How to talk about substance use

Where do I start?• If you don’t know much about alcohol and other drugs you may feel

cautious about talking to people about their use of them.

• Think again – put it into perspective.

• If someone was talking to you about a newly diagnosed health condition or some new medication they were taking and you didn’t have a clue about it, what would you do?

• Hopefully, you’d ask questions to explore what it was, what effect it had on them and so on.

You don’t have to be an expert

• In some professional roles, a person’s substance use may require you to raise concerns about their health and well-being, or that of dependent family members. Even then, you need to start by listening to them and then asking them if they have any concerns about their use.

• Talking to someone about their alcohol and other drug use does not require you to be an expert. It requires you to have a conversation which draws out their expertise by talking with them about their experience.

You don’t have to be an expert (cont.)

• In the following clip, Addictions Consultant and Trainer, Trevor McCarthy identifies how a lack of knowledge of substance use does not have to stop you from having a conversation.

• In this film clip, advanced practitioner, Vicki Ellis, from the SWIFT family service offers advice on how to talk about substance use .

• This resource will help you to consider how to go about talking to someone about their substance use and some of the skills and techniques you can use.

Remember!

This is about having a conversation

first and foremost.

Don’t make this a bigger issue than it is.

In the following clip, Trevor McCarthy talks about how to ask questions with confidence.

Initial considerations(Galvani 2012)

• There is a huge amount of stigma and stereotyping that surrounds substance use and people who use substances problematically.

• This can act as a barrier for people to disclose substance use, particularly if they think their substance use is becoming problematic in some way.

• Your job is to overcome that barrier, or hurdle, in the (often short) time you have.

• Consider how this will be done – consider what you would want to see or hear from a health or social care practitioner if you were in their shoes?

Engagement(Galvani 2015)

• No matter how little or much time you have, the key to supporting people is the relationship you manage to build with them in the time you have; effective engagement with the person is vital.

• If you needed support from someone or had to disclose something private, or perhaps embarrassing, on what basis would you quickly judge the person?

• We would probably hope to see a number of human qualities very quickly, e.g. warmth, compassion, a genuine interest, friendly manner, evidence that the person is actually listening to us.

Engagement (cont.)• The key to engagement is the extent to which you can communicate

well with people in a range of contexts.

• Your communication skills need practice – they should not be taken for granted.

• One communication style that is seen as the ‘gold standard’ is Motivational Interviewing (Miller and Rollnick 2012).

Communication style• Motivational Interviewing (MI) is evidence-based communication style

(Miller and Rollnick 2012).

• To be a proficient MI practitioner takes time and training, but the skills, techniques, and spirit of MI, should underpin everyone in the helping professions. Some of the techniques include:– Asking open questions, listening; reflecting; affirmation;

summarising; informing and advising with permission

• The practitioner’s role is to guide conversations; they adopt a “middle ground” between directing conversation and following it/ just listening. It is not about telling people what to do, nor is it about being passive.

• “MI is about arranging conversations so that people talk themselves into change, based on their own attitudes and values.” (p4)

MI in practice• At MI’s core is the assumption that people are

often ambivalent about change; MI accepts, and works with, that ambivalence.

• In the following film clip, one of the originators of MI, Professor Stephen Rollnick, talks about the importance of engagement (even when you have little time).

• There are four key processes to MI:1. engaging, 2. focussing, 3. evoking, 4. planning.

In this film clip Professor Stephen Rollnick talks about need to focus on listening to enable the client to reach their goal.

Asking people about substance use

• Professionals can get stuck on what questions to ask. This will depend on:

What point in/type of assessment is it, ie. is it part of a comprehensive assessment, a brief triage assessment, first telephone discussion, or the main focus of the visit?

What you’ve asked/know already, e.g. from your service user/patient or from family members or professionals.

What stage they person is at in relation to changing their substance use behaviour.

The following slide illustrates the Stages of Change model that can help you to reflect on how ready the person appears to be to change - the model can also be a tool for discussion with the person.

