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By Dr Peter Kelly MAPS
Clinical psychologist in private practice and Project Coordinator, Illawarra Institute for Mental Health, University of Wollongong

Individuals experiencing alcohol and other drug (AOD) problems have typically been under represented within private practice. For example, in the general population the prevalence of substance use disorders (7.7%) is comparable to that of anxiety (9.7%) and affective disorders (5.8%; Andrews, Hall, Teesson & Henderson, 1999). However, a recent APS survey showed that while 48 per cent of people treated by psychologists under the Better Access initiative presented with anxiety or depression, only 6 per cent presented for assistance with substance misuse problems (Giese, Littlefield & Mathews, 2008). Recent changes to the Medicare system have largely reduced financial barriers, presenting an opportunity for private practitioners to play a more active role in AOD treatment. This has the advantage of expanding the range of substance misuse services and increasing client choice. With psychologists commonly reporting reluctance to work with substance misuse problems (Miller & Brown, 1997), this article provides a description of the role that private practitioners can play in addiction treatment.

The role of private practice

There is an opportunity for private practitioners to complement specialist substance misuse services or target those individuals who do not typically access these programs. For many people, the perceived stigma associated with attending a psychologist will be substantially less than that associated with attending traditional AOD services. Specialist substance misuse services often require the client to be sufficiently ‘ready' for treatment, often resulting in the person not attending or dropping out in the early stages of these programs. Private practitioners have training in a range of motivational strategies that prepare them well to support clients to identify their own treatment goals, plan further activities and access other specialised substance misuse programs as required. Additionally, specialist AOD programs typically focus on individuals with more severe substance misuse problems, often at the exclusion of people with less severe problems. Private practitioners are well suited to work with people in the early stages of problematic use or with individuals who are still functioning relatively well (e.g., currently employed).

What do psychologists have to offer?

Private practitioners have not traditionally promoted themselves as being able to work with AOD problems. For example, 87 psychologists in the Illawarra and Sydney regions have a Yellow Pages advertisement that describes the range of clinical problems they treat. Only seven (8%) of these private practitioners specify that they work with substance misuse problems. With university training in the assessment and treatment of substance misuse being highly variable, it is likely that many psychologists feel poorly prepared to work with this population (Harwood, Kowalski & Ameen, 2004; Miller & Brown, 1997). However, most private practitioners are well equipped to work with AOD problems in their practice. Research examining client outcomes in addiction treatment has consistently demonstrated the primary importance of the therapeutic relationship. Engagement in the initial stages of counselling is essential to maintain the person in treatment. This is primarily facilitated through a warm, trusting and non-judgmental approach, where the person feels comfortable to discuss their problematic behaviour (Washton, 2001). These are the same skills that most private practitioners would use for all clients attending their practice. Similarly, private practitioners are extremely well placed to work with co-occurring mental health problems. Psychologists have the advantage of being able to provide an integrated approach, where both the person's mental health and substance misuse problems are addressed concurrently in treatment.

Screening for substance misuse

As part of all initial assessments, private practitioners should routinely screen for the presence of AOD problems. At a minimum, this should involve asking all clients if they have ever misused drugs or alcohol as a component of the initial assessment interview. Where a person indicates that they may have problems, follow-up should examine the degree of their substance use. This would include identifying the types of substances used, and exploring the amount (e.g., total standard drinks) and frequency (e.g., days per month) of use. This information can then be used to track progress. Substance misuse problems rarely occur in isolation. It is important to use a holistic approach to assessment that examines the person's individual needs and how the substance misuse impacts on the rest of the person's life. This should include examining mental health, family relationships, work functioning, physical health and possible legal problems.

Intervention strategies

The Stages of Change model (Prochaska & Norcross, 2001) provides an extremely useful way to conceptualise a client's desire to tackle problematic substance misuse. It proposes that people progress through a series of stages as their desire and motivation to change increases. A common mistake made by many health professionals is to assume that because the person has turned up for treatment, they are in the ‘Action' stage. People often attend private practitioners for a range of ‘other' problems and although they may admit to misusing substances and may view this as problematic, this does not necessarily mean they are ready to make a change. Thus, it is extremely important that assessment and intervention strategies target the person's readiness to change (see Table 1). It is also important to consider that the individual may be at different stages for different problems. For example, they may be in the ‘Action' stage regarding their amphetamine misuse, although still in the ‘Pre-contemplative' stage regarding their drinking.

