may be necessary to go through the problem solving steps again until an effective solution is reached.

Objective

To provide the patient with skills in understanding cravings and how to effectively manage cravings.

Rationale for patient

It is normal to experience a strong desire to use your drug of choice. This is called a craving. In this session we are going to talk about how you can manage cravings to reduce the risk of relapse.

Method

There are three components to craving management – recognising, avoiding and coping.

First, explain the nature of cravings to the patient. Cravings happen because of cues – situations or feelings that make you want to use drugs. However, if the patient is able to ignore the cravings, they will become weaker and less frequent over time.

There are different types of cues that may trigger cravings.

• External cues: these are locations (e.g. nightclubs), people (e.g. drug-using friends) or situations (e.g. having extra money) that are associated with using drugs.

• Internal cues: these are thoughts or feelings that are associated with using drugs. For example, the person may associate looking forward to going out with using drugs.

Ask the patient to identify their own craving cues. It is important that the patient identifies their own cues, not just ones that you mention. If the patient is unable to identify any cues, ask questions such as:

• What people were around the last time you wanted to use drugs?

• Where were you the last time you wanted to use drugs?

• How were you feeling the last time you wanted to use drugs?

• Do you think these people/situations/feelings may be craving cues?

The next step is to ask the patient to describe their own cravings. Ask about the following:

• Physical symptoms during the craving

• Thoughts during the craving

• Intensity of the craving

• Duration of the craving

• Level of discomfort experienced

What does the patient currently do during cravings? Is he or she already using some coping strategies? If yes, provide positive reinforcement.

After developing an understanding of the patient's cravings and the external and internal cues that trigger this patient's cravings, move onto cue avoidance. Learning to avoid cues is an important part of maintaining abstinence. Some avoidance strategies include:

• Reducing contact with friends who use drugs

• Avoiding places where drugs are readily available

• Getting rid of any remaining drugs the patient has at home or hidden elsewhere

• Staying away from places where the patient used drugs

Although avoidance is a good start for managing cravings, it cannot be the only strategy the person uses. The patient needs to develop a range of other strategies that can be called on when a craving begins.

Some commonly used coping strategies include:

• Distraction: Discuss enjoyable activities that the patient can undertake to distract away from the craving to use drugs. Have the patient develop a list of activities that can be used to distract. Examples may include going for a walk or a bike ride, reading, or creative activities such as drawing or writing.

• Sharing: Discussing the craving with a trustworthy person can be very useful – it allows the patient to talk about the craving without giving in to it. Help the patient to identify people who may be able to help in this regard. They may be close friends who don't use drugs, family members, or other former drug users.

• Positive self talk: Assist the patient to identify some short, positive messages that can be repeated when a craving occurs. For example, ‘I can cope with this’ or ‘this is temporary and I will get over this feeling soon’.

• Think about consequences of drug use: When a person is craving drugs, it is very easy to minimise the negative consequences of drug use and think only about the positive things about using drugs. Explain to patients that during cravings, they should try to think rationally about drug use. That is, they should balance the positives – e.g. I will feel better – with the negatives e.g. I will spend all my money, I might be arrested.

It can be helpful for the patient to write down some of their external and internal cues, and how they plan to cope with these. Encourage the patient to write this down and carry it around with them so that they can refer to it as needed.