OHP 1

1

• Introduce yourself to your partner
• Name, place of work and job title
• Your experience of counselling individuals with
  substance misuse problems and of groupwork
• What do you hope to get from the course

2

• Functions of substance use can be categorised as
• social
• emotional
• physiological

3
Some factors which may affect the development of
a drink or drug problem

• The Drug
• Pharmacology
• Dependence potential
• Physical and psychological effects

Individual Inherited factors eg hangovers,
risk-taking Upbringing Past trauma Self-esteem Hea
lth consciousness Values
Environment Availability/price Legal
status Access to alternatives Social support
networks Occupation Culture Peer group
Aquarius
4
The Alcohol Dependence Syndrome

• 1 A narrowing of drinking repertoire
• 2 Salience of behaviour
• 3 Increased tolerance
• 4 Repeated withdrawals
• 5 Relief of withdrawals by further use
• 6 Subjective awareness of compulsion
• 7 Rapid reinstatement following abstention
• Edwards Gross (1976)

5
Moral

• Person sinful
• Lack of self-control
• Difference from others
• Sin clearly defined (by others)
• Blame-worthy

6
Disease

• Medically defined- loss of self-control- cravin
  g
• Not to blame (not responsible)
• Genetic origins (?)
• Minnesota/Twelve Step

7
Functional

• People use for reasons
• People make choices
• Behaviours learned/unlearned
• Behaviours lie on a continuum
• Deviant behaviour looked at from perspectives of
  normal

8
Motivational Models

• Cognitive Behavioural models
• The Stages of Change model

9
Heredity and Genetics

• Estimate 20-25 with severe alcohol dependence
  may have inherited predisposition (Badawy 1996)
• Research suggests genetic vulnerability in
  certain individuals to develop alcohol problems -
  increased risk which leads to increased
  probability - it does not imply predetermination

10
Personality Theories

• Addictive personality been questioned
  conclusion - no one type more likely to develop
  problems (Nathan 1988)
• But aspects linked to substance misuse are
• - sensation seeking trait common (Zukerman
  1979)
• - self-medication for stress-dampening (Sher
  1987)
• Anti-social personality characteristics
• Personality disorder
• Risk taking
• Novelty seeking
• Reward dependency
• Lack of harm avoidance (Otter Martin 1996)

11

• Biological theories central to Western medical
  approaches.
• Brain/nervous system activity
• - detoxification
• - substitute medication

12
Stages of Change
Established change
Action
Maintenance
Preparation
Contemplation
Relapse
Precontemplation
Based on Prochaska DiClementes model
13
The 9 processes are

• consciousness-raising
• social liberation
• emotional arousal
• self re-evaluation
• commitment
• countering
• environment control
• rewards
• helping relationships

14
Motivational interviewing

• A directive client-centred counselling style
  that is designed to assist clients in exploring
  and resolving ambivalence to increase motivation
  to change.
• Rollnick Miller 1995

15

• Key aspects of Motivational Interviewing are

• A de-emphasis on labelling
• Individual responsibility
• Internal attribution
• Ambivalence

16

• 1 Express empathy
• 2 Develop discrepancy
• 3 Avoid argument
• 4 Roll with resistance
• 5 Support self-efficacy
• Miller Rollnick

17

• Cognitive Behaviour Therapy
• Aims to modify maladaptive thoughts that
  contribute to inappropriate behaviour or
  emotional states.
• Bennett 2002

18

• Cognitive-behavioural strategies
• identify and challenge negative thoughts/beliefs
• setting up behavioural challenges
• substance use diaries
• distraction techniques - short term alternatives
• flash cards
• negative imagery
• functional analysis
• anxiety management and relaxation skills

19
GOAL SETTING

• Goals should be SMART
• S SPECIFIC in their objectives
• M MEASURABLE
• A AGREED by the people concerned
• R REALISTIC
• T TIME-SPECIFIC

20
Maslows Motivation of Needs Hierarchy
Personal growth, self-fulfilment
Self-esteem, achievement,recognition, status,
success
Belonging, social needsAcceptance by others,
identification with others
Security needs freedom fromthreats to health,
safety, redundancy etc
Basic physiological needs - food, shelter, (or
the money to provide it)
21