The types of intervention strategies used with substance misuse problems are very similar to approaches psychologists would use with other health-related problems. When the individual is in the early stages of change, Motivational Interviewing is used as the primary tool to increase the person's motivation. As people move into the ‘Action' stage, problem-solving strategies are used to develop practical behavioural skills to manage cravings and associated high-risk situations. Cognitive approaches are used to highlight and challenge permissive substance misuse thoughts. Additionally, relapse prevention planning is used to assist the person to maintain the positive change. Family support is encouraged throughout the person's treatment. There are several evidence-based treatment manuals available online that elaborate on these interventions and may be useful for private practitioners (e.g., Carroll, 1998).

Stage  Description  Examples of intervention strategies 

Pre-contemplation 

Unaware of the problem or not considering change 

Aim: Raise consciousness

  • Motivational Interviewing
  • Harm minimisation 

Contemplation 

Becoming aware, but still undecided about change 

Aim: Consider costs and benefits

  • Increased awareness through Motivational Interviewing
  • Decisional balance to explore costs/benefits 

Preparation 

Starting to take steps to change 

Aim: Increase commitment and develop plan

  • Individualised change plan development
  • Self efficacy promotion
  • Social support assistance 

Action 

Engaging in change behaviours 

Aim: Commence change plan

  • Behavioural strategies to manage cravings
  • Social skills training 

Maintenance 

Consolidating gains 

Aim: Maintain successful change

  • Relapse prevention strategies
  • Problem solving regarding difficulties 

 

Collaboration and referral

There are a range of specialist AOD services available in the community. These include detoxification, rehabilitation and pharmacotherapy services, and self-help groups. Private practitioners should be aware of the services available in the local area and continue to provide clients with a choice regarding further treatments. For example, self-help groups are likely to provide valuable social support for many people (e.g., Alcoholics Anonymous, Self Management And Recovery Training [SMART] groups). In relation to the physical health of the person, it is important that the private practitioner works collaboratively with their client's general practitioner. In particular, when a client is referred under a GP Mental Health Care Plan there should be liaison with the general practitioner when planning detoxification.

Conclusion

Changes to the Medicare system have the potential to increase the range of treatment options available to people with AOD problems. While psychologists have reported a lack of confidence working in this area, it is likely that most private practitioners currently have the skills to work quite successfully with individuals who have substance misuse problems. There is certainly need for such services in the community and it is likely that the more psychologists provide services to people with substance misuse problems, the more their confidence will grow. n

The author can be contacted on pkelly@uow.edu.au.

References

Andrews, G., Hall, W., Teesson, M., & Henderson, S. (1999). The Mental Health of Australians. Mental Health Branch, Commonwealth Department of Health and Aged Care.

Carroll, K. M. (1998). A cognitive - behavioral approach: Treating cocaine addiction. Maryland, United States: U.S. Department of Health and Human Services. Available online from www.drugabuse.gov/txmanuals/cbt/cbt1.html.

Giese, J., Littlefield, L., & Mathews, R. (2008, June). Survey of members providing Medicare-funded services under the Better Access initiative. InPsych, 30, 36-37.

Harwood, H. J., Kowalski, J., & Ameen, A. (2004). The need for substance abuse training among mental health professionals. Administration and Policy in Mental Health, 32, 189-205.

Miller, W. R., & Brown, S. A. (1997). Why psychologists should treat alcohol and drug problems. American Psychologist, 52, 1269-1279.

Prochaska, J. O., & Norcross, J. C. (2001). Stages of change. Psychotherapy, 38, 443-448.

Washton, A. M. (2001). Private practice of addiction psychology. Available from www.apa.org/ppo/issues/washton303.html.