Week 10 - Ethics and Facilitating Change Flashcards
Principles of effective treatment
- No single treatment is appropriate for all individuals
- Treatment needs to be readily available
- Effective treatment attends to multiple needs of the individual, not just his or her drug use
- An individuals treatment plan must be assessed continually & modified as necessary to ensure the plan meets the person’s changing needs
Principles of effective treatment 2
- Remaining in treatment for an adequate period of time is crucial for treatment effectiveness
- Counselling (individual or group) & other behavioural therapies are critical components of effective treatment for addiction
- Medications are an important element of treatment, especially when combined with counselling & other behavioural therapies
Principles of effective treatment 3
- Clients presenting with coexisting
mental health & substance abuse
should have both disorders treated in
an integrated way. - Medical detoxification is only the first
stage of treatment & by itself does little
to change long-term drug use - Treatment does not need to be
voluntary to be effective - Possible drug use during treatment
must be monitored continuously
Priniciples of effective treatment 4
- Treatment programs should provide
assessment for blood borne viruses &
other infectious diseases, & counselling
to help modify or change behaviours
that place the person or others at risk
of infection. - Recovery can be a long term process
& frequently requires multiple episodes
of treatment
Miller & Hester Informed Eclecticism
4 assumptions:
- There is no single superior approach to
Treatment (Rx) for all individuals
- Rx programs/systems should be
constructed with a variety of approaches
that have been shown to be effective
- Different individuals respond best to
different Rx approaches, and
- It is possible to match clients to optimal
Rx, therefore increasing Rx effectiveness and efficiency
Australia Treatment Outcomes Study (ATOS) overview
- Heroin users
- Replacement; withdrawal; residential rehabilitation; non-Treatment control
- 3 and 12 month post entry follow-up
- Treatment sample differed from general population
- More PTSD, Depression, Borderline PD, and disability.
- High suicide and overdose rate; criminality
ATOS Outcomes
- General functioning improved
- Majority of participants abstinent for the 1 month prior to 12 month follow-up
- 65% Replacement
- 63% residential rehabilitation
- 52% withdrawal
- 25% non-Treatment control - Noticeable reduction in criminal behaviours, improved injection related health, decline in depression
Future directions
- Improve understanding of dependence & withdrawal
- Greater attention to the use of psychosocial interventions as primary
& adjunct treatment - Consider significance of lifetime treatment history & how individual
treatment episodes fit together to achieve recovery - Assess effectiveness & efficiency under typical circumstances
- Assess effectiveness of treatment interventions with subgroups
Unique moral, ethical and legal issues
- Unique risks to user and community balanced with therapeutic goals
- Potential impact on the therapeutic relationship, clinician and client’s reactions, and services offered
- Who should have access to treatment? (esp. public)
- Consent (intoxication, third party pressures)
- Illegal behaviours and confidentiality limits
- Minors
- Harm reduction vs No Tolerance/Abstinence approaches
Impact of ethics & values
- Different beliefs associated with different drugs
- Differences between personal beliefs
and evidence of harm - Stigmatisation of drug use often means
clients have often experienced judgemental approaches and rejection in the past - Stigma is a barrier to accessing
treatment
what are the 3 general prinicipals the APS is built on?
- Respect
- Propriety
- Integrity
APS- Code of ethics
Psychologists
Psychologists only provide psychological services within the boundaries of their professional competence. This includes,
but is not restricted to:
A) working within the limits of their education, training, supervised experience & appropriate professional
experience
B) basing their service on established knowledge of the discipline and profession of psychology
C) adhering to the APS Code and Ethical Guidelines
D) complying with the law of the jurisdiction in which they provide psychological services; &
E) ensuring their emotional, mental, & physical state does not impair their ability to provide a competent psychological service
Clinical vs Ethical decisions
According to the APS:
- A&D treatment based on established
knowledge requires clinical decision making based on evidence in order to provide a competent service to the client. However,
- Ethical A&D treatment decision making
requires respect, propriety & integrity.
- Thus,
- Clinical decision making is based on
evidence & ethical decision making is
based on respect, propriety, & integrity
The 5 moral principals of a healthy therapeutic relationship
- autonomy
- justice
- beneficence
- non-maleficience
- fidelity
Key points of autonomy
- addresses respect for independence, and self-determination
- allows individual freedom of choice and action
- encourage clients when appropriate to make their own decisions based on their own values
- help clients understand how their decisions may be perceived and may affect the rights of others
- assess whether a client is able to make sound and rational decisions (minor, mental disabilities)
Key point of justice
treat each client with equity
Key point of beneficence
- to do good, be proactive and to prevent harm when possible.
