Supporting Intervention

Frameworks

To ensure consistent and relevant best practices in the change model, frameworks are created to provide quality guidance—these support both the professional in their role and the patients in receiving quality care.

One framework created in 2015 and supported by the Royal Australian College of General Practitioners is the 5As Framework:

FLAGs Framework

Feedback

• Provide individualised feedback about the risks associated with continued drinking based on current drinking patterns, problem indicators, and health status.
• Discuss the potential health problems that can arise from risky alcohol use.

Listen

• Listen to the patient’s response.
• This should spark a discussion of the patient’s consumption and how it relates to consumption in the general population and any false beliefs held by the patient.

Advice

• Give clear advice about the importance of changing current drinking patterns and a recommended level of consumption.
• A typical 5–10-minute brief intervention should involve advice on reducing consumption in a persuasive but non-judgmental way.
• Advice can be supported by self-help materials that provide information about the potential harms of risky alcohol consumption and can provide additional motivation to change.

Goals

• Discuss the safe drinking limits and assist the patient in setting specific goals for changing consumption patterns.
• Instill optimism in the patient that his or her chosen goals can be achieved.
• Motivation-enhancing techniques encourage patients to develop, implement, and commit to plans to stop drinking.

Strategies

• Ask the patient to suggest some strategies for achieving these goals.
• This approach emphasizes the individual’s choice to reduce drinking patterns and allows them to choose the approach best suited to their own situation.
• The individual might consider setting a specific limit on alcohol consumption, recognize the antecedents of drinking, and develop skills to avoid drinking in high-risk situations. This helps them pace their drinking and learn to cope with everyday problems that lead to drinking.

Create Change Within Stage

Returning to the ‘Stages of Change Model’ discussed previously, the following strategies are recommended within the model. They are to be adopted by the professional in supporting each stage appropriately:

Stage of Change	Strategy for Support
Precontemplation	At this stage, the patient is typically not ready. The need for the professional at this stage is to have begun to build rapport with the person. And raise questions about whether the behaviour requires change and the associated problems that may stem from this. Basic harm reduction strategies can be supplied, e.g., discuss programs, reduction, and education.
Contemplation	The contemplation stage is when the professional, with the person, weighs up the pros and cons of continuing the behaviour vs giving it up. They also look at the barriers that hinder change and ask ‘what will happen if you don’t change?’ This stage might include working from the motivational interview to explore ways to shift thinking from ambivalence to action. Steps are taken to build confidence in having the power and ability to make the changes needed.
Preparation	At this point, the patient is ready for change. The professional and the person create goals together, plan and take steps towards change.
Maintenance	This is the ongoing review process that ensures that change is sustained. Strategies are engaged to avoid relapse from occurring.

Change Talk and Relapse or Lapse

To create change, you need to talk and bring about the necessary motivation and optimism to make it happen. The table below by the AFP (Australia Family Physician) organisation explores this process:

Change Talk Questions to Elicit Change Talk	Example of Patient’s Change Talk
Disadvantages of the Status Quo What worries you about your blood pressure? What difficulties have resulted from your drinking? In what way does your weight concern you?	‘I guess, if I’m honest if I keep drinking, I am worried my family are going to stop forgiving me for my behaviour’.
Advantages of Change How would you like your health to be in 5 years’ time? What are the advantages of reducing your drinking? What would be different in your life if you lost weight?	'If I lose weight, at least I won’t have to wake up feeling guilty every morning that I am not taking care of myself’.
Optimism for Change When have you made a significant change in your life before? How did you do it? What strengths do you have that would help you make a change?	‘I did stop smoking a few years ago for a year, and I felt so much healthier. It was really hard, but I usually stick to it once I put my mind to something.
Intention to Change In what ways do you want your life to be different in 5 years? Forget how you would get there for a moment. If you could do anything, what would you change?	‘I never thought I would be living like this. I want to go back to being healthy and strong, with enough energy to enjoy my friends and family. ‘I want to manage my diabetes better’.

Use the information you have learnt to answer these questions below.

