An eleven session Cognitive Behavioural Therapy based intervention for problematic use of Methamphetamine and Amphetamine-Type Stimulants

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1 An eleven session Cognitive Behavioural Therapy based intervention for problematic use of Methamphetamine and Amphetamine-Type Stimulants With thanks to Turning Point Alcohol and Drug Centre Inc s for permission to adapt material from: Clinical Treatment Guidelines for Alcohol and Drug Clinicians: No 14; Methamphetamine Dependence and Treatment (2007).

2 Session one: introduction to treatment and CBT Enhance motivation to change Refer to the model of short term intervention using Motivational Interviewing and Cognitive Behavioural Therapy, provided in: Interventions and Treatment for Problematic Use of Methamphetamine and other Amphetamine-Type Stimulants (ATS), Matua Raki Negotiate treatment goals Motivational exercises such as the decisional balance and looking back and looking forward can help the person to decide on treatment goals. Helping people to keep these realistic, based on their readiness to change, can improve the chances of success which can in turn feed into motivation to make greater changes in behaviour. Appropriate goals for pre-contemplators and contemplators might be harm reduction behaviours or tracking use over time. People beginning to change patterns of methamphetamine and ATS use may need some assistance to identify the necessary steps to achieve their goals. Selecting the goals for each step can be an opportunity to model problem solving. Continuing to emphasise that change is a personal choice and helping people to recognise their successes and potential hurdles will help to enhance commitment to change. Use Worksheet One to record the positive and negative things about methamphetamine and ATS use for the person. Explain the CBT model Clinicians should: explain the concept of how learned behaviours are rewarded and strengthened describe the relationship between thoughts, feelings and behaviours discuss skill building as a technique that can be learnt It is useful to describe the assessment process as the foundation for the development of tailored practical tools to manage moods and behaviours. Establish ground rules Communicate clear expectations about the structure of sessions, attendance and mutual responsibilities. 2

3 Introduce functional analysis Functional analysis assesses the person s thoughts and feelings in circumstances where substance use is likely. It can be used to plan strategies for high risk situations and monitor the effectiveness of behaviour change. Worksheet Six provides a tool for functional analysis of the steps leading to substance use and the consequences. Session two: coping with cravings Intense cravings can persist for weeks and months after stopping using methamphetamine and amphetamine-type stimulants. Not knowing what cravings are or what triggers them, and not having strategies to manage them, is a major factor in relapse. Understanding cravings Normalising cravings as a typical part of methamphetamine and ATS use helps people put their experience of cravings into perspective. Depending on their patterns of use, a variety of situations, activities, emotions and feelings will have become associated with methamphetamine and ATS use through conditioning and reinforcement. Using the example of Pavlov s Dog, or the cat running in when the fridge opens, can help explain how this process happens. Triggers can include places, people, occasions, thoughts and emotions. Emphasising that cravings are conditioned responses to these triggers and that they will fade over time, over the course of an hour for most people, can help people to learn to tolerate them. Over time not reinforcing cravings will extinguish much of the conditioned response to triggers. Describing cravings Ask the person to recall their last experience of cravings or get them to record the experience as it is happening. Recording what they are like for them, how intense they are, how much of a problem they are and how long they last? Cravings can be experienced as thoughts, emotions, physical feelings and sensations. Some people may struggle to recognise them for what they are and others may be overwhelmed. Asking people how they manage cravings will help to identify how long cravings last and what style of management they generally favour. This can help with working out further helpful strategies and unhealthy strategies (e.g. drinking alcohol) can be identified. Identifying triggers Functional analysis should provide the clinician and person with a list of triggers and these can be ordered in terms of their frequency or the degree of association with using. 3

