Effective interventions
What works?
Treatment implies something being done to help someone get better, to reach recovery. Ideally it is a psychosocial intervention which may be packaged with other interventions such as medication and harm reduction advice. Help seekers bring with them their substance use history, their mental health and their social circumstances and so it is important to be realistic about what difference treatment can make. Some people have all they need to get better without help, others need a lot of help.
Harm reduction
Harm reduction happens all the way through contact with helping agencies. It is about improving a person’s quality of life without necessarily stopping substance use. It is a way of engaging people with helping agencies and of helping those who are unable or choose not to work towards recovery. Examples are:
✔︎ needle and syringe exchange ✔︎ substitute prescribing ✔︎ dietary advice and nutritional supplements ✔︎ coping strategies for partners, friends and children ✔︎ immunisations ✔︎ naloxone for opiate overdose ✔︎ housing support
Is harm reduction an end in itself?
For some individuals harm reduction might be all that they wish for. They want to carry on drinking or taking drugs but want to do so as safely as possible.
For practitioners the story is different - the clue is in the name: 'harm' and 'reduction'. For anyone helping someone with a drink or drug problem then the ambition will be to go beyond harm reduction even if that goal turns out to be unachievable.
Assessment and and the 4Ps
Before starting any intervention there are some things that practitioners need to know: some basics about the service user’s circumstances, their current motivation for change (or stage of change if using this model), their substance use and severity of dependence, psychological wellbeing, and if there is any support from family and friends. The 4Ps Framework is a good way to formulate this information, which may need revision as more is known.
Predisposing Factors (Vulnerability): Factors that made the person vulnerable to the current issue, such as genetic history, early childhood trauma, or personality traits.
Precipitating Factors (Trigger): Specific events or stressors that triggered the present problem, such as a breakup, job loss, or a move.
Perpetuating Factors (Maintenance): Factors that maintain the problem or make it worse, such as poor coping strategies, ongoing stress, or social isolation.
Protective Factors (Strengths): The strengths, resources, and support systems that help mitigate the problem, such as resilience, a strong social network, or previous positive response to therapy.
It is useful to include some self-assessment questionnaires before starting any treatment. These are some of the benefits of doing so…
Just completing a questionnaire helps people to think more about what their problem looks like and what they want to do about it.
The information collected is a framework for building up a working alliance between practitioner and service user.
Scores from the questionnaires are important in themselves and especially so if the scales are repeated at regular intervals so that progress can be charted and strengthen motivation.
Well validated questionnaires provide objective data of service activity.
Components of treatment
A good treatment is fashioned collaboratively by the practitioner and their service user. Preparation is important so that everybody knows what to expect and so that the right support can be put in place. All treatments have essentially the same elements. In what order the elements are dealt with depends on factors such as personal choice, motivation for change, whether it is relevant. The whole treatment could happen in one go, but more usually it is a stepwise process…
Detoxification or stabilisation
Before any real change in psychological wellbeing or lifestyle can take place a person’s substance use needs to be under some degree of control - it is very difficult for someone who is repeatedly intoxicated to move forwards. A period of abstinence is preferable because it will be easier to follow a treatment plan. A medication assisted detoxification may be indicated if a person is experiencing significant withdrawal symptoms or is using a mix of drugs. People feel better very quickly, which is rewarding but also a risky time for relapse.
Relapse prevention
Relapse prevention is about looking for triggers for drinking or drug taking and starts as soon as a treatment programme starts. Triggers occur everyday: people who you drink or take drugs with, places that are high risk, wanting to celebrate, feeling saddened by something, overconfidence after days of abstinence. The list is endless but it matters to identify accurately where relapse risks lie. Deep-seated traumas and mental illness may also be triggers and need to be dealt with alongside the addiction by suitably qualified practitioners.
Lifestyle change
The absolute key to successful treatment is to make lifestyle changes. This can be a difficult and long process especially for someone who has been embedded in a drinking or drug-taking culture for many years. Simply accepting that big changes are needed is daunting. Of course, there may well be some things that cannot be changed. Regrets for things in the past that cannot be undone is not going to help, rather set out a plan for enjoyable and more healthy activities. Most importantly stay away from problem drinkers or drug users.
Choosing an effective intervention
It turns out that apparently different talking therapies often have crucial ingredients in common. Treatment is invariably some form of psychosocial intervention, which may be enhanced with medication, and which should build resilience into the future. The prescribing interventions are usually specific to each substance and work only for as long as they are given.
What works
Effective therapies include these specific strategies...
