Assessing Intervention Need

As discussed in the previous topic, identifying a person’s strengths can lead the way to hope and growth. The professional aims to create and promote their humility to gather strengths-based information. This approach establishes the person as the expert in their own life. It builds an acceptance that enables them to work together with the professional, following their lead towards change.

Identifying strengths may include:

• Identifying goals
• Identifying interests
• Understanding the person's history and experiences
• Identifying skills, capabilities, and personal strengths
• Exploring networks and supports that already exist in their lives
• Exploring their culture
• Listening to their stories and the impact these have on them
• Building a rapport with the person, ensuring a positive and effective relationship

Although strengths-based questions and implementation are core to the person-centred practice, it is important to not ignore why the person has been screened for requiring brief interventions.

Providing the person with relevant resources, such as reputable and current information on the impacts of drug use and clinically sound (EBP) questionnaires around the established concerns, may help to provide a barrier between ‘opinion’ and ‘reality’. At times, patients may feel that they do not need support, and it may be the ‘opinion’ of a professional that they do.

A collaborative approach means that the person is working together to agree to a decision about what will occur. This gives them autonomy and power over their own decisions and life choices, including change. It is important to remember this is a collaborative approach that also involves negotiation and ongoing education and support. Gathering information helps to develop a solid understanding of the person's experiences, strengths, and challenges and also in order to prioritize goals.

It can help to gather information from the person around:

Their home life and environments	Understanding the reality and lifestyle of the family, home life, or culture can support the professional to know where the reasoning and actions of the person may have stemmed from. This can also highlight supportive factors that may assist in sobriety or positive behaviours (change).
Their education and employment history	This information helps to understand the goals and educational and professional challenges the person may face. And how these may impact their lifestyle, employability, and self-esteem. This can also support an understanding of their behaviours and their potential effect on their work environment.
Relationships and sexuality	This information helps the professional to understand the support that may be available. Also, social challenges they may be facing regarding their sexuality and relationships with others, currently and in the past.
Preferred activities (in addition to the interests named above in strengths-based questions)	These help the professional to support the person from a strengths and interests-based approach. Positives and opportunities in their lives are recognized and utilized as life highlights and goals. It also helps to understand the individual culture of the person.
Previous/current diagnosis (conduct or risk-taking difficulties, psychosis, depression, ADHD, anxiety, etc).	Many challenges and diagnoses often become paired with dependencies. Understanding the underlying factors can help the professional and the person positively work through these.
General health and nutrition	The professional will better understand their lifestyle choices and challenges when identifying any health challenges and how they impact their emotional and physical capabilities.
Current drug use and method of ingestion, frequency, duration and age of first use.	This information is vital in understanding the support required. Some people with longer histories of drug abuse require more intensive support.

There are a variety of tools that can be used to complete questionnaires around health concerns, especially drugs, alcohol, and smoking, such as:

• AUDIT-C questionnaire for engaging patients about their alcohol use
• Severity of Dependence Scale (SDS)
• Alcohol, Smoking and Substance Involvement Screening Test (ASSIST-Lite)
• AUDIT, Alcohol Use Disorder Identification Test
• CRAFFT (for 12-21-year-olds)

Each state will have variations and preferences in the tools they use, as will different organizations, but typically at least one of the above will be used in most organizations in Australia for screening and assessment.

According to the Australian College of General Practitioners (2016), there are some key factors that may help people to accept alcohol or other drug assessments:

• Establishing a clear reasoning for the discussion around drug or alcohol use, e.g., specific information and data on how it may be affecting them
• Utilization of a health framework such as SNAP
• Using a person-centered and positive collaborative style. Avoiding over-interrogating when the person is not ready or comfortable
• Being comforting and aware of potential sensitivities within the discussion
• Negotiating the agenda and purpose of the meeting around a scope of comfort. E.g., this may begin with a discussion of the person's discomfort around any perceived concerns
• Avoiding moral language-use data-oriented information e.g., highlight health risks rather than use labels such as 'sensible' drinker

The transtheoretical model for understanding behaviour change focuses on the change process as a series of stages through which the person moves until they are ‘ready’ and motivated to change their behaviour. These stages are:

This theory is helpful in developing support strategies to assist a person in changing negative health behaviours, such as alcohol and/or drug use, because it recognises that, unless the person is ready and motivated to change, interventions are not likely to succeed.

In some domains, four stages of change are considered:

READING

Read this article to understand the transtheoretical model:The Transtheoretical Model (Stages of Change)

Watch

Watch this video to learn about the stages of behavioural change.

The context is encouraging healthy exercise, but the same principles apply within an AOD context.

Assessments for change used in Australia include:

• The University of Rhode Island Change Assessment (URICA) scale
• The Readiness to Change Questionnaire (RTCQ)

Barriers to Change

It is important for the professional to always remember that ‘change is hard’ and to empathize. Changing behaviour requires a process such as the stages of change mentioned above. Those who don’t follow a process are found to be less likely to successfully change.

Barriers to change can occur for many reasons, both situational and environmental, that are individual to the person, such as:

Situational factors

Difficulty passing the contemplation stage. The person may be content with the problematic behaviour (problem recognition).