Stages of change

Stages of change (cont.)• The stages of change model is a way of understanding the

process of behaviour change.

• It is part of a model called the Transtheoretical Model of Intentional Human Behaviour Change (TTM) (Prochaska and DiClemente 1983).

• Change is viewed as a progression from precontemplation, to contemplation, to preparation for change.

• If successful, the next stages are action and maintenance.

Stages of change (cont.)

• What is most helpful in talking to people about their substance use is identifying which stage of change a person is at.

• This can indicate which motivational strategies to use when talking to the person.

• TTM suggests cognitive processes of change come earlier in the change process while behavioural change comes later.

• The following slide looks at each stage in greater depth and provides ideas about the types of questions or topics for conversation that may be appropriate in each one.

How to assess/intervene (Galvani 2012)

• Denying there’s an issue (pre-contemplation)

– This is about raising the issue/stating your concerns/offering support/“discuss again soon” …or crisis intervention! However, tone and manner is important.

– In this film clip, addictions consultant and trainer Trevor McCarthy discusses what to do when people minimise problems.

– Never get adversarial: when you feel like you’re arguing, you have gone very wrong!

How to assess/intervene (cont.) Always watch your tone. Be aware of your body language. Reflect back what is being said to you to prove you’re still listening. State carefully and clearly your thoughts and concerns (as appropriate). Reiterate your willingness to support the person. Remain empathic and genuine.

• Social and health care professionals often report that parents using substances minimise or deny having a problem with substances (pre-contemplative).

• Listen to Vicki Ellis, Advanced Practitioner with the SWIFT family service, offering advice on how to talk to parents about their substance use who may resist disclosure.

How to assess/intervene (cont.)• Thinking about change (contemplation)

This would include motivational questions – “what would be some of the benefits of changing your drug use” /decisional balance – asking about pros and cons of change (with more emphasis on pros!)/providing information if the person wants it/delivering brief interventions (see later in this resource)

How to assess/intervene (cont.)• Doing/nearly doing something to change (action)

Encouragement – “sounds like you’ve given this a lot of thought and made a really good decision, how can i help?”/practical support, eg. care for children during appointment at specialist/make referral/supporting them to appointment/providing information/follow up calls or contact/positive encouragement/joint working with specialist and appropriate others/ looking ahead with the person/organising other support and/or referrals.

How to assess/intervene (cont.)• Helping people to talk about their drinking is about asking the right

questions - in the right way. Tone of voice and an empathic approach are crucial.

How does your drinking help you? Does drinking ever cause problems

for you? Would you like to change your drinking? Have you successfully made changes

before? How confident are you that you could

change your drinking if you wanted to? What help do you need to change?

How to assess/intervene (cont.)• Relapse/returning to problematic levels of use

– People often feel a failure, ashamed and hugely embarrassed when they relapse. They can often be met with disdain, dismissal and an “I knew it wouldn’t last” attitude. This will serve to de-motivate them further.

– Your role is not to collude with those attitudes. It is to remain optimistic and strengths focussed and draw out the positives in the person’s actions.

– You can still reinforce how well they had done previously, followed by questions about what worked/didn’t work before/what led up to the relapse/why did you stop/cut down before/ what would make you try again/what are some alternatives to drinking/using

– Keep focussed on motivational questions.

How to assess/intervene (cont.)• Maintenance/maintaining the changes

– People often report that maintaining the change they’ve made is the hardest part. Services and support will often disappear and the person is left thinking ‘am i strong enough to do this on my own’.

– When crises occur they may fear relapsing. Don’t assume people don’t need support because they’ve made the change.

– Conversation with people at this stage should be encouraging and include the positives that have come from their decision to change.

How to assess/intervene (cont.)Maintenance/maintaining the changes (cont.)

• It can also include discussion on whether and how they have identified their risk factors for relapse and discussion about what strategies they have in place to cope with those risks.

• An important component of maintenance is also checking out whether the person has positive social support – if not, you can help them identify who that might be.