- comes in form of prevention and early intervention actions that contribute to betterment of clients
key points of non-maleficence
- not causing harm to others
- weighing potential harm against potential benefits
key points of fidelity
- loyalty, faithfulness, and honouring commitments
- clients must be able to trust counsellor and have faith in therapeutic relationship
APS Guidelines on Confidentiality
- Understand he legal context and the organisational requirements associated with confidentiality and limitations
- Informed consent
- Only breach confidentiality when:
- Consent exists to do so
- There is a legal obligation to do so
- There is an immediate and specified risk to an identified person that can be averted by the disclosure of confidential information - When disclosing information, only disclose what is needed to achieve the purpose of thedisclosure and only to individuals who require the information
- Where safety permits, psychologists inform their clients if, what, why, and who their information is being disclosed
The old way of change facilitation
- Confront “addictive personalities”/denial
- Key Skill – Coercion (shame, guilt,
threats, force) - Leads to - Resistance, argument,
reduced change
What is the problem with the old approach
- demoralises and
leads to higher rates of relapse - when therpaist takes stop using stance, clients responds with keep usin position and argue from this perspective
- people are more likely to be persuaded by what they hear themselves than what other people tell them
Five important assumptions of new way (motivational interviewing)
- Motivation is a state not a trait
- Resistance is not a force we must overcome
- Ambivalence is normal
- Person seeking help should be an ally rather than an adversary
- Recovery and change are innate, constant and intrinsic to the human experience
Background centrality of ambivalence
- central to addictive behaviours
- awareness of risks, costs and harms
- also attached and attracted to behaviour
- confrontation about adverse consequences
- often results in argument
- reinforces reasons for continuing
Stages of change
- precontemplation
- contemplation
- preparation
- action
- maintenance
- termination
- relapse
Precontemplation - Happy user
- Not planning to change in foreseeable
future - Uninformed or under informed
- Families/friends etc… see the problem
- Resistant to change
- Sometimes demoralised following relapse
Contemplation - on the fence/ambivalent
- Aware of problem
- Seriously thinking about/considering change
- Not yet made commitment to
change - Ambivalence (weighing up the pros and cons)
Understanding Ambivalence
- Normal, understandable, acceptable, and expected
- Strong & sometimes long held attachment to problem behaviour
Preparation - making a plan for change
- Plan for action in next month
- Open to information and support
- May have made small changes
Action - making changes
Putting plan into action
- Modification of behaviour, thoughts,
environment
Behavioural changes (1 day to 6 months)
- Considerable commitment of time and energy
High potential for relapse
Maintenance - changes that last
- Changes maintained for 6 months or longer
- Focus is on preventing relapse
- More confident, “living the change”
Lapse vs Relapse
- Rule rather than exception
- Most people don’t make it on first
attempt - Can go back to any stage
- Can happen on multiple occasions
- Does not mean that the person is
unmotivated - A lapse is a short term “slip up” and
a relapse is a return to past usage
patterns
Percentage of drug addicted patients that relapse
40-60%
Prevalence of relapse
- Relapse is a common occurrence - The
rule rather than the exception - 90% of clients will experience a lapse
within 12 months of completing treatment (brief return to use) - 60% of clients will experience a relapse
(return to old patterns) within 12 months
Stages of change spiral
- Each time learning more about themselves and triggers for relapse
- 85% of relapsers return to contemplation then eventually move on through the stages
- 15% of relapsers return to pre-contemplation
- Key difference: attributions to personal failure; embarrassed, ashamed and guilt
not linear and organised and cycle back and forth
Matching interventions to the stage of change
precontemplation and contemplation
change processes traditionally
associated with the experiential, cognitive, and psychoanalytic approaches, e.g., education and feedback (consciousness raising) and motivational interviewing
(self-reevaluation and emotional arousal)
Matching Interventions to the
Stage of Change
Action and maintenance
Existential (e.g., self-liberation and will power) and behavioural approaches (i.e., practical) most useful
Matching Interventions to the
Stage of Change
Maintenance
Behavioural approaches e.g.,
relapse prevention plan
What is Motivational Interviewing (MI)?
A directive, client-centred approach for initiating behaviour change by helping clients to explore and resolve ambivalence
five assumptions of MI
- Motivation is a state not a trait
- Resistance is not a force we must overcome
- Ambivalence is normal
- Person seeking help should be an ally rather than an adversary
- Recovery and change are innate, constant and intrinsic to the human experience
The spirit of MI
- Partnership
- Acceptance
- Compassion
- Empowerment
PACE
The four tasks of MI
- Engaging
- Focusing
- Evoking
- Planning
These four processes are NOT a linear sequence, rather the client can double back and repeat throughout the session
Engaging
- Use of client centred counselling skills to develop a therapeutic alliance
- Relational foundation
- Client-centred
- Acceptance facilitates change
- Skilful reflective listening is fundamental
- Express empathy
- Empathy through reflective listening
Focusing
- Clarifying the goals and direction of
counselling (i.e., being on the same page) - Ask the client to identify a target area in which they are struggling to make change by:
- Setting an agenda
- Asking the client what is important to them
- Be transparent about what the target is, once identified
Evoking
- Eliciting the client’s reasons for change.
- Attention is paid to the clients “change talk” in order to explore, understand and summarise it.
- Use client’s own motivators to highlight discrepancy between present behaviour and important personal
goals or values- ‘psychological squirm’ - Planning- When readiness for change seems apparent, proceed to determine what the next steps will be
- NOT a linear sequence, rather these processes can double back and repeat throughout the session
Planning
When readiness for change seems apparent, proceed to determine what the next steps will be
- The bridge to change – negotiating goals and plans and strengthening commitment.
- Development of a change plan.
- Client’s belief in possibility for change - important motivator
- Client responsible for change
- Counsellor’s belief in client also important
- Client is primary resource for solutions
- Review change plans to determine if more support is needed
OARS - the engaging skills of MI
O- Open ended question to allow exploration
A- Affirming. Watch for and affirm client’s
strengths
R- Reflecting your understanding back to
the client
S- Summarise. Shows you’ve been
listening and value their words enough to remember them, also can link material together and can help emphasize certain points.
MI Evoking skills
DARN
Desire
Ability
Reasons
Need
MI Evoking skills
CAT
Commitment
Activation
Taking Steps
giving advice in MI
- Ask permission first
- use autonomy supporting statements
- offer small chunk of information in a sequence of elicit-provide-elicit
Assessing Change
Importance - refers to how much change matters to you.
Confidence - means how strongly you believe you can change and how self assured you feel
Readiness - is how ready you feel right now to make the changes you desire. Consider if this is the right time.
Decisional Balance
- Perceived advantages (pros) and
disadvantages (cons) of staying the
same Vs making a change - Assumption - motivation for change
affected by decisional balance - A useful tool to raise self-awareness and assist in assessment of stage of change
