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Psychosocial Interventions for Addiction Disorders

R. Dhanasekara Pandian[1] & Sojan Antony[2]

Introduction

Addiction disorders affect all spheres of Indian society (Benegal, 2005; Murthy, 2008). People start usage of various substances like tobacco, alcohol, cannabis, opioids etc. to experience pleasure or to relax. Behavioral and learning theories report pleasurable activities would be repeated. Most of them learn these habits from their peer group. Later it leads to severe adverse consequences. A person starts use to relax, later without substances he would not be able to live. This is like a use of kerosene in petrol car. Benefits of use would be enjoyed for initial stage, soon engine would be spoiled. Same way substance use would affect physical, psychological and social functioning of human being. Family has a crucial role for preventing substance use and in recovery from addiction disorders (Pandian, 1999; Lakshmi, 2007). Modern human brain related science adds that changes in the brain structure and chemistry do not allow few among users to stop, though they face harmful effect. Socialization process by family, peer, school, religion and work environment do play a vital role in the life of persons to develop against or supportive attitude towards substance use. Relearning or change in attitude would make constructive move in the life of a person with addiction. Individual, family, group and community based structured psychosocial interventions have been found to be an effective element in addiction treatment.

 

Severity of problem

Addiction has been a bio-psycho-social problem in India. The use and abuse of substances cause social, economical, physical and psychological problem in the society (Murthy, 2008; Benegal, 2005). Prevention is primary goal or policy in India. But due to various reasons it could not be achieved. Substances have been classified as licit and illicit. Licit substances like alcohol and nicotine were identified as one of the prominent sources of income for government. Also considering easiness in production of such substances and wide use prevented legislative force to ban those drugs. Illicit drugs like cannabis, opium, cocaine were produced, transported and distributed by antisocial forces to meet their financial needs. Some of substances are prescriptive medicines which are abused as a source of relaxing or stimulant agent. Not surprisingly even children are not spared from substance abuse majority initiate their use with less tobacco products. Psychosocial interventions are essential to prevent the initiation of use and to help individuals stopping the use of substances.

 

Psychosocial Interventions

Major psycho-social interventions are divided based on target groups.

 

  1. Individual based interventions
  2. Family based interventions
  3. Group based interventions
  4. Community based interventions

 

Individual based interventions

Motivation enhancement therapy

Motivation has been found to be a significant factor in recovery from substance use. It has been understood as a desire or urge to change from using to non-using status. Motivating factors belong to either internal locus of control or external locus of control. Internal factors such as body ache, sleep difficulty or tiredness are more powerful reasons than external factors like for due to advice from somebody or for having good name. Strength of the motivation is classified based on the thoughts and actions of the individual. Motivation varies in each stage. Enhancing motivation is the main part of change process.

Motivational interview or motivational enhancement therapy has been used to enhance client’s motivation to stop or decrease the use of substances among adult population procedure and principles are adaptable to enhance motivation of children who use to change. Motivation is not static. It tends to vary in different time. There is scope to use motivational interview techniques to reduce risk of initiating use, stopping use or reduce use.

Diagram 1: Stages of Motivation

 

 

Pre contemplation

Person may think at this stage of motivation, one’s use of drinking alcohol or smoking is absolutely normal. It is rationalized with following thoughts “our life situations require some substances to relax”. He will not think possible benefits of change in this stage. They are happy with use; do not recognize the adverse effects on their health and functioning.

 

Contemplation

Health difficulties, severe loss or drive to better and peaceful life would encourage person to think about stopping use of substance. It is very difficult to point why some people seriously consider stopping or decrease the use. It varies individually. This stage the individual may weigh benefits and difficulties associated substance use. If perceived difficulties outweigh benefits of use will be the turning point in stopping.

 

Determination

Determination means strong decision to not use, decrease use or stop use. This is the launching stage of action. Individual will be fully sure about benefits of stopping or not using substance. It is the stage to decide when, where and how action of change can be launched. He might report to family members about his determination of stopping the use.

