This is the first 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 second installment of this series will focus on treatment strategies and will appear in our July 9edition. The author, an occupational therapist, is aqualified 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. Research suggests that substance abuse and/or dependence often go undiagnosed and unrecognized by rehabilitation professionals, even though they greatly reduce successful outcomes in rehabilitation. (Stoffel and Moyers, 2001)

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. Even minimal intervention can reduce the impact substance abuse has on treatment outcomes and increase the quality of life of people it affects.

Substance Abuse in the U.S.

According to a 2004 national survey on drug use and health done by the Office of National Drug Control Policy, 19.1 million Americans (7.9 percent) who were 12 years or older used drugs illicitly. In addition, 121 million Americans (50.3 percent) who were 12 years or older were current drinkers of alcohol, with 55 million (22.8 percent) admitting to binge drinking (defined by drinking five or more drinks at one sitting on at least one occasion in the last 30 days).

Heavy drinkers (defined by binge drinking at least five days in the prior month) accounted for 16.7 million Americans (6.9 percent). Of those 12 to 20 years old, 10.8 million (28.7 percent) drank alcohol in the 30 days prior to the survey, with 7.4 million (19.6 percent) binge drinking and 2.4 million (6.3 percent) drinking heavily. Pregnant women aged 15 to 44 reported past-month alcohol use at a rate of 11.2 percent and binge drinking at a rate of 4.5 percent in the month prior to the survey. (Sept. 8, 2005)

The 2004 survey reported that 22.5 million Americans (9.4 percent) who were 12 years and older met criteria for substance abuse or dependence. However, only 3.8 million of these people (1.6 percent of Americans) had been treated for drug or alcohol problems in the previous year. This left a staggering number of individuals in need of, but not receiving, treatment for their substance abuse problems.

Regular drug and alcohol abusers are more likely to be involved in accidental injuries, motor vehicle accidents and incidents of violent and aggressive behavior. In fact, approximately 20 percent of emergency room admissions, as well as 20 percent of all general hospital admissions, are alcohol-related. (Professional Practice Council of American Academy of Physician Assistants, 1996)

Drug and/or alcohol use is also involved in as many as 79 percent of injuries requiring rehabilitation. (Hubbard, Everett and Khan, 1996) The increase in violent and aggressive behavior among substance abusers contributes greatly to child abuse and neglect in U.S. homes. (Professional Practice Council of American Academy of Physician Assistants, 1996)

For the purpose of simplicity in the remainder of this article, I'll use the term "substance abuse" as a global term to include substance dependence. This is reasonable because the end result of both abuse and dependence is some form of occupational dysfunction.

A Theoretical Approach

Current practice in the treatment of substance abuse is grounded in the Transtheoretical Model of Change (TMC), which was pioneered by Prochaska and DiClemente in the late 1970s while working with smoking cessation. The TMC describes five distinct stages that categorize the process of change:

1.precontemplation,

2.contemplation,

3.preparation,

4.action, and

5.maintenance.

In the pre-contemplation stage, the individual is either unaware or unwilling to recognize that a problem exists. In the contemplation stage, he recognizes that it does exist and considers options to address it. Next, he prepares by deciding on and developing a strategy to address the problem. Putting that plan into motion follows, but he must successfully continue to use that strategy for at least three to six months in order to achieve maintenance.

Eventually, when the change is fully integrated into the lifestyle of the individual, the process is said to terminate. (DiClemente and Prochaska, 1998)

While the stages of change are described linearly, the process is cyclical, with regression to an earlier stage possible at any time. Regression is considered a normal part of the process, so individuals may progress to any stage, regress to any prior stage, and then begin progression again from that stage. They may accomplish specific tasks within a given stage very quickly or may take extremely extended periods of time to reach the next stage. "Because the substance use disorder often took years to develop, it is recognized that change may take years to fully occur." (Moyers and Stoffel, 2001, p. 326)

An individual may be at multiple stages at the same time in regard to different problems. For instance, she may be in the pre-contemplation stage in regard to alcohol abuse while simultaneously being in the action stage in regard to methamphetamine use, even though the alcohol abuse may be causing significant impairment in function. (DiClemente and Prochaska, 1998)

Using MOHO

The TMC can be viewed through the lens of the Model of Human Occupation (MOHO) quite effectively. Within MOHO, the concepts of volition, habituation and performance capacity are central to understanding human occupation. (Kielhofner, 2002)

Three factors are involved in volition: personal causation, values and interests. Personal causation is an individual's "...sense of competence and effectiveness...," while values refer to things an individual "...finds important and meaningful to do...;" interests "...refers to what one finds enjoyable or satisfying to do." (Kielhofner, 2002, p. 15)

People use volition to navigate the world by anticipating, choosing, experiencing and interpreting daily life activities. Habituation is the preset pattern of responses individuals develop in order to automatically answer repeated patterns of temporal, physical and social environments without needing to think consciously or make a new decision. Individuals' performance capacity is bounded by their physical and mental resources and their analogous subjective experiences. (Kielhofner, 2002)

Substance abuse can begin as an attempt to satisfy an unmet nee, such as providing temporary stress relief from difficult relationships or financial problems, or it may be an artificial means to achieving pleasure because the individual's roles and routines are not providing satisfactory pleasure experiences. (Helbig and McKay, 2003)

Substance abuse temporarily addresses the need and becomes habituated when the individual routinely turns to substances to meet the same unmet needs.

In further application of the concepts of MOHO to the TMC, pre-contemplation can be seen as a lack of valuing changing a behavior or a strong interest in maintaining the status quo. An individual who engages in substance abuse is in pre-contemplation because that person has no interest in quitting, but rather has an interest in continuing to use. The substance abuse has become habituated, and her performance capacity is lacking for changing the behavior. Helping her recognize that the unmet need persists despite the substance abuse response, and that there are negative aspects to the behavior (such as difficulty with specific relationships or a lack of goal achievement in the face of otherwise strong effort) can facilitate her move toward contemplation.

A person in the stage of contemplation develops interest in quitting because her values change and she considers the benefit of another strategy to address unmet needs. However, she has not developed sufficiently strong personal cause and performance capacity to take action and break the habituation. During contemplation, she is struggling to reconcile previous attempts to quit with the anticipation of the difficulties this means, and interpretations of the pros and cons of changing the behavior in relation to her temporal, physical and social environments.

At this stage the goal of intervention is to increase her interest in achieving control over the substance abuse by helping her to appreciate abstinence from it, or at least the reduction of it in her life.

In the preparation stage, the individual has internalized the value of abstinence but may still lack some personal cause. Substance abuse is still a habit, and she lacks the capacity to address unmet needs in a healthier manner. The goal in this stage is to increase her capacity to do that.

When the individual attains sufficient volition to make the needed change and break the substance abuse pattern, she needs to increase her performance capacity in the replacement skills to a level high enough to overcome the habituation. When she has done that to a level that is beginning to be more stable, she can maintain it by building successful experiences and developing further resources to sustain the change.

Although a client may habituate new behavior, the environments in which he or she lives and engages will continue to contain incentives to return to substance abuse. Clients must be prepared to withstand these challenges. The goal in terminating the process is to ensure that clients have sufficient resources readily available.

References available at www.advanceweb.com/OT or 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. He is a 1997 graduate of Pacific University School of Occupational Therapy and is currently working on his OTD at Creighton University, expecting to graduate in December.