Relapse, Lapse, and Maintenance

Relapse, lapse, and maintenance are three very different concepts. Relapse is a longer-term behaviour that is reignited. A lapse is a brief, short-term resumption of the dependent behaviour. Maintenance is finding supporting strategies to stop either of these from occurring.

A relapse is often expected as a part of the process of recovering from dependencies and can be a feature of the recovery process. This happens when a person stops maintaining the goals set in the intervention and returns to previous use levels.

It is important to remember that a relapse or lapse isn’t about a person being weak or giving up. The process is very personal and often occurs because the body and brain are trying to sustain new patterns over the old ones, which are often more ingrained.

Relapses can occur for many reasons and will often occur when personal challenges arise, and dependency is triggered.

Reasons for a relapse may include:

1. Tempting situations: Exposure to people or places the person connects to drug use, this may also include days of the week e.g., Saturday nights.
2. Coping strategy needs: These occur when a problem arises that fuels the need for dependency, e.g., a break-up, work problem, or financial issues.
3. Emotional, physical, or mental health issues: These may include a variety of issues. Physical pain from illness or injury, or mental illness such as depression.
4. A lapse: This can ignite a feeling of failure or a feeling of ‘well I’ve ruined it now anyway’ thought pattern. The lapse then develops into a relapse.

Supporting a person through the change process can be challenging, and the professionals, as well as identified support networks, may use the following strategies to support maintenance:

• Use of change talk and strength-based discussions
• Ongoing meetings or appointments to support, make change accountability, and celebrate progress
• Update and support goals. Share goals so that all supports can help work towards them
• Psychological and medical help where required
• Avoiding people and places, as stated above, that may trigger a relapse
• Where possible, avoid negative people, behaviours and people that will cause emotional responses
• Engage in meaningful activities that result in a feeling of achievement, e.g., community support, planning a child’s birthday party, participating in a health or cooking club, and meditating daily.
• Engage in self-care, e.g., quality nutrition, finding joy in nature and life, sleeping well, and creating healthy life routines.
• Positive thinking, positive affirmations, and positive self-talk are needed to improve self-image and goals.

What if a Person Doesn’t Want to Change?

In practice, sometimes patients either refuse to change or are not ‘ready’ to change. They may have unrealistic expectations or goals that are either not achievable or will not benefit their health. At times, the person and their ideals cannot be negotiated with in the treatment program. In this case, the professional attempts to create a mutual plan for success but still allow for the client to lead as much as is practical. For example, the client says ‘I will still take this drug on Saturdays’ and the professional sets the condition, ‘ok on Saturdays, for the next 2 months’.

Some methods for managing these moments include:

• Declining assistance and explaining that it would be unethical for you to support such a goal.
• Accepting the goal provisionally for a stipulated period.
• Negotiating a short period of abstinence to provide some recovery from the effects of alcohol and provide time to acquire new skills, such as controlled drinking strategies.
• Agreeing to gradually reduce drinking to achieve abstinence. Setting realistic, intermediate goals and monitoring the number of drinks consumed daily.
• Negotiating a period of trial moderation, including daily drink monitoring and controlled drinking strategies (coping skills training).
• Consider peer work with ‘lived experience’ workers: those who have been through drug or alcohol problems and created change and now support others in the change process.
• Encouraging them to hear the stories of those that are within the change process e.g., support groups. This could be in the form of an Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meeting. Some clinics will encourage attendance at these sorts of support groups early in the intervention process. The client may find they identify with the people in the meeting who share openly and honestly about their experiences of drinking and taking drugs as well as their process of stopping.
• Support harm minimization: These are ways to support those who will not stop using at this time, with the aim of supporting their health and well-being (or preventing harm). For example, providing training for family and friends in first aid, ensuring they drink water, and having a driver to pick them up after a night/day out using drugs or alcohol. These steps are taken while they are contemplating change (rather than focusing on prevention).

As a brief intervention is only brief, the professional must be aware of the right channels for further ongoing support. They should also provide opportunities for the person to indicate with their own thoughts and ideas ‘What’s next?’. What we don’t want is a gap in support or for the person to head to a support service they don’t want. This could hurt the change that has occurred. Referrals typically occur when the needs of the person exceed the scope of brief interventions and the skills and opportunities they can provide.