 

Action

In action stage individual will stop using substance. There is a chance to face psychological and physical difficulties. Guidance (Clark 2005) to get medical help will ease the process of stopping than stopping self. Especially street use of sleeping tablets, pain killing tablets and injections cause severe withdrawal symptoms. This might create fear among users; in turn it may lead to continuation of use. Psycho social support and medical care have to be facilitated by those who help to substance use. Occasional users may not face those severe withdrawal difficulties. Action stage is meant for initiation of abstinence. Person takes decision to skip substance using friends, places and situations.

 

Maintenance

Continuation of not using status is known as maintenance or abstinence. Stressful life realities pose multiple barriers to this goal. But it is sure strong individual motivation and professional help would empower individual to continue this status. Help has to be continued for certain duration not less than 6 months to stabilize with substance free life.

 

Relapse

Relapse is part of recovery cycle. It can be caused in various high risk situations (Martino, 2007) such as craving to use, peer pressure, difficulty to cope with emotions and problems and boredom. Relapse is not the end of effort. It is not the end of helping process also. Continuous further effort would help individual to maintenance again. Professionals and client have to be prepared mutually to face this stage at any point of help.

 

Principles of Motivational Interview

Following principles would help the smooth process of motivational interview.

 

Empathy

Genuine understanding and concern towards individual’s growth and development would help one to express empathy. It is important to know various substances and positive and negative effects on mind and body. Otherwise there is a chance to contradict with client’s view about benefits of using. It may lead to arguments between client and helper.

 

Avoid arguments

Arguments are not going to help client. There is a chance to develop negative attitude to helping process. Though client may bring certain arguments, those can be reframed or summarized.

 

 

Role with resistance

Denying or not engaging the helping process reflects the resistance. Resistance is a door of hidden issues. Agreeing argument and exploring functioning level of client would bring successful turns in therapeutic sessions.

 

Develop Discrepancy

Motivational grid (Diagram 2) can be used to develop discrepancy in the mind of client when they are preoccupied with the benefits of use. This exercise can be used in individual level or in group level also.

Diagram 2: Motivational Grid

Good things about using Not so good things about using
Disadvantages of stopping Advantages of stopping

 

 

 

Support self efficacy

Brainstorming techniques are used to elicit client’s version of problems and possible solutions. Sometime client may share how he or she could avoid use in past such techniques or attempts have to be reviewed and supported child to adopt same way to come out of present problems.

 

Relapse Prevention (Individual based and Group based)

Individual based interventions would help to specific and confidential issues. Group based interventions (Karen & Murthy 1998) have been seen as a source of support, information and stage for attitude change and skill training (Moos et al., (2008)). Following contents would be dealt in both individual and group sessions.

 

Psycho-education

Individuals and family who seek treatment are not aware fully about nature of problem, process of treatment, stages of change and prognosis. This might lead to early drop out from treatment. Psycho-education from mental health professionals would motivate persons to continue treatment which has been shown better outcome in clinical experience.

 

 

Myths and misconceptions

Drug use is associated with certain myths and misconceptions. Few of them are “it relaxes me”, “I get confidence to do things, I wont get fear if I use and do”, “I can do work much more time with high concentration”,  “night for sleep, it is helpful”,  “drinking is good for heart” “little use is a booster in sexuality” and “for my bad mood this is a solution”.  These are few sample conversation which have been shared by patients in group. Current understanding of addiction show that chronic drug use would give adverse effect in almost all above mentioned expectations of use. Peer interaction based learning and experience of abstinence may change these misconceptions.

 

High risk situations

Peer group interaction (Martino et al., 2006) has been reported as a main precipitating and maintaining factor of addiction. Even after the treatment, old friends may force the individual to use again. Individual gets environmental cues related feeling to use. It may be during the celebration of festivals, family gathering or in the occasion of major life events like marriage, child birth or death. Problems or difficult life situation are being identified as risk situations of restarting use. Identifying various high risk situations along with individual, family and group would help individuals to prepare themselves to prevent post treatment relapse.