4 Triggers with the strongest association with using should be targeted first unless the person has little faith in themselves, in which case picking off an easy trigger can help develop confidence. Monitoring and identifying triggers, and high risk situations, is an ongoing part of treatment that helps with unravelling the more subtle triggers to use substances. Avoiding cues Reducing contact with using peers, avoiding certain localities, getting rid of pipes and other paraphernalia, limiting other substance use and having small amounts of cash and no eftpos card available at high risk times and places, are all useful early strategies to reduce exposure to triggers and cravings. Reality testing each strategy with the person is helpful to avoid potential problems, such as ending up having no social contact. Managing cravings Drawing attention away, distraction, from the experience of craving by becoming involved in doing something enjoyable is an important tool to help manage cravings. People may require support to develop a list of realistic and achievable alternative activities, remembering that physical activities are more distracting that inactive ones. Worksheet Four can be used to record and plan these activities. Talking about cravings with a supportive non using friend, family or whānau member can help to reduce feelings of anxiety and vulnerability. Choosing who these people could be may require some discussion. If no one is available or suitable, contact information about the Alcohol Drug Helpline, , and peer support groups should be provided. Going through cravings without fighting the experience, urge surfing using imagery such as riding a wave or allowing it to pass over them, may help some people accept cravings. Focussing on the associated feelings and sensations and recording the intensity can help people develop a sense of control over the experience of craving. People tend to automatically remember the good things about using, especially from the first few times they used and later on from the relief of withdrawal. Reminding themselves of the costs and consequences of using and the things they have to gain by not using can help people to maintain their motivation to change. Writing these things down on a card and having them handy, in a wallet or handbag or on their fridge can make this easier to do. Assisting the person to identify emotionally charged either or thought patterns that accompany cravings can help them to counter these automatic processes that people can be almost unaware of as they occur. These automatic thoughts can be accessed through functional analysis or by deconstructing the series of thoughts and behaviours that preceded cravings, creating a verbal videotape of events. Once identified clinicians need to help people to develop more realistic patterns of self talk, patterns that are not 4

5 emotionally charged, that normalise cravings and increase the person s belief in their ability to manage. Planning to reward themselves for periods of no use, or as an alternative at high risk times can help people to maintain motivation. People are likely to need help to work out possible activities or treats that feel good but are not risky or unhealthy. The intensity and frequency of cravings will diminish over time using these strategies but they will not go away all together. Helping the person to accept that life has emotional ups and downs is an important part of them learning to challenge using thoughts triggered by feeling depressed, anxious or sad. Session three: encouraging motivation and commitment to change It is important to recognise that people will wax and wane about making changes in their use of methamphetamine and ATS, as ambivalence is a natural feature of all change. Acknowledging and responding to this will enhance the effectiveness of treatment interventions. Clarify goals Reviewing goals at the beginning of every session and ensuring that the person still considers them worthwhile and achievable, helps to maintain engagement and commitment. It also provides an opportunity to adapt treatment when goals change. When motivation to change is low or is to please others, rolling with the resistance and supporting self efficacy are useful techniques to use. Focussing attention on the impact of methamphetamine or ATS use on their lives, socially, emotionally and physically can help to clarify the level of motivation at this stage. Discuss ambivalence Revisiting the pros and cons of both using and stopping using in a non directive manner, can help to get clear about any barriers to change. These barriers may be beliefs about the positive benefits of using and concern about the loss of these benefits. Once identified, these barriers can be discussed. Use Worksheet One to help record the pros and cons. Managing thoughts about methamphetamine and ATS Each person develops their own thoughts and beliefs about methamphetamine and ATS that can lead to using again. Thoughts and beliefs that are pro use can become virtually automatic and unrecognised as they occur. Clinicians can help people to recognise these processes and to identify when they are based on distorted perceptions. 5

6 Common automatic thoughts that can precede a lapse can include: Life will be so boring without P diminished pleasure I m an addict identification with self Hanging out with my mates won t be problem now I am in treatment testing control I ve just used so treatment s not going to work, might as well keep using abstinence violation This is way too hard, time for a break escape I ve been good for week, I deserve a treat entitlement What the fuck, once won t hurt gambling Thought challenging People can often recognise these thoughts and beliefs as being illogical. However they could need some help to develop responses that they can use to challenge a belief, while continuing to acknowledge the underlying issue. For example; The diminished pleasure example could be countered by, While using P has been really exciting, it has made me miss out on a lot of natural buzzes. This acknowledges the bias of the pro use thought and then counters the belief while indicating a benefit of not using. The entitlement example could be countered with Yeah I have done well, but if I use I will feel like shit tomorrow so I d be better off going out to a movie. Session four: refusal and assertiveness skills Many people fail to recognise that their methamphetamine or ATS use happens in a particular social context, believing it is a purely personal choice. Talking about changing where people visit and who they spend time with can often bring out previously unacknowledged resistance to change. Clarifying the availability of methamphetamine and ATS within their peer group is an important first step to help people develop skills to assertively manage offers of methamphetamine and ATS in the future. 6