The referral need will depend on the individual and their journey, as well as the behaviour or drug problem at hand and the associated risks.

Referrals for the individual may include:

• Government drug programs
• Community programs and support groups
• Social and family support services, e.g., emotional and financial support
• Psychological interventions and pharmacotherapies, e.g., Cognitive Behavioral Therapy (CBT), contingency management therapy, or motivational therapies.

Here is a framework on how you can make a referral:

1. Assessment: Conduct a thorough assessment of the individual's needs and situation to determine the appropriate level of support required.
2. Educate: Educate the individual about the available support options and the benefits of seeking further assistance.
3. Collaborate: Collaborate with the individual to develop a referral plan that aligns with their goals and preferences.
4. Access Resources: Provide the individual with information and resources about the referral services, including contact details and eligibility criteria.
5. Follow-Up: Follow up with the individual to ensure they have accessed the referral services and provide ongoing support as needed.

As a professional service and one that is often engaged in supporting people over many years, it is important to understand how to record information in an effective way. This includes records of the person's stage of change, stage in the decision-making process, and attempted progress. The documentation will also include the person's motivations for change to inform any other professionals about the needs and progress of the individual.

Brief Intervention Document	Purpose	Application Example
Initial Triage or Screening Documentation, Referral (Entry or Exit)	To find out why they were referred for brief intervention. Information gathered about their life and challenges relating to the behaviors and dependencies. Referral should include a letter to the GP and other referral services. This should include feedback on the level of risky consumption and advice on the need for ongoing monitoring and further intervention.	Peter is referred due to informing during triage that he drinks a bottle of whisky a night. This is causing both medical, physical, psychological and relationship problems in his life.
Motivational Interview	To understand what the positives may be for the person in minimizing or ending dependency.	Peter acknowledges that he wants to change to better support his relationship with his family and minimize the impacts to his health and wellbeing.
Strengths-Based Information and Other Selected Assessments e.g., AUDIT, ASSIST, CRAFFT	This assessment information (in the form of a questionnaire) is to understand the strengths and supports of the person and assess their individual needs. It is useful for engaging them in a conversation about their use and provide them with a score or result.	Peter discusses his interests, goals, and needs with the worker. He discusses what is important to him and how this may affect his willingness and ability to change. He discusses that his children were his main motivation and reason for change, he is ready to change now and wants to be sober by his daughter’s wedding in 6 months and manage in that environment.
Stage of Decision Making and Change	In the case that the person does not return to, or engage in the change process through to completion, the professional must record: • The barriers • Change that has occurred • What motivated any change. This information is useful as a baseline if the person decides to return to receive support.	Peter discusses with his worker that he is ready for change and wants to begin. His stage of change is assessed as being in the preparations stage, which is then documented along with all of the above factors for change. The barrier he mentioned about the challenge of the wedding environment is also documented.

The professional must always ensure ethical and best practice and work within industry standards. These include areas such as rights, meeting diverse needs, access, privacy, and confidentiality.

Codes of practice and standards of practice will vary according to the professional supporting the intervention, see the National Practice Standards for the Mental Health Workforce 2013.

The National practice standards are the expectation within any setting where mental health care is provided.

National Practice Standards 2013

• Standard 1: Rights, responsibilities, safety, and privacy
  • Rights and responsibilities
  • Safety
• Standard 2: Working with people, families and carers in recovery-focused ways
  • Consumer and carer participation
• Standard 3: Meeting diverse needs
  • Diversity responsiveness
• Standard 4: Working with Aboriginal and Torres Strait Islander people, families, and communities
• Standard 5: Access
  • Delivery of care (supporting recovery, access, entry, assessment and review, treatment and support, exit and re-entry)
• Standard 6: Individual planning
• Standard 7: Treatment and support
• Standard 8: Transitions in care
• Standard 9: Integration and partnership
  • Integration
• Standard 10: Quality improvement
  • Governance, leadership, and management
• Standard 11: Communication and information management
• Standard 12: Health promotion and prevention
  • Promotion and prevention
• Standard 13: Ethical practice and professional development responsibilities

National Standards for Mental Health Services 2010

Note: Read more about the standards by following the link on page 44.