Psychological Therapies for Risk Reduction

1. Psychological Therapies for Risk Reduction Dr Barbara Hedge Consultant Clinical Psychologist

2. Is there more to risk prevention than MI? • Flavour of the month • Relaxation therapy • Cognitive behaviour therapy • Solution focused therapy • Motivational interviewing • Why recommended • Looks to be effective but cheap • Never mind the problem

3. NICE guidance 2007

4. Putting therapy into context • Sexual health setting • A normal, universally practised behaviour • Risk • Probability of danger and/or undesired outcomes • Individual • Partners and families • Society • Undesired outcomes • Sexually transmitted infections • Pregnancy • Aim to change behaviours to reduce risk • Identify useful psychological therapies

5. What factors are associated with risk? • Lack of knowledge or understanding • Resources • Skills • Communication • Ability • Conceptualisation of personal risk • Motivation to reduce risk • Lack of care for self or others • Low mood • Shame • Power differential • Cultural • Coercive

6. Lack of knowledge or understanding

7. Sexual health expert knows best • Assumptions • Patients are always rational so act on knowledge • The goals of patients are the same as goals of sexual health practitioners • All patients want what is best for themselves • UK national guidelines on safer sex advice • BASHH 2011 • Conclusions • Giving knowledge is all that is necessary • Telling people what to do is the same as giving advice

8. They just don’t listen! • Repeated STIs • HIV transmission • Unwanted pregnancies • Repeated requests for PEP Information is necessary but not sufficient

9. Conceptualisation of personal risk andmotivation to reduce risk

10. Theory of reasoned action • Fishbein, 1979

11. Which therapy? • What, who needs to change? • Who wants or doesn’t want to change? • What are the risk factors • Goal to be achieved • How to bring about change • Learning theories • Skinner’s Operant Conditioning theory • Bandura’s Social Learning theory

12. Risk reduction

13. Behaviour change therapies • Cognitive Behaviour Therapy • Systemic Therapy • Solution focussed Therapy • Motivational Interviewing • Peer Influence • Nudge

14. Cognitive behaviour theories

15. Personal risk cognitions • Not want to transmit • Not want to disclose • Not want to use a condom • Not want to become infected • Not want to think about it • Not want to confront

16. Self-serving attributions • Constructed narratives that allow justification of our behaviours • Before and/or after action or non-action • ART means I have no virus to transmit • PEP is available if need it • If partner is willing to have unprotected sex they are probably already positive • Partner wouldn’t suggest unprotected sex if they were positive • Can trust negotiated safety agreement

17. Cognitive behaviour therapy • Addresses non-adaptive cognitions • Replaces with adaptive • Can confront the issue • Can plan to remain uninfected • Raises mood • Lowers anxiety • Increases self-esteem • Adoption of self affirming behaviours • Assertiveness • Acceptance of rejection of the behaviour rather than of the self

18. Learning new behaviours • Operant Conditioning • Reinforcement • Positive  repeat of behaviour • Great sex with a condom • Remove negative  • Finally agree to sex when agree to condom • Negative • Fail to keep erection with a condom • Remove positive  • No sex as no condoms

19. Chains of behaviour

20. Nudge theory • Suggestion + positive reinforcement • Address one element of behaviour in the chain • If positively reinforced by others or internally • Repeat behaviour • Reinforce additional elements in chain • Gradually approach goal of protected sex

21. Solution focussed therapy • Not concentrating on the problem • Uses resources patient already has • Encourages trying a course of action (possible solution) • Strengths patient already has • Advantages • Quick • Cheap • Patient generated • Builds self esteem and self efficacy • Disadvantages • Failure for complex issues • Key factors may not be identified • Difficult engagement when depressed

22. Cycle of change – Prochaska and Diclemente

24. Motivational interviewing • Directive, client-centredcounselling style to resolve ambivalence (Rollnick & Miller, 1995) • Motivation = Importance + Confidence + Readiness • Aims to elicit and boost these factors • NICE • Quick • Cheap • Catch people on first visit • Evidence of effectiveness • A stand alone intervention • Possible service approach

25. Peer interventions • Use of a peer educator • Group leader • Introduce safer sex into conversation • Set up group norm • ‘cool to use condoms’ • Social learning theory + Nudge + MI • Efficacy • Some support • ? Culturally specific • Review: Simoni et al, AIDS Behav, 2011, 1589-95

26. When do I need systemic therapy? • Risky sex is rarely an individual practice • What is the influence of the partner? • What is the perceived influence of the partner • Is there a power in-balance? • Communication • Negotiation • Agreement between partners to change

27. Summary • Motivational interviewing a good place to start • Finding out the whole picture • Patient suggests the next step • Moves to action from pre-contemplation • More commitment to meet their own challenge • Ready to address cognitions and beliefs and learn skills • Able to identify when there are greater unmet needs • Pathways for onward referral to meet general needs • Appropriate use of therapeutic techniques brings best results