7 Assessing availability Assessing their ease of access to methamphetamine, ATS and other substances helps people and the clinician to map risks and develop strategies to avoid temptations to score. People who are manufacturing or dealing may find it more difficult to make the decision to stop because of the financial costs of doing so and also because of the status this gives them. Other people who use may also put pressure on them to remain in these roles. Getting detailed knowledge of the person s networks where methamphetamine and ATS use is common will help to tailor recommendations about avoiding risks. Helpful questions could be: If you wanted to use today where would you go to get it? Have you got any methamphetamine, pipes or other equipment at home? Thinking about the last few times you used when you did not plan to, what could you say or do to avoid using in those sorts of circumstances? What else could you do to make it harder to score? Handling people who use In some cases where ongoing social contact is unavoidable people can be supported to deliver clear and assertive messages about not using or wanting to use. Clinicians will need to emphasise to people that it will be difficult to avoid using when methamphetamine and ATS are being used in front of them or when it could be available very quickly. It is useful to explore the concept that people can put themselves at risk of using without consciously being aware of making the decision to use. For example; I haven t seen John for ages and he owes me some money, I really should catch up. Making the decision to avoid certain people and places may be the only realistic way to avoid allowing these processes to happen. Clinicians will need to explore patterns of using with partners and the nature of the relationship. If possible getting both people together to discuss this can improve the possibility of successful treatment. If this is not possible it can be very difficult for one party in a relationship to stop, or even reduce their patterns of use, if the other person is still committed to using. People who are more vulnerable emotionally will find changing their behaviours even more difficult. However, specifically talking about these issues and their thoughts and beliefs about the relationship can lead to the development of strategies to reduce the risks and empower the person to make changes. Encouraging and then role playing sensible and assertive language and behaviour to use with partners can have flow on benefits for also learning how to handle other people. Effectively turning down offers of methamphetamine and ATS requires people to communicate in a direct and unambiguous manner. If done well this will reduce the likelihood of future offers without being stressful or embarrassing for either party. 7

8 Statements need to: be delivered as quickly as possible without any indication that the offer is being considered, such as a hesitation or a maybe be delivered with assertive body language keeping eye contact and standing straight, face on to the person make it clear that future offers are unwanted avoid explanations or reasons for stopping, which may be embarrassing or can leave the way open for future offers Role playing refusal skills can help the person become more comfortable and confident with using them. While role playing can seem artificial and contrived, the clinician can frame it as being a safe way to practise the skills, while emphasising that there is no perfect way to do it. Taking the part of the methamphetamine or ATS user provides an opportunity for the clinician to role model refusal skills and can make it easier for the person to engage in a role play. Once the skills have been demonstrated then roles can be reversed. As the person becomes more confident using the skills then the clinician can become more insistent and or seductive in their attempts to get the person to use. Practising handling questions about physical and mental health, comments about the hopelessness of treatment and offers of free methamphetamine or ATS can help the person have a better chance of succeeding in real situations. Many people will struggle to be able to communicate in an assertive manner, believing it to be rude or aggressive. Other people will find it easier to be aggressive as they may find it difficult to formulate statements that address the behaviour of the person rather than the person themselves. Developing and becoming comfortable with assertiveness skills may require separate training or significantly more practise. Session five: seemingly irrelevant decisions When using the concept of seemingly irrelevant decisions people need to have reasonably intact cognitive functions. They also need a reasonable ability to reflect on their own thought processes and behaviour. This approach is particularly helpful for people who are impulsive and have problems thinking through the consequences of their behaviour, though it can take time to be absorbed. A seemingly irrelevant decision is a decision to do something that is apparently harmless but which could ultimately put people in a high risk situation, where using is more likely. These decisions are sometimes made at an unconscious level and are driven by subtle cravings. While they can seem unrelated to using on the face of it, careful questioning will be able to identify how they put the person at risk. 8

