Old Assumptions about patients

Preparing for the Substance Abuse Interview:Getting All “Psychological” on Patients Presenting for Treatment

Old Assumptions about patients • Patients have come to us for our expertise. • In substance abuse settings, the person is using and wants to stop using for good • There is an implicit understanding that, since the patient has come to us for our expertise, he/she is now ready to engage in whatever behaviors we prescribe for them

“New” assumptions • The person in front of you is experiencing negative consequences • The person would prefer to remove the negative consequences with minimum effort, and with a minimum change to their lifestyle • The person wonders if you can assist in removing those consequences so they can get back to business as usual

Assessing the patient’s assumptions • The person may not any causal link between their behavior and the consequences (example: Patient court-ordered to treatment after a DUI) • The person may have little desire to change the behaviors that lead to those consequences (a smoker wants treatment for cancer, but may have no desire to quit smoking)

Examples No awareness of link of substance use and life problems: • I got a DUI because of random check points. • I’m here because my parents are making me do it. • I’m in this program because I have to be in a program to get housing/voc rehab/DSS/to apply to disability • I have to go to treatment as part of my probation

Examples Some awareness of a link: • I’m drinking too much and I need to cut down. OR I know I need to quit for now (but when I can I start again?) • I know smoking’s bad, but I already have to give up sweets, fatty foods, and now I need to exercise – smoking is the last pleasure I have left • AMBIVALENCE: the coexistence within an individual of positive and negative feelings toward the same person, object, or action, simultaneously drawing him or her in

Examples Clear awareness of a link • I know I can never drink or use drugs. Not even a little. • I know what will happen if I start to drink again – I might end up in jail – or worse, I might end up dead • I need to be totally abstinent

The point: Don’t assume • While it’s pretty safe to assume a patient wants to rid him/herself of some negative consequences, you don’t know where the client stands with respects to his/her understanding of what’s happening or his/her desire to make changes • Summary: You can’t assume they’re ready to embrace your agenda

Helpful Heuristic: Stages of Change

Note: Presentation of Substance Problems can differ • People who use alcohol and pills are using legal, socially sanctioned substances. Although marijuana is illegal, there is a strong movement to support its benefits, and it is actually legal for medicinal purposes in many states. • In my experience, these people seem more vulnerable to failing to link use of these substances to their problems. These people will often state ‘moderation’ as a goal. • Crack and heroin users know these drugs are illegal, they know there is a stigma. It is therefore harder to make the argument that these substances are not linked to problems. They don’t argue for moderation, though they would secretly prefer to be able to continue to use without negative consequences.

Challenges of First Interviews • Usual purpose of interview: OBTAIN DIAGNOSTIC INFORMATION, SEVERITY • Through a series of structured, close-ended questions, we attempt to identify/quantify substance abuse problem by asking direct questions related to substance abuse • How’s a person in ‘Pre-contemplation’ going to react to this? • Maybe they’ll get defensive, argumentative, or shut down

First, find out why they think they are here (“Finesse Play”) • Although we feel pressured to get information, resist this urge, and try the following: • Ask the patient open-ended questions like: “Why are you here? What brought you here?” • Follow up with further open-ended prompts: “Tell me more about that.” • Clarify with: “What do you hope that our working/talking together will accomplish?”

Second, Acquire the data in a manner that fits their understanding • Persons who are in Preparation/Action generally acknowledge alcohol/drugs are a problem and can probably better tolerate direct questions about drug/alcohol use and negative consequences • Persons in Precontemplation/Contemplation might get very defensive if you do rapid-fire substance abuse questions • Work your way up to it gradually as part of the psychosocial history. • Pay close attention to things in the history that may be indicative of substance abuse problems

Assess Severity (Yeah, but why?) • Severity can affect how you approach treatment • Someone with a long and severe history of use will probably not benefit from harm reduction/moderation, and might be more willing to embrace total abstinence • Someone with a shorter, less severe history, may only be willing to entertain moderation at the present time. Arguing for total abstinence will probably shut down treatment

Assess severity • Starting use prior to 21 years of age (biologically increases risk of developing addiction) • Use for 5-10 years (about the time it takes to develop alcohol dependence) • Family history = more possibility of genetic predisposition (did anyone die of liver problems?) • NOTE: You don’t have to know all the signs of substance abuse – if you are taking a good history, you should be able to present it to someone with the background, and they can help you recognize these signs

More problem = greater severity • “Tell me about any legal issues you have…” (DUI, open container, posession) • “Tell me about your work history…” (Unstable employment pattern, conflicts at work, tardiness) • Recreational activities (lots of things that involve drinking) • Relationship patterns (divorces, loss of friends) • Physical symptoms – sweaty hands, shakes, sleep problems (alcohol), lots of complaints pain (opiates/pain killers) • “When did you first try x or y?” • “Tell me about your family, parents, their health” (looking for drug-related problems)

When doing history, you are listening for DARN CAT: • Desire to change • Ability to change • Reasons for change • Need for change • Commitment to change • Actions • Taking Steps NOTE: Using open-ended questions might give you more access to this information than would a closed yes/no kind of question

Why gather all of these data? • As you gather data that the client gives you, you are actually compiling a list for reasons for that person to change • Later on, as you negotiate what you do in treatment, you can reflect these data back to the patient in the form of feedback (e.g. a written summary or report) • Feedback can be a compelling motivator to faciltate the desire to change – the data come from the patient and not from you • They provide their OWN reasons to change

Stylistic tips • Use reflective empathy statements (e.g. “that must have been difficult”) • Builds rapport • Allows for clarification • Gives the patient a feeling of being heard • Reflective summary statements also build rapport, show the patient you are listening, and allows for clarification

Keep in mind • Patient unaware of problems related to drug use are probably going to give more information that points to those problems • Patients who are aware of problems might report fewer problems, as there is a universal tendency to present oneself in a favorable • Patients who are aware they are being evaluated for drug/alcohol problems are going to be motivated to under-report their use • Remember, self-report is but one source of information that, in the case of addiction especially, requires corroboration

Fact checking – for drug/alcohol specialists • Corroborate information with significant others, family members • Corroborate using drug screens, breathalyzers, lab values • Feel uncomfortable about doing the above? Work it into your consent to treat and be right up front from the beginning • Preventing underreporting and increases accountability is a highly effective intervention in its own right!

Old Assumptions about patients