✔︎ Set and keep checking goals
✔︎ Provide rewards as goals are achieved
✔︎Set clearly described take-home tasks and monitor their achievement
✔︎ Involve family and friends
✔︎ Find alternative activities unlikely to trigger substance use
✔︎ Rehearse ways of dealing with risky situations
✔︎ Create flexibility in the recovery plan
Integrated Social Behaviour and Network Therapy, iSBNT, is a versatile, structured, psycho-social intervention which is accessible to most practitioners and makes for a good default addiction therapy. You can try it online here…
Effective and commonly used treatments…
How good is treatment?
The short answer is ‘It all depends’. There are good treatments for addiction problems, but the one thing that makes the most difference to treatment outcome is where the person is starting from. 50-60% of how well people do is down to social capital: education, family and friends, employment, health. A useful way of thinking about ‘where somebody is at’, where are they starting from, is the stages of change model originally described by Prochaska and DiClemente…
In the pre-contemplation stage, the person is either unaware of a problem that needs to be addressed or aware of it but unwilling to change the problematic behaviour.
The beginning of change is characterised by the contemplation stage, where ambivalence regarding the problem behaviour, the advantages and disadvantages of the behaviour, and of changing it are expressed and explored, leading in many cases to decision-making.
In the preparation stage, a resolution to change is made, accompanied by a commitment to a plan of action.
This plan is executed in the action stage, in which the individual engages in activities designed to bring about change and in coping with difficulties that arise.
If successful action is sustained, the person moves to the maintenance stage, in which an effort is made to consolidate the changes that have been made.
Once these changes have been integrated into the lifestyle, the individual exits from the stages of change. Relapse, however, is common, and it may take several journeys around the cycle of change, known as “recycling”, before change becomes permanent.
Psychosocial interventions...
CBT :: Cognitive behaviour therapy is probably the most researched and effective treatment. CBT works by i) identifying risks of drinking or taking drugs ii) working out ways of dealing with these situations - developing 'coping skills' iii) practising these 'coping skills'. (iSBNT is a basic form of CBT with added network support at its core)
CM :: Contingency management, which works by rewarding abstinence or some other goal, typically with vouchers, medication take-away privileges and prizes. (CM can be used to supplement iSBNT)
RP :: Relapse prevention, which is the same as CBT but with a relapse prevention focus. (RP is a key element of iSBNT)
MI :: Motivational interviewing is more of a method than an intervention. It works by helping service users to become aware of what they most want to change in their behaviour. (MI is a key element of iSBNT)
NT :: Network therapy works by recruiting family and friends willing to give practical and emotional support to help people make changes to their substance use. (NT is a key element of iSBNT)
CN :: Counselling is something of an umbrella concept but typically means allowing a person to talk about their problems and feelings in a confidential and safe environment. (CN is a non-directive approach iSBNT is directive)
Social support :: Includes help with housing, employment, rewarding occupations, leisure activities, relationships and so forth. (a support network is a key element of iSBNT)
Prescribing interventions...
Prescribing interventions are a useful adjunct to iSBNT
Substitution :: Some drugs of misuse can be 'substituted' with a safer prescribed medication. This is most commonly the case for heroin and other opiates.
Detoxification :: Medication can help relieve the cravings and withdrawal symptoms that occur when people addicted to alcohol or a drug either stop suddenly or rapidly reduce their intake.
Relapse Prevention :: For some addictions there are medications that help prevent slipping back into drinking or drug use.
Nutritional :: Dietary advice and nutritional supplements may be needed because a person has neglected their diet due to their substance use or because of specific deficiencies.
Rudi Moos. Professor Emeritus, Stanford University, USA
Rudi Moos talks about good outcome predictors...
✔︎ Having supportive family and friends
✔︎ Being ready to make lifestyle changes
✔︎ Having employment or a satisfactory occupation and income
✔︎ Having housing or at least reasonable accommodation
✔︎ Understanding that dependence can be undone
✔︎ Being in reasonably good mental health
✔︎ A readiness to move away from others with addiction problems
What does recovery mean?
Recovery that occurs in the absence of help-seeking is called natural recovery. 60-80% of people recover from their addiction without professional help. There are many different ways that people change their thinking and behaviour around substance use or other addictive habits.Recovery is about lifestyle change - ‘being better’ or being back to the ‘old you’. People in recovery know what it is about as do their family and friends. Recovery is associated with twelve step approaches, but whether it necessarily includes abstinence is controversial, nonetheless the Betty Ford Institute has produced this definition:
"Recovery from substance dependence is a voluntarily maintained lifestyle characterised by sobriety, personal health, and citizenship".
In the UK the idea of sobriety is controversial and a different definition has been proposed:
“The process of recovery from problematic substance use is characterised by voluntarily-sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society”.