 

Craving management

Craving has psychological and social dimension though it is defined as an intense urge to use substance. Social cues are one among reasons of craving. Avoiding such cues would reduce risk of relapse. Usually patients are helped to identify the flagging thoughts of craving such as “only for today, let me take my last drink”, “I have stopped for 2 years so let me”, “I wont take let me just sit with my friends while they are having”, “wine is a soft drink, it is not harmful”. Individual must see the psychological and physical cues. Then they can use 4-D distraction techniques with the awareness of sea wave nature of craving. Like a wave in sea side, craving would come and go and they need balance in that time. Distraction, Deep breathing, Drinking water and Delay (4-D techniques) would help individual to manage craving.

Substance refusal skills

Role plays are used to train substance refusal skills. This is basically training of assertive skills. This would empower individual to say “No” when friend, relative or others force him to use. Tone of voice and non-verbal expressions are vital part off assertive skills. These would be trained in a role through enacting a party scene or road side scene. Individuals are encouraged to leave that place as early as possible while others force to use.

Coping skills

Coping skills are trained in two aspects, emotion based coping and problem based coping. In emotion based coping individuals are taught temporary nature of emotion, how emotions can be reduced using relaxation techniques. Individuals are educated not to take any hasty decisions or to negotiate with others while they are in emotions. The need for waiting while they are emotionally up would be discussed with life examples. Problem solving techniques has been used in problem based coping.

Problem solving structure

Addiction has been a cause and result of problems. So it is important to teach problem solving pattern to break this vicious cycle. Problem solving is a process, which includes identifying the main problem, understanding the problem, identifying the resources, identifying solutions, implementing the best possible solution considering personal resources and social support, evaluating the result, and if problem is not solved try again or attempt next best solution. This training can be done with analyzing their any one of the problems. It would help individuals not to resort drugs as a solution in their difficult situations.

Positive addiction and lifestyle change

Lifestyle change need to be promoted through diverting individuals attention to positive addiction such as sports and games, exercises, yoga, meditation, social activities, spiritual activities and hobbies like watching T.V.. Positive addiction would give alternative pleasure as well as keep individual engaged in some sort of activities. In turn it reduces the risk of relapse.

Sleep, money and time management

Difficulty in sleep, money and excessive free time are some of the factors for relapse. So it is necessary to teach sleep hygiene and money management skills in terms of saving. Free time needs to be planned in advance to avoid boredom which has been reported as a primary reason of restart of use.

Relapse management and follow up

Relapse is a possibility in addiction treatment. Anticipating relapse in advance and being prepared to deal in a supportive medical model as early as possible would ensure recovery. Long term follow up has been rated as major factor in the success of treatment. Family should be trained to help individual in non critical manner during relapse.

Family based interventions

Family dynamics and related factors are important in addiction treatment. As a victim of addiction they ought to be helped to ventilate their suppressed emotions in the absence of individual. Proper training and supportive psycho-education can change the attitude of family. Quality of marital and family life (Pandian, 1999) and family rituals (Shankaran 2007) are found to be positive factors in family dynamics of recovered or resilient individuals. This would promote the quality of social support to individual. It has been documented social support is a crucial factor in recovery (Gillfford, et.al, 2006; Ashok, 2008; Kiran & Muralidhar, 2004). Healthy family interaction (Shankaran, 2007; Pandian, 1999; Thirumoorthy, 1995; Veela, 1994) and regular treatment follow up with support of family (Rajaram, 1990) are found to be the major protective factors of abstinence after treatment.

