Week 10 - Treatment and Ethics 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 (ii)
- 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 (iii)
- 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
Principles of effective
treatment (iv)
- 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 for all individuals
Treatment programs/systems should be constructed with a variety of approaches that have been shown to be effective
Different individuals respond best to different treatment approaches
It is possible to match clients to optimal treatment, therefore increasing Rx effectiveness and efficiency
Australian 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
Effective Treatment
- Many people recover from harmful substance use without psychological therapy.
- There is no single superior approach to treatment for all individuals: different individuals respond best to different treatment approaches at different times and it is important to match clients to their stage of change to maximise treatment effectiveness and efficiency.
- Comprehensive assessment, including mental health assessment, is essential as substance use and mental health problems often occur together.
- Treatment approaches should consider the needs and engagement of other family members, including children, to improve outcomes for all those affected by an individual’s problematic alcohol or other drug use.
- There are effective withdrawal and replacement pharmacotherapies for some
substances, which can be important adjuncts to psychological treatments. - Current evidence-based psychological interventions include contingency management (but not so much for tobacco), CBT, and motivational interviewing
approaches. Other intervention approaches await evaluation. - Relapse is an expected part of the treatment process and relapse prevention should be routinely incorporated. Relapse prevention needs to focus on enabling clients to
identify and cope with risky situations for relapse. - It is important to recognise that alcohol and other drug problems occur in social and cultural contexts.
- This is best done through the adoption of a biopsychosocial approach
What does future treatment needs to improve on?
- 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
What are the 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
- Different beliefs associated with different drugs –> Based on personal experiences?
- Stigma is a barrier to accessing treatment ( Stigmatisation of drug use often means clients have often experienced judgemental approaches and rejection in the past)
What are the three general ethical principles of the APS code of ethics
- Respect for the rights and dignity of people and peoples, including the right to autonomy and justice.
- Propriety, incorporates the principles of beneficience, non-maleficience (including competence) and responsibility to clients, the profession and society.
- Integrity, reflects the need for good character & acknowledges the high level of trust intrinsic to professional relationships, and the impact of conduct on the reputation of the profession
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
Clinical decision making is based on evidence
Ethical decision making is based on respect, propriety, & integrity.
What are Forester-Miller & Davis five (5) Moral
Principles as the “cornerstone” of a healthy therapeutic relationship.
Autonomy
Justice
Beneficence
Non-maleficience
Fidelity
What is autonomy?
The principle that addresses respect for independence, and self-determination.
This principle allows an individual the freedom of choice and action.
It addresses the responsibility of the counsellor to encourage clients, when appropriate, to make their own decisions and to act on their own values.
There are two important considerations in encouraging clients to be autonomous.
First, helping clients to understand how their decisions and their values may be received within the context of the society in which they live, and how they may impinge on the rights of others. The second consideration is related to the client’s ability to make sound and rational decisions. People not capable of making competent choices, such as children and some individuals with mental disabilities, should not be allowed to act on decisions that could harm themselves or others.
What is justice?
Justice does not mean treating all individuals the same. If
an individual is to be treated differently, the counsellor needs to be able to offer a rationale that explains the necessity and appropriateness of treating the individual differently. An example of justice is that a counsellor would give a person who is blind a form that is in braille, or would go through the form with that individual orally, instead of giving him or her a standard written form to fill out. But the counsellor would treat him or her the same as any other client in all other regards
What is benefice
reflects the counsellor’s responsibility to contribute to the welfare of the client. Simply stated, it means to do good, to be proactive, and also to prevent harm when possible. Beneficence can come in many forms, such as prevention and early intervention actions that contribute to the betterment of clients
What is non-maleficence
Non-maleficence is the concept of not causing harm to
others. Often explained as “above all, do no harm,” this principle is considered by some to be the most critical of all
the principles, even though theoretically they are all of equal
weight. This principle reflects both the idea of not inflicting
intentional harm, and not engaging in actions that risk
harming others. Weighing potential harm against potential
benefits is important in a counsellor’s efforts toward ensuring “no harm.
What is fidelity
Fidelity involves the notions of loyalty, faithfulness, and
honouring commitments. Clients must be able to trust the
counsellor and have faith in the therapeutic relationship if
growth is to occur. Therefore, the counsellor must take care
not to threaten the therapeutic relationship or to leave
obligations unfulfilled.
Who is Duncan, Williams, and Knowles (2013)
Explored views of 264 Australian Psychologists
Case of a fifteen year old client using drugs and alcohol,
and a number of other concerns
Asked when they would breach confidentiality for different
drug types and use frequencies
APS Guidelines on Confidentiality
- Understand the legal context and the organisational requirements associated with confidentiality and limitations
e.g. Child safety requirements - Informed Consent
- Prior to treatment, ensure clients are aware of the limitations of confidentiality
- Consider the capacity of the person to provide consent (e.g. minors, intoxication, mandated clients etc…) - 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 the disclosure and only to individuals who require the information
- Where safety permits, psychologists inform clients:
- if their information is to be disclosed;
- about what information is to be disclosed;
- of the circumstances and the reasons for the intended disclosure of information; and
- to whom and when the disclosure is to be made
History of change facilitation - How did we used to get people to change their behaviour?