• The person may need to be further informed on the deficits of the behaviour e.g., they often require something more concrete such as information or facts to move on.
• The person may see it as a necessary method for minimizing either physical or emotional pain.
• They may not be ready for change or have no desire for help.

Environment and family

The behaviour is one of an environmental culture from which, were they to change, they would feel or be excluded. It is an everyday behaviour that is seen as ‘the norm’.

• Some may need to see the adverse effects firsthand within themselves or in others around them at a dangerous level to prompt change.
• A person may have limited positive supports to encourage the change process and be a part of their network for change.
• Many may see themselves as functioning in areas of life which demonstrate no need for change; they may have employment, a relationship and no obvious physical or mental health problems.
• Intergenerational drug and alcohol abuse can bring a denial of side effects and a natural inclination to take up the drug use. This can be a common cause for the ongoing abuse of alcohol and drugs within families, communities and environments. The Australian government have put a lot of time and advertising into ‘breaking the cycle’ within these families and communities.

Co-dependency

Many of those with addictions have also been found to have relationship co-dependencies as well. This means that the relationship appears to ‘work’ through the ‘need for support’ of the addicted person and the ‘carer’ role of their (usually) non-addicted partner. The relationship is co-dependant because while the addicted person has a need for support, the carer also tends to need to be needed to feel secure. This can lead to a self-perpetuating cycle of both addictive and enabling behaviours.

Recovering addicts often find that a major challenge for them is their co-dependency. As a result, they can experience strong feelings of guilt and shame. Guilt and shame are both emotions that can fuel addictive behaviours and ongoing co-dependent cycles. Guilt is a judgment to whether you have done something right or wrong and shame is how you feel about yourself, which can include ‘self-talk’ e.g., self-loathing, inadequacy, inferiority. When addicts feel this within themselves, they need the co-dependent to enable them and tell them otherwise, so they don’t feel unlovable, defective or undeserving of happiness for using. People with co-dependency and addiction problems both run on a cycle of shame, bouncing their inadequacy back and forth to each other. The co-dependent can feel guilt and shame for enabling the person to continue to be needed, as the carer, themselves.

Culture and Drug Use Barriers

Category	Description
Culture	In many cultures there is a stigma attached to drug and alcohol problems, where they may be considered either weak, or not an issue at all. A person may be seen as bringing shame on their family by appearing weak and needing support. Religious beliefs can promote ideas that western treatments will not support such needs whereas prayer and religious affiliation will. In many cultures it is important to have a cultural liaison to support AOD treatments in a culturally respectful manner. Culture plays an important role in the expectations of the group, including use of drugs and alcohol. Where for some, such substances are strictly forbidden, for others they may only be used for ceremonial purposes. And, for some, their use is standard practice in everyday life. Often in Australian Aboriginal support services, it is imperative to have a liaison or elder as a part of the process of a person challenged with these struggles.
Drug Use Barriers	These can vary depending on the drug of choice (including alcohol), patterns of use and involvement in crime or the criminal system. The drug itself can be seen as a way of life and the length of use, type of drug, intake of drug and challenges associated with giving it up are seen as too much of a barrier. Some may also see the drug as an element that enhances their quality of life or functioning.
Organisation Barriers	These may include waitlists, costs, limit of support groups, dismissed need during triage or poor community collaboration for ongoing supports.
Effects of Treatment Barriers	Barriers may include a person feeling like the treatment will not work or will not work for them. They may feel treatment could bring about backlash, embarrassment and they will be stigmatized. Conflicting evidence demonstrates that the train of thought is often the barrier for intervention and support or ‘covert antecedents’.
Privacy and Confidentiality Barriers	Confidentiality and privacy mean that information cannot be disclosed to others regarding the treatment or anything that is said as part of it. There are varying forms of confidentiality in Australia according to age. ‘Automatic confidentiality’ means that your information must be maintained as private (unless you are at risk of harm) from all others, including parents or guardians. ‘Pre automatic’ confidentiality is the assumption that no matter your age, most information will be confidential anyway, but it is advised to check with the professional which areas will be maintained in confidentiality. Many have noted that a barrier to support was that they wanted to hide their problem from others, often including spouses and that their privacy was an issue for them. There may be concerns around a lack of confidentiality resulting in social challenges such as embarrassment, loss of employment or criminal persecution. This may also result in economic downfalls, all in relation to the loss of privacy or confidentiality. This may be particularly challenging in cases of alcohol and drug abuse, mental illness and illegal or sexual activities.

Incentives for Change

Many studies show that the major incentives for change include:

• Social dysfunction due to the behaviour or use
• Pressure to seek help from others
• Inability to function well and solve own problems
• Workplace related pressures and inducement to seek help

Loss of control is a key factor for many and often ‘hitting rock bottom’ is informed about when discussing why choice for change occurred. Many people experience family, friend, and financial difficulties due to the behaviour and also physical ailments that are alcohol or drug induced.