• You can also check out whether they have employment/training/ meaningful activity each day to stop them getting bored and providing them with a focus other than their substance use.

Practice examples(Taken/adapted from Galvani 2012)

Dawn, 38, is a single mum of 5 yr old Amy. You have been told that there are concerns about Dawn’s drinking when she has collected Amy from school in the car. On talking to Dawn, she thanks you for your interest, states she wasn’t drinking that day, that she does have a drink occasionally but not during the day and she would not drink and drive. She discloses she has been drinking more since her partner left two months ago just to help her relax and that while she’s “not an alcoholic or anything” she would be prepared to speak to someone if you think they can help her relax.

Practice examples (cont.)

Andy, 24, living in a hostelAndy has been referred to your team because of concerns about his mental health and related behaviour. Hostel staff understand that he has a history of drug use which coincides with a rapid deterioration in his mental health as he increasingly forgets to take his medication. On speaking to him he denies using drugs and says he just needs to get his medication sorted out.

Practice examples (cont.)Gary, 72, retired, husband of Helen, 66.Gary is an active man who is a keen gardener and is a season ticket holder for West Bromwich Albion FC. In recent years he has developed some mobility problems and has become increasingly frustrated at his inability to do things he normally does. You have been assessing Gary’s support needs and Helen’s ability to care for him. Helen tells you he had not been drinking for 20 years since she threatened to leave him if he didn’t get help but that recently he has started to drink spirits heavily in the evening for ‘medicinal’ purposes and gets angry with her when she raises the issue. In the last month she has found him asleep on the floor in front of the fire on many occasions in the night. When she wakes him he is verbally abusive to her. On speaking to Gary in private he becomes tearful and says he doesn’t want her to leave him but he’s not coping and has started drinking heavily again.

ActivityIn small groups choose one of the practice examples above:

Discuss how you would approach talking to the person about their substance use.

What are you hoping to achieve?

What questions would you ask?

What possible responses might you get?

If someone gets defensive and you feel some tension between you, what skills will you use to overcome this potential barrier?

Common principles

• Empathy (requires honest reflection on values)

• Identify the person’s personal strengths first including resilience factors, their family values, parenting skills

• Prove that you are listening, e.g. reflect and recap on their strengths

• Be honest and open (yet gentle) about your concerns around their substance use, i.e. conflicting with their stated values?

Common principles (cont.)• Briefly acknowledge/discuss positives of substance use – “what are

some of the good things about your use of [insert the substance/s of choice]”. In Motivational Interviewing this is known as ‘sustain talk’ – potentially it sustains the motivation to use substances (Miller and Rollnick 2012).

• Ask about negatives of substance use – “what are some of the negative things about your use of [insert substance]” – in MI this is known as ‘change talk’ – it helps people to say, out loud, the reasons that might help them make the decision to change.

Discussion as Intervention!• Assessment/conversation/discussion – done well – can be an

intervention in itself.

• Actions/decisions work best when suggested by the person themselves not the practitioner telling them what to do.

• Role of the practitioner is to:– engage with substance use as part of their duty of care to support

their service users, their families and dependents.– motivate people to consider changing their problematic substance

using behaviour and support them (their families and carers) in their efforts to do so.

– support change and provide, or refer to, aftercare for people in their efforts to change their substance use.

(Galvani 2015)

References• Galvani, S. (2012) Supporting people with alcohol and drug problems. Bristol: Policy

Press.

• Galvani, S. (2015) Working with substance use: the roles and capabilities of social workers. Funded by Public Health England. Manchester: MMU.

• Miller, W.R. and Rollnick, S. (eds.) (2012) Motivational Interviewing: Preparing People to Change Addictive Behaviour. (3rd edition). London: Guilford Press

• Prochaska, J.O., DiClemente, C.C. and Norcross, J.C. (1992) In Search of How People Change: Applications to Addictive Behaviors. American Psychologist, 4 (9), 1102-1114