By Sarah Ford, Freelance Journalist
A CLIENT arrives for her first counselling session and reveals that her regular heroin use is playing havoc with her relationships. What do you do? Say her behaviour is dangerous and that she should stop using? Immediately refer her on?
Both of these reactions are common amongst psychologists who often hesitate when a client presents with alcohol and other drug (AOD) issues. The common view is that substance users can be 'difficult' and intervention requires special skills.
But psychologists do have the basic skills required to effectively help people with AOD-related problems, says Helen Mentha, Convenor of the APS Interest Group on Psychology and Substance Use.
She says AOD work essentially involves helping people change their behaviour, a core skill of psychologists. "We sometimes feel we don't have the expertise to help the person change their substance use, forgetting that it's not so much about what they want to change; it's the process of how people make change that is at the heart of most of our work."
This is also a key message in the APS Discussion Paper, Psychology and substance use: Potential contributions and professional training needs, which was produced early this year. The paper, written by the APS Working Group on Substance Use, states that psychologists' core competencies are adequate to intervene effectively in AOD-related issues, provided they are extended to specifically apply to the AOD field.
The authors acknowledge that psychologists have contributed much to the area, but they also argue there is room for more involvement at all levels, including education, prevention, treatment and policy.
The paper is one of a few AOD publications that the APS is producing on the topic this year. An AOD Tip Sheet was published in June to provide a practical and accessible resource to the wider community, and a Position Paper detailing psychological approaches to AOD issues is due out later this year.
Helen Mentha is a clinical psychologist working as a drug and alcohol counsellor in Melbourne. She says that when a client presents with an AOD-related problem, some psychologists get distracted by the drug and focus on it, rather than on the person using the drug.
"Unfortunately some of our clients have reported seeing psychologists, who may have been well meaning in their approach, but the client felt that they were not being treated as a person; the drugs dominated, particularly if the drug use was risky," she says.
The result can be a missed opportunity to help someone who, like most other clients, is basically trying to meet a healthy, normal need, such as soothing painful feelings.
"Substance use is usually a solution to other deeper needs. If you take the substance use out - without replacing it with other, more sustainable ways to meet that need - it leaves an opportunity for them to just fall back into substance use," Helen says. "Alcohol and other drug use can't realistically be isolated from other areas of human experience."
The Discussion Paper states that AOD issues are widespread in the community, but substance misuse is more common amongst people with mental health disorders and problems and comorbid AOD issues can seriously affect treatment efforts.
"While we require more knowledge in the area of dual diagnosis, psychology's specialist knowledge of mental health issues and behaviour change ideally places it in a position to make significant contributions to this complex area," Helen says.
Knowing how to work with someone who is struggling with a history of sexual abuse, or coming out of their first psychotic episode, cannot be learnt in an AOD introductory course, Helen says.
"What a lot of our clients need are professionals who have a very well informed, evidence-based approach to very complex psychological difficulties," she says.
Barriers to psychologists' involvement
Psychologists may avoid working with AOD issues for numerous reasons. These include unfamiliarity with AOD issues and a belief that specialist skills are necessary, stereotypical views that substance users are difficult to work with and that relapse is common, and a belief that referral is the most appropriate response.
Helen says an intimate knowledge of the area is useful but not necessary. Consulting another psychologist or asking a client to explain a point is everyday practice for psychologists. "We know how to ask questions when we don't know something," she says.
It is more important to be genuine and respectful to the client than have expertise, especially as the stigmatisation of drug use often means the client has experienced judgmental approaches and rejection in the past. At the same time, it is important to be aware of your limits, consult with AOD specialists and refer when necessary.
Helen says another barrier is the popular yet misinformed notion that you need to have experienced substance use or abuse to understand it. "That's like saying you have to have experienced panic disorder to assist someone to cope with their own panic attacks - it might be helpful, but it is not essential and of itself does not guarantee the client's needs will be met."
Substance use interventions
A biopsychosocial approach to AOD issues is essential, says Dr Debra Rickwood, Convenor of the APS Working Group on Substance Use and Senior Lecturer in the Centre for Applied Psychology at the University of Canberra. "This makes psychologists well equipped to provide various treatments and modify those approaches as the person's needs change," she says.
"The challenge and the way forward is to work with multidisciplinary teams that see the complexity of substance misuse, and where people are seen holistically," Debra says.
The amount and quality of research in AOD treatment and prevention has increased substantially in the past decade and a half, providing a broad knowledge base to draw on.
Key knowledge and skill areas that are generally not taught in postgraduate training programs include understanding and applying the Transtheoretical Stages of Change model (Prochaska & DiClemente, 1984) and the technique of Motivational Interviewing, which can be integrated into various intervention approaches.
