Human Psychology 101

Preparing for the Substance Abuse Interview:Getting All Psychological on Patients Presenting for TreatmentPatients have come to us for our expertise. In substance abuse settings, the person is using and wants to stop using for goodThere is an implicit understanding that, since the patient has come to us for our expertise, he/she is now ready to engage in whatever behaviors we prescribe for themOld Assumptions about patientsThe person in front of you is experiencing negative consequencesThe person would prefer to remove the negative consequences with minimum effort, and with a minimum change to their lifestyleThe person wonders if you can assist in removing those consequences so they can get back to business as usualNew assumptionsThe person may not any causal link between their behavior and the consequences (example: Patient court-ordered to treatment after a DUI)The person may have little desire to change the behaviors that lead to those consequences (a smoker wants treatment for cancer, but may have no desire to quit smoking)

Assessing the patients assumptionsNo awareness of link of substance use and life problems:I got a DUI because of random check points.Im here because my parents are making me do it.Im in this program because I have to be in a program to get housing/voc rehab/DSS/to apply to disabilityI have to go to treatment as part of my probation

ExamplesSome awareness of a link:Im drinking too much and I need to cut down. OR I know I need to quit for now (but when I can I start again?)I know smokings bad, but I already have to give up sweets, fatty foods, and now I need to exercise smoking is the last pleasure I have leftAMBIVALENCE: the coexistence within an individual of positive and negative feelings toward the same person, object, or action, simultaneously drawing him or her inExamplesClear awareness of a linkI know I can never drink or use drugs. Not even a little.I know what will happen if I start to drink again I might end up in jail or worse, I might end up deadI need to be totally abstinentExamplesWhile its pretty safe to assume a patient wants to rid him/herself of some negative consequences, you dont know where the client stands with respects to his/her understanding of whats happening or his/her desire to make changesSummary: You cant assume theyre ready to embrace your agendaThe point: Dont assume

Helpful Heuristic: Stages of Change

Helpful Heuristic: Stages of Change

People who use alcohol and pills are using legal, socially sanctioned substances. Although marijuana is illegal, there is a strong movement to support its benefits, and it is actually legal for medicinal purposes in many states.In my experience, these people seem more vulnerable to failing to link use of these substances to their problems. These people will often state moderation as a goal.Crack and heroin users know these drugs are illegal, they know there is a stigma. It is therefore harder to make the argument that these substances are not linked to problems. They dont argue for moderation, though they would secretly prefer to be able to continue to use without negative consequences. Note: Presentation of Substance Problems can differUsual purpose of interview: OBTAIN DIAGNOSTIC INFORMATION, SEVERITYThrough a series of structured, close-ended questions, we attempt to identify/quantify substance abuse problem by asking direct questions related to substance abuseHows a person in Pre-contemplation going to react to this?Maybe theyll get defensive, argumentative, or shut downChallenges of First InterviewsAlthough we feel pressured to get information, resist this urge, and try the following:Ask the patient open-ended questions like: Why are you here? What brought you here?Follow up with further open-ended prompts: Tell me more about that.Clarify with: What do you hope that our working/talking together will accomplish?First, find out why they think they are here (Finesse Play)Persons who are in Preparation/Action generally acknowledge alcohol/drugs are a problem and can probably better tolerate direct questions about drug/alcohol use and negative consequencesPersons in Precontemplation/Contemplation might get very defensive if you do rapid-fire substance abuse questionsWork your way up to it gradually as part of the psychosocial history.Pay close attention to things in the history that may be indicative of substance abuse problemsSecond, Acquire the data in a manner that fits their understandingSeverity can affect how you approach treatmentSomeone with a long and severe history of use will probably not benefit from harm reduction/moderation, and might be more willing to embrace total abstinenceSomeone with a shorter, less severe history, may only be willing to entertain moderation at the present time. Arguing for total abstinence will probably shut down treatmentAssess Severity (Yeah, but why?)Starting use prior to 21 years of age (biologically increases risk of developing addiction)Use for 5-10 years (about the time it takes to develop alcohol dependence)Family history = more possibility of genetic predisposition (did anyone die of liver problems?)NOTE: You dont have to know all the signs of substance abuse if you are taking a good history, you should be able to present it to someone with the background, and they can help you recognize these signs

Assess severityTell me about any legal issues you have (DUI, open container, posession)Tell me about your work history (Unstable employment pattern, conflicts at work, tardiness)Recreational activities (lots of things that involve drinking)Relationship patterns (divorces, loss of friends)Physical symptoms sweaty hands, shakes, sleep problems (alcohol), lots of complaints pain (opiates/pain killers)When did you first try x or y?Tell me about your family, parents, their health (looking for drug-related problems)More problem = greater severityDesire to changeAbility to changeReasons for changeNeed for changeCommitment to changeActionsTaking StepsNOTE: Using open-ended questions might give you more access to this information than would a closed yes/no kind of questionWhen doing history, you are listening for DARN CAT:As you gather data that the client gives you, you are actually compiling a list for reasons for that person to changeLater on, as you negotiate what you do in treatment, you can reflect these data back to the patient in the form of feedback (e.g. a written summary or report)Feedback can be a compelling motivator to faciltate the desire to change the data come from the patient and not from youThey provide their OWN reasons to changeWhy gather all of these data?Use reflective empathy statements (e.g. that must have been difficult)Builds rapportAllows for clarificationGives the patient a feeling of being heardReflective summary statements also build rapport, show the patient you are listening, and allows for clarificationStylistic tipsPatient unaware of problems related to drug use are probably going to give more information that points to those problemsPatients who are aware of problems might report fewer problems, as there is a universal tendency to present oneself in a favorable Patients who are aware they are being evaluated for drug/alcohol problems are going to be motivated to under-report their useRemember, self-report is but one source of information that, in the case of addiction especially, requires corroborationKeep in mindCorroborate information with significant others, family membersCorroborate using drug screens, breathalyzers, lab valuesFeel uncomfortable about doing the above? Work it into your consent to treat and be right up front from the beginningPreventing underreporting and increases accountability is a highly effective intervention in its own right!Fact checking for drug/alcohol specialists