When providing intervention, it is important to identify what a person’s incentives may be, asking things like:

• What is important to them?
• What can they not lose?
• What makes them who they are?
• Who or what matters the most in their lives?

The aim of the questioning is to understand what their barriers to change may be, but also, what could become an incentive.

A large part of the change process is having reason or motivation (incentive) for change. It is typically more successful to focus on the benefits of change than to place moral ideals onto others, such as ‘drink responsibly’, or stating that one is not being a ‘responsible drinker’. Often a person who is not contemplating change will be motivated by further information about the effects that drugs and/or alcohol may be having on their health and life, now and in the future.

Information to Bring About Awareness

Providing valuable and meaningful information is imperative for incentivising the change process. Professionals provide current, accurate and relevant self-help materials from reputable sources. These are combined with verbal affirmations on why change will bring about a more positive and healthier lifestyle for the person.

This process informs the person on the deficits they face if they continue, and the benefits of making change. The result is that they can now be considered to be both informed and aware. By becoming more aware of the negative impacts, the aim is that they will find at least one reason to change.

Discovery Brings Awareness

Asserting awareness may also include supporting a person in discovering why they exhibit the behaviour and what their objective was/is for substance use. This may also include discovering why any barrier may occur to them making change and where this may stem from. The professional may need to provide proof, or documentation to hopefully ‘debunk’ the reason for the barrier. E.g., showing them their privacy and confidentiality policy if they are concerned others will find out. Or, providing data or current research that shows when and why change has occurred for others, if they are concerned about the efficacy of the intervention.

Resources

Providing information to bring about awareness and the intervention questionnaires themselves are both wonderful resources to support the person in making change. Below are various sites and resources that could be used to support a better understanding of the harmful effects of AOD, the process of change, and areas for support.

When providing resources, there is standard information that is provided to a person. However, the professional would need to consider the individual’s needs, abilities, stage of change, and accessibility when contemplating the resources they provide. For example:

• Is the person educated?
• Are they literate?
• Do they have access to the internet?
• Do they have visual impairment?
• How do they want information provided to them?

This can all be taken into account when considering what resources to provide for them to be purposeful and intentional.

Watch

Understand more about the change process by watching the following video.

5 minutes.

In the age of technology, it can be useful to have online access to information that is reputable and impacting on a person to make change. Watch the following video to understand more about the effects of alcohol on the brain.

5 minutes.

Note:

There is a list of helpful clips for many drug varieties on the ‘your room' website below, along with fact sheets.

Motivational Interviewing

Motivational interviewing is a therapeutic approach that supports a person’s willingness and motivation to change. It is often used in working with people with addictions but can also be used to encourage a person to change any harmful behaviour. It includes:

• Assessing the person’s readiness to change their behaviour
• Using collaboration rather than confrontation
• Encouraging self-direction and autonomy.

Motivational interviewing techniques address the needs and interests of the individual and are based on the belief that people make their own choices. This means you do not try to persuade or coerce the person to change. Instead, you support the person in identifying for themselves the benefits and barriers to change and working out their strategies for initiating and sustaining changes in their behaviour.

Motivational Interviewing

Resist telling the person what to do:

Avoid telling, directing or convincing the person about the right path to good health.

Understand their motivation:

Seek to understand their values, needs, abilities, motivations and potential barriers to changing behaviours.

Listen with empathy:

Seek to understand their values, needs, abilities, motivations and potential barriers to changing behaviours.

Empower them:

Work with them to set achievable goals and to identify techniques to overcome barriers.

A key aspect of motivational interviewing is to shift the person’s mindset from one in which change does not seem possible to one in which change does seem both possible and desirable. Strategies in motivational interviewing include:

• Active listening
• Avoiding confrontation and ‘rolling with’ resistance
• Developing the person’s awareness of discrepancies or inconsistencies between their negative behaviour and their values and aims
• Helping the person to move through the stages of change
• Providing feedback
• Planning and strengthening the person’s commitment to change.

Steps for Motivational Interviewing

Question

Questions are open-ended and encourage the person to explore the question with the professional instead of provoking a yes or no answer. This helps the professional to understand their needs, interests, and what they care about. For example: 'I understand you have some concerns about your drug use. Tell me about some of these?'

Affirm

The professional uses affirmations such as statements of understanding or compliments, helping to demonstrate empathy and build rapport. This affirms and validates the patient’s strengths and actions. For example: 'You are really proud that you made the step to come to see me today. You seem almost excited about change. It sounds like you have so much you want to achieve in life.'

Reflect

Reflections occur when the professional rephrases statements and information to capture the feelings or meanings that the person is expressing. This encourages an understanding of the motivations involved in reinforcing the desire for change. For example: 'You are worried about the effects this behavior is having on your work life and employability. In fact, you were recently approached about the behavior by your workplace. This is making you doubt the sustainability of the behaviour and recognize the need for change.'

Summarize

This is where the professional meaningfully pulls together and links key information provided and reiterates, to ensure a clear understanding. For example: 'So, if I understand correctly, some areas of discussion so far have been… … is that correct?'

Watch

The following video shows a good example of motivational interviewing in action. 10minutes