- ## Confront them for their “addictive personalities”/denial
- Key Skill in the old way was making them feel guilty – Coercion (shame, guilt, threats, force). However thisled to Resistance, argument, reduced change
- Shame, fear and coercion would demoralise the person and lead to higher rates of relapse
- Central role of ambivalence in the client - if the therapist takes the “stop using” stance, this forces clients into the “keep using” position and they then argue from this perspective
- “People are more likely to be persuaded by what they hear themselves say than by what other people tell them”
New Way – Motivational Interviewing
Five Important Assumptions
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
Centrality of Ambivalence
Ambivalence - central to addictive behaviours
- Awareness of risks, costs & harms
- Also attached and attracted to behaviour
Confrontation about adverse consequences
E.g. “Drugs are bad…”
Often results in argument
- E.g. “But, I really like being high”
Reinforces reasons for continuing
Stages of Change - Transtheoretical Model (Prochaska and DiClemente’s Wheel of Change)
Pre/Contemplation
Preparation
Action
Maintenance
Relapse
PRECONTEMPLATION - “Happy User”
Not planning to change in foreseeable future
Uninformed or under informed
“It isn’t that they can’t see the solution. It is that they can’t see the problem.”
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 (e.g. physical dependence, social affiliation, conditioned responses, self medicating, etc.
PREPARATION - Making a Plan for Change
Plan for action in next month
Open to information and support
May have made small changes
e.g. Cut smoking down by two
cigarettes a day
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 a 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
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
In practice, the stages of change are not usually linear and organised
Typically cycle back and forth several times
- 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 guilty
Spiral Pattern of Change
SEE pic
Precontemplation Contemplation Preparation Action
Relapse
Precontemplation Contemplation Preparation Action
Relapse
Preparation Action Maintainence
Relapse
Contemplation Preparation Action Maintainence
Termination
Matching Interventions to the Stage of Change
Precontemplation: and contemplation: in general, change processes traditionally associated with the experiential, cognitive, and psychoanalytic approaches, e.g., education and feedback (consciousness raising) and MI (self reevaluation and emotional arousal)
Action and Maintenance: Existential (e.g., self-liberation and will power) and behavioural approaches (i.e., practical) most useful
Maintenance: Behavioural approaches e.g., relapse prevention plan
What is Motivational Interviewing
A directive, client-centred approach for initiating
behaviour change by helping clients to explore and
resolve ambivalence
or
MI is a particular way of having a conversation about change so that it is the client rather than the clinician who voices the arguments for change
The 5 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 Motivational interviewing (PACE)
Partnership- A collaboration between the clinician’s
professional expertise and the client’s personal expertise in
their own life. Not expert/recipient but a partnership that utilises shared resources
Acceptance- includes empathy- the position of respecting the client’s autonomy, affirming their strengths, and valuing each person’s absolute worth as a human being.
Compassion- the intention to put the client’s best interests,
growth and welfare first
Empowerment- Eliciting the client’s wisdom, ideas, plans and
values
The Four Tasks of Motivational Interviewing
1. Engaging
2. Focusing
3. Evoking
4. Planning
What is engaging (in the four tasks to motivational interviewing)
- 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
OARS- The Engaging Skills of MI
Counselling micro-skills that are utilised:
O – Open ended questions 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 certainpoints
What is focusing(in the four tasks to motivational interviewing)
- 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
What is evoking (in the four tasks to motivational interviewing)
- 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 sessio
MI Evoking Skills
he goal here is developing “change talk” in favour of “sustain talk”
Recognise, Elicit and Respond to change talk.
Acronym to remember the four types of preparatory change talk: DARN
D- Desire (I want to feel less anxious)
A- Ability ( I am able to resist temptation sometimes)
R- Reasons (If I get arrested again I’ll lose my job)
N- Need (I need to keep my licence)
Mobilizing change talk signifies movement in the direction of change: CAT
C- Commitment (I am going to …)
A- Activation (I am ready to …)
T- Taking Steps (I bought a pair of running shoes this week
What is planning (in the four tasks to motivational interviewing)
- 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
These four processes are NOT a linear sequence, rather the
client can double back and repeat throughout the session
Advice in MI
Information and advice can be given in MI engagement,
however this needs to be done skilfully
Ask permission first e.g., “Would it be helpful if I told
you…”
Use autonomy supporting statements e.g., “You may or
may not agree, it’s up to you”
Offer small chunks of information in a sequence of
elicit-provide-elicit
Assessing Change
Change is difficult. It is important to not only know why change is important but to feel confident and ready.
Ratings of importance, confidence and readiness can
allow clinicians to assess how ambivalent or how prepared a
client is for 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
