This is the second installment in a two-part series that looks at how OT practitioners can add simple procedures to their routine that will aid substance abusers in their recovery. The first installment of this series focused on theoretical approaches to substance abuse and appeared in our June 25 edition. The author, an occupationaltherapist, is a qualified mental health practitioner (QMHP).
It is very likely that, on a regular basis, OTs and OTAs will encounter people with active substance abuse or dependence, or people somehow affected by these problems. So regardless of practice arena, OTs and OTAs should be knowledgeable about how to influence an individual's substance use and how to access local resources for assistance, whether those practitioners are working with children whose parents are substance abusers, pre-teens and teens who are substance abusers themselves, or adult substance abusers.
Evaluation and Intervention
Doing an occupational profile can help OT practitioners determine what stage of change a client may be in regarding substance abuse and therefore guide intervention. The profile describes the client and articulates his concerns regarding ability to perform daily life activities and engage in occupations. It outlines areas of success and difficulty, contexts that are supportive and inhibiting, life experiences, values and interests, occupational patterns, and the client's priorities and desired outcomes. (AOTA, 2002)
In order to determine the need for intervention specific to substance abuse, clinicians should incorporate some type of screening into the regular profile and plan of treatment in any setting by interviewing the client regarding health behaviors with a tool such as the CAGE questionnaire. Ewing, (1984) one of the two originators of the CAGE, identifies it as consisting of the following questions:
Have you ever felt you ought to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?
Answering positively to two or more questions on the CAGE indicates a need for intervention. The CAGE can easily be modified to include potential abuse of other substances (CAGE-AID) by adding the phrase "or drug use" to each issue. (Martin & Bonder, 2004)
After development of the occupational profile, the therapist can begin to analyze occupational performance to determine factors influencing substance abuse. Occupational performance consists of "?the complex and dynamic interaction among performance skills, performance patterns, context or contexts, activity demands and client factors rather than any one factor alone." (AOTA, 2002, p. 617)
Identification of specific factors, as well as the intersection of factors, that precede substance abuse may give valuable clues as to what types of interventions may be most helpful in treating substance abuse. The focus of intervention may be on modification of the context, development of client performance skills, change in the demands of an activity, or change in patterns of performance depending on the specific needs of the individual client. (AOTA, 2002)
"Brief interventions are those practices that aim to investigate a potential problem and motivate an individual to begin to do -something, either by client-directed means or by seeking additional substance abuse treatment." (Barry, 1999) Brief interventions have been found to be practical, cost effective and useful in multiple settings for producing change in substance abuse behaviors.
The primary goal of any brief intervention is to facilitate progress through the stages of change by matching services to the client's current stage of change. For example, OTs or OTAs address pre-contemplation (the individual is either unaware or unwilling to recognize that a problem exists) by helping the client to discover and acknowledge that the substance abuse is a problem by recognizing the incongruence in his/her perception as compared to the actual performance outcome.
Through this process, the OT or OTA assists the client in moving toward contemplation (the individual recognizes the problem does exist and considers options to address it).
Brief interventions can be identified by the mnemonic FRAMES. The OT or OTA provides Feedback to the client regarding potential problems resulting from substance abuse; Responsibility for changing behaviors as belonging to the client; Advice on how to change through a Menu of options, provided in an Empathic manner. This empowers the client with Self-efficacy. (Barry, 1999; Miller, 1999; Moyers & Stoffel, 2001)
Kielhofner (2002) identified strategies for enabling change that are quite similar to the FRAMES mnemonic. He identified validating the individual, identifying potential areas of change, giving feedback, advising, negotiating, structuring, coaching and encouraging as primary strategies employed through the use of the Model of Human Occupation (MOHO) to enable change in clients.
Validating means giving respect to the client's personal perspective based on his life experience. The OT or OTA helps the individual to identify potential areas for change through feedback and advice in regard to potential interventions.
The OT or OTA negotiates a menu of options with the client based on the individual's particular situation and then helps to structure a plan of action based on the individual's preferences. Once a plan is agreed upon, the OT or OTA coaches the client in an empathic manner and encourages self-efficacy through emotional support and reassurance.
Brief interventions may be provided during face-to-face interactions, by phone or in written form. They should be non-confrontational in nature, be fact driven, provide choice and reinforce confidence in the client's ability to instigate change.
A client's resisting participation should be interpreted as a reflection of her stage of change, and the OT or OTA should adjust accordingly. (Miller, Zweben, DiClemente, Rychtarik, 1999) Therapeutic activities that are not well-matched with the participant's stage of change lead to decreased -effectiveness of therapy and increased frustration experienced by both the OT or OTA and client. The end result of poorly matched therapeutic approaches can dramatically hinder therapeutic relationships and can have a lasting impact on the quality of life of the client.
Miller (1999) summarizes the application of brief interventions to the Transtheoretical Model of Change (TMC) as follows:
To encourage change, individuals in the pre-contemplation stage must increase their awareness.
To resolve their ambivalence, clients in the contemplation stage should chose positive change over the status quo.
Clients in the preparation stage must identify potential change strategies and choose the most appropriate ones for their circumstances.
Clients in the action stage must carry out change strategies. This is the stage toward which most formal substance abuse treatment is directed.
During the maintenance stage, clients may have to develop new skills that help maintain recovery and a healthy lifestyle. Moreover, if clients resume their problem substance use, they need help to recover as quickly as possible and reenter the change process. (Tailoring Motivational Interventions to the Stages of Change section, para. 2)
Potential interventions are summarized and matched to stage in Table 1.
Twelve-Step and Secular Self-Help
Self-help groups for substance abuse are often said to have formally begun with the development of Alcoholics Anonymous (AA) in 1935. AA membership has been estimated to have grown to more than 100,000 groups with more than 2 million members in at least 150 countries as of 2006. (Alcoholics Anonymous World Services, 2006) There are now many groups based on the basic principles of AA, including Narcotics Anonymous (NA), Cocaine Anonymous (CA), Dual Diagnosis Anonymous (DDA) and many others.
Seppala (2001) recommended that, "due to the prevalence of the addictive disorders, all clinicians should have a working knowledge of the Twelve Steps" In addition, clinicians may greatly benefit from becoming acquainted with the Twelve Step groups in their areas by attending at least one open meeting. Open meetings are available to anyone interested in AA, with no further requirements for participation. Information regarding AA can be found at http://www.aa.org.
Many secular self-help groups have emerged in the last half-century as an alternative to the spiritual approach of Twelve Step Groups, including LifeRing, Secular Organizations for Sobriety (SOS), and YES Recovery. Information regarding these alternatives and others can be found at http://www.health.org under "Resources."
Conclusions and Recommendations
The TMC is very compatible with OT theory and practice. Through the use of brief interventions and support of self-help strategies, occupational therapists can help clients move toward habituation of change in their daily lives. By providing treatment that matches the client's stage of change and promoting movement through the stages, OTs and OTAs can make the best possible use of treatment time, promote the best possible outcomes and improve the quality of life for those they serve.
References available at www.advanceweb.com/OT and upon request.
Sean Roush, OTR/L, QMHP, works in the Yamhill County Abacus program in McMinnville, OR, a psychosocial, psychoeducational, and vocational treatment program for individuals diagnosed with serious and persistent mental illness.
For More Information...
For a more thorough discussion of sample interventions, visit us online at www.advanceweb.com/OT for "Substance Abuse and OT: Sample Interventions to Use with Clients." This supplemental feature gives specific examples of interventions that OTs and OTAs can use with clients in each of the Transtheoretical Model of Change's stages.