• A contract/working agreement should include

• substance use goal
• short term alternatives
• agency offers/conditions
• specific steps (SMART) - to be taken within time
  frame
• timescale for review

22
Two Stages of Relapse

• 1 Processes occurring BEFORE first drink/drug is
  taken (triggering of a resumption of drinking).
• 2 Processes occurring AFTER first drink/drug is
  taken (the continued excessive use).
• Marlatt Gordon 1980

23
Triggering of the Resumption of Substance Use

• 1 An apparently irrelevant
• decision
• 2 A high risk situation
• 3 A no-coping response
• 4 A feeling of helplessness and
• low self-control
• 5 A positive expectancy that the
• drug will make the person feel
• better
• Marlatt

Leading to first use
24
High Risk Situations

• 75 of relapses are associated with high risk
  situations falling into one or more of the
  following categories

• Negative emotional states
• Interpersonal conflict
• Social pressure Marlatt Gordon, 1980

25
Lapse Becoming Relapse

• 1 Stress - broken no drink/drug rule
• 2 Self blame - internal weakness
• 3 Reducing stress, guilt, self-disgust
• 4 Positive effects of drug
• Marlatt

26
Supervision involves a balance of these functions

• Formative - develop new skills
• Normative - maintaining standards
• Restorative - personal support
• Perspective- stepping back, reflecting
  patterns/relationships

27
Counselling Individuals

• Therapeutic groupwork often involves
• creating personal change in behaviour/thoughts/
  feelings
• possible facilitation - although not always
• temporary nature - finite time of group or for
  individuals (open group)
• size
• examines its own behaviour, past/present
• contract/boundaries

28
Counselling Individuals

• Moreno (1908) Psychodrama
• Pratt (1906) Structured Support
• Freud - Slavson Wolf Schwartz
• AA (self help) 1930s
• Klein Object Relations TheoryBion - Tavistock
  GroupFoulkes - Group - Analysis
• Jones - Therapeutic Community
• Lewin - T-group
• Schutz - encounter
• Rogers - encounter

29
Counselling Individuals

• To interpret or relate to individual members of
  the group as though the others were not present
  is a failure to utilise the opportunities
  afforded by the use of groups rather than
  individual treatment.
• Northfield analysis
• quoted by Peter B Smith

30

• A group therapists overall purpose is to enable
  and assist each individual in a group to achieve
  personal benefit through making as full use as
  possible of the potentials of the group as a
  medium for help.
• D Stock Whitaker

31

• 1 To plan and conduct the group so as to maintain
  a general sense of safety at a level at which
  members feel safe enough to stay in the group and
  to take personal risks.
• 2 To avoid the irredeemable collapse of
  structure.
• 3 To work towards the establishment and
  maintenance of norms and shared beliefs and
  assumptions, which support the group as a
  positive medium for help.
• Continued ...

32

• 4 To utilise events occurring in the group for
  the benefit of individual members.
• 5 To avoid harmful consequences for the members
  of the group, for oneself as therapist, and for
  the groups wider environment.
• 6 To avoid making errors as much as possible and
  to discern such errors as occur and think out how
  to retrieve their consequences.
• Dorothy Stock Whitaker

33

• All groups have 2 basic functions
• i) to complete a task/goal
• ii) to provide maintenance/support and meet
  individual/group needs.

34
Counselling Individuals

• Roles
• Maintenance
• Encourager
• Harmoniser
• Compromiser
• Gate keeper
• Follower
• Rulemaker
• Problem solver

35

• Task
• Leader
• Questioner
• Facilitator
• Summariser
• Evaluator
• Initiator

36
Counselling Individuals

• Individual
• Victim
• Monopoliser
• Seductor
• Mute
• Complainer
• Truant/late-comer
• Moralist

37
Counselling Individuals

• Group dynamics often include
• Cohesiveness
• Norms/shared beliefs
• Development
• Roles
• Boundaries
• Leadership
• Communication
• Sub-groups
• Climate

38
Counselling Individuals

• Group Development
• Forming (initial phase)
• Storming (conflict phase)
• Norming (cohesive phase)
• Performing (working phase)
• Mourning (termination phase)