9 Examples of seemingly irrelevant decisions include: using alcohol and or other drugs keeping alcohol and or other drugs in their home not destroying paraphernalia going to visit a friend who lives with or next door to a dealer going to parties where methamphetamine and ATS might be available spending time with or talking to people who use methamphetamine and ATS not telling associates and friends who use of the decision to stop using not planning how to spend free time lack of self care: not eating regularly, not sleeping enough, etc Talk about times in the past when they have used despite not wanting to and unravel the path that led to using. Help the person to identify where seemingly irrelevant decisions were made, making it clear that this is not an exercise in blame. Once the person has grasped the concept of a seemingly irrelevant decision discuss how they could go about becoming aware of these as they occur and how to make safer decisions. Practising becoming aware of and recognising the apparently minor decisions they make every day, then thinking through the safe and unsafe consequences of those decisions, will help people to become less vulnerable to unwittingly putting themselves in high risk situations. Worksheet Seven can provide a framework to guide practise between sessions. Session six: a multi purpose management plan Help the person to identify a range of potential high risk situations and develop concrete management plans for each situation. As not all situations can be predicted a back up plan for unexpected high risk situations is necessary. A management plan might include: a list of numbers for support people for emergencies, including the Alcohol Drug Helpline: keeping the list of negative consequences from Session one handy to read when needed as a reminder a range of reliable distractions, some of which need to be immediately doable a list of safe places to spend time when in a crisis 9

10 Session seven: problem solving Introduce the basic steps of problem solving: recognising the problem identifying and specifying the problem considering a range of approaches to solving the problem selecting the most promising approach assessing the effectiveness of the approach if it did not work trying another approach and assessing that With the person identify two or three recent life problems, one of which should be related to methamphetamine or ATS use, and work through the problem solving steps for each one. Start with a relatively straight forward problem and support the person to work through the steps, clearly identifying the problem, rather than straight away coming up with solutions. Session eight: case management People who use methamphetamine and ATS can often also have a range of associated problems. Issues such as domestic violence, psychosis, income and housing need to be addressed before people can actively engage in and concentrate on treatment. Other issues can be more safely addressed once the person is more settled and not using methamphetamine or ATS. Many of these issues are psychosocial and contribute to use and are high risk areas for lapse and relapse. Case management in this context means: identifying the problems that could be barriers to staying off methamphetamine and ATS prioritising problems for ongoing treatment identifying solutions and resources to address problems developing a support plan 10

11 Session nine: blood borne virus risk reduction If the person is an intravenous drug user discuss the risk of contracting HIV, HCV and HBV. Screen for risky behaviour and practices: re-use of injecting equipment, equipment sharing, sharing rinsing water or other paraphernalia. Discuss sexual behaviour and risk taking, being very specific with questioning, e.g. Do you always use condoms? Do you share razors or toothbrushes? Use motivational interviewing techniques and strategies to elicit behaviour change statements from those people ready to make changes, again emphasising that change is a personal choice. When the person is ready to act help them to set concrete behavioural risk reduction goals and identify any potential barriers to change. If barriers are identified, use problem solving strategies to work through them. Session ten: partner, family member and whānau involvement Involving partners and family and whānau members in the person s treatment helps to demystify what treatment has been about and to encourage support for the person to make changes in their behaviour and lifestyle. Partners, family and whānau members will probably need the opportunity to ventilate about the impact of the persons using on them. If their feelings are extreme and likely to undermine the changes the person has been making they may require the opportunity to talk with a different clinician about how they feel. This would also provide an opportunity to assist the family and whānau to discuss how to set boundaries and general self care. Explain how the CBT model of behaviour change works. With the person and their partner and or family and whānau members work out: what specific changes the person can make to meet the needs of their partner and or family and whānau members how they can support the person to stop using methamphetamine or ATS 11

12 Once there is an agreement on what behavioural changes and strategies are needed this can form the basis of a contract between the person and their partner and or family and whānau members. Session eleven: closure Review the treatment plan: what the persons goals were how they have changed what has been achieved what still needs to be done Particularly focus on the skills that the person has developed and those that could be worthwhile developing further. Discuss what the possible indicators of the steps to achieving their goals would be, and how to recognise and celebrate them. Talk about what were the most and least helpful parts of treatment and ask the person if they are concerned about finishing treatment. Those people who have not met their goals or have not developed stable behavioural changes may need ongoing counselling, referral to a support group, referral to a day programme or referral to residential treatment. 12

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