Concepts of harm minimisation and strategies for harm reduction are equally important. Harm minimisation focuses primarily on reducing harm, not use. It is not in conflict with abstinence, despite some misconceptions, but rather the aim is to find immediate and achievable goals to reduce harm - including the availability of options for users who can not be expected to stop currently.
Efforts have also been made to help those who are about to, or have just started, misusing substances. But this relies on appropriate screening tools and, although some have been developed, such as brief questionnaires that GPs administer, there is a lack of reliable and valid methods to assess people that may require early intervention.
Debra says little is known about how to identify young people at risk and divert them. One problem, particularly in the area of illicit drug use, is how to help young people who are experimenting with drugs in a way that doesn't label them and push them further down the drug-using path.
"For example, taking young people and putting them in programs with established drug users often does a lot of damage," she says. "It provides modelling and learning and gets them in with an even stronger drug-using peer group culture."
Prevention and education
There is a similar lack of knowledge in the area of AOD prevention and education. Prevention programs have generally focused on education about the harmful effects of substances, and controlling and reducing supply. But there is controversy about the success of such programs, including evidence that some strategies have been associated with increased drug use.
"We really don't know how to prevent young people starting to use drugs," Debra says. "They have more and more drugs available to them and there seems to be an increasing uptake of them."
Drug education programs risk normalising and providing modelling for substance use behaviour, she says. "But you can't say nothing, because it is equally dangerous for young people to be uninformed."
There have been suggestions that prevention approaches should shift the focus from drug education to building up healthy behaviours and resilient processes in young people.
There is also some preliminary evidence about the benefits of increasing young people's self-efficacy, such as developing skills on how to "say no".
As with treatment and early intervention, psychologists are well placed to develop and evaluate evidence-based preventive interventions that include a biopsychosocial perspective on behaviour and behaviour change.
The Discussion Paper reports that internationally Australia is considered a leader in AOD interventions, research and policy, mostly due to our early adoption of a harm minimisation approach.
Our establishment of needle exchange programs in response to HIV is an example. The decriminalisation of personal cannabis use in some states also shows a willingness to trial more liberal approaches than many other countries.
Debra says that compared with the United States, for example, where a moral and zero tolerance approach dominates, "we are a more tolerant society and have been prepared to have more options".
But policy does not always translate to practice. Substance users continue to be demonised in Australian society, particularly users of illegal drugs. Until AOD is treated as a health and social issue, there will still be problems moving forward, Debra says.
A professional, legal and ethical approach
Working with substance users can raise unique moral, ethical and legal issues that challenge assumptions and boundaries. It is important for psychologists to be aware of this stigma and how it might affect treatment of a client. For example, many people will struggle to maintain compassion when a client is drink driving and risking the lives of others.
Helen Mentha says that it is OK not to like someone's behaviour, but that doesn't mean you take the next step to judge them as a whole person. "You can treat the person with respect while having reservations about how appropriate their behaviour is. Remembering that the information a client provides is always limited and not to make assumptions about them is also vital."
Helen says that is hard to balance protecting the therapeutic relationship, which might itself be quite fragile, with the need to protect other people, and where possible, trying to address the risks to others.
Ending the therapeutic relationship doesn't necessarily stop the person from continuing their risky behaviour, but it does end the opportunity to help them to change that behaviour.
Another challenge of working with substance users occurs when clients arrive intoxicated for a session. This may at times be a way of testing the counsellor, and although from the outside the client may seem impaired, being intoxicated may be their more familiar, functioning state. If the client is still able to engage, it is possible and often beneficial to continue with the session, if only in a limited way, Helen says.
For all the complexities AOD work can raise, Helen says it is a stimulating area to work in. Her clients cover most of the major mental illnesses, personality disorders, acquired brain injury, trauma, plus all the normal range of difficulties with self
worth, identity, relationships and so on.
The only difference is that they happen to be using alcohol or other drugs to meet their needs, while other people might use a different solution, such as immersing themselves in work or maintaining unhealthy relationships.
"What also makes the drug and alcohol area so interesting is all the other layers involved," Helen says.
"You've got the clinical work, research, the legislation and policy level, the moral level and the stigma attached to it," she says. "You are never bored".
The Substance Use Position Paper is available at www.psychology.org.au/publications/inpsych/substance_abuse and Tip Sheets are available to order from the APS National Office, phone (03) 8662 3300.
Each state and territory provides a 24-hour drug information and counselling phone line.
Prochaska, J. O., & DiClemente, C. C. (1984). The Transtheoretical Approach: Crossing the Traditional Boundaries of Therapy. Malabar, FL: Krieger.