 

Community based interventions

Community based interventions (Pandian & Sinu, 2007) are found to be effective in ensuring the long term abstinence. Training of primary health care doctors, NGO staff, volunteers, counselors, college, school and preprimary teachers, strengthening self-help groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) and having an effective network with various service organizations in the community can be useful in addressing substance use disorders in case identification, diagnosis, referral to treatment, providing long term care and rehabilitation services.

Conclusion

Bio-psycho-social aspects of addiction support the need for multidisciplinary treatment efforts. Support from multiple sources ensures fast and stable change. Psychiatric social workers play a vital role to reduce the risk of relapse due to social factors through empowering patient to face social and environmental risks.

 

References

  1. Ashok KH. Social support among abstinence and non-abstinence alcohol dependents. Unpublished M.Phil Thesis, NIMHANS (Deemed University) Bangalore, 2008.
  2. Benegal V. National experiences, India: alcohol and public health. Addiction, 2005;
  3. Gillford EV, Ritsher JB, McKellar JD, Moos RH. Acceptance and relationship context: a model of substance use disorder treatment outcome. Addiction. 2006; 101:1167-1177.
  4. Karen DK, Pratima Murthy. Group therapy with alcohol dependents: process and perception. NIMHANS Journal, 1998; 16(3), 197-201.
  5. Marlatt GA. Cognitive assessment and intervention procedures for relapse prevention. In: Marlatt GA, Gordon J, eds. Relapse prevention: a self-control strategy for the maintenance of behaviour change. New York: Guilford press, 1985.
  6. Martino SC, Collins RL, Ellickson PL, Schell TL, & McCaffrey D. Socio-environmental influences on adolescents’ alchohol outcome expectancies: a prospective analysis. Addiction. 2007; 101:971-983.
  7. Miller W, Hester R. Treating the problem Drinker: modern approaches. In The Addictive Behaviours: treatment of alchoholism, drug abuse, smoking and obesity. New York: Pergamon Press. 1980.
  8. Moos RH. Active ingredients of substance use-focused self-help groups. Addiction. 2008; 103:387-396.
  1. Murthy P. Introduction. In: Murthy P, Nikketha SBS editors. Psychosocial Interventions for Persons with Substance Abuse Theory and Pratice. . Bangalore: National Institute of Mental Health and Neuro Sciences De-Addiction Centre; 2008; 64.
  2. Pandian RD. Family actors associated with abstinence among alcoholic dependence. Phd thesis, Unpublished Ph.D Thesis, NIMHANS (Deemed University) Bangalore 1999; 109-132.
  3. Pandian RD, Sinu E. Community care or workers with alcohol dependence. In: Sekar K, Parthasarathy R, Muralidhar D, Chandrasekar Rao M editors. Handbook of psychiatric social work 1st ed. Bangalore: National Institute of Mental Health and Neuro Sciences; 2007.
  4. Rajaram. Social Indicators in the prognosis of Alcoholics. Unpublished Ph.D Thesis, NIMHANS (Deemed University) Bangalore.1990.
  5. Shankaran L. Protective family factors in adult children of alcoholics. Unpublished Ph. D Thesis, NIMHANS (Deemed University) Bangalore, 2007.
  6. Suveera P, Pratima Murthy, D.K. Subbakrishna, & P.S. Gopinath. Treatment setting and follow-up in alcohol dependence. Indian Journal of Psychiatry, 2000, 42(4), 387-392.
  7. Thirumoorthy. The experiences of wives of alcoholic abstinent and relapsed employees – A follow-up study. Unpublished M.Phil Thesis, NIMHANS (Deemed University) Bangalore, 1995.
  8. Veela MD. Alcohol long term abstinents and relapsers in an industrial setting. Unpublished M.Phil Thesis, NIMHANS (Deemed University) Bangalore,1994.

 

 


[1] (Associate Professor), Department of Psychiatric social work, NIMHANS, Bangalore-29

[2] (Ph.D. Scholar) Department of Psychiatric social work, NIMHANS, Bangalore-29

 

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