Best Practices - Early Intervention, Outreach and Community Linkages for Women with Substance Use Problems

2.5.4 Motivational Interviewing

Motivational interviewing is an effective method for enhancing brief intervention approaches (Miller & Rollnick, 1991). It has been designed to incorporate the levels of motivation outlined in Prochaska and DiClemente's (1986) stages-of-change model. The acronym FRAMES has been used to conceptualize the approach:

• F - Feedback is given to the client with respect to current health status and problem substance use.
  
  
• R - Responsibility for change on the part of the client is emphasized.
  
  
• A - Advice is given regarding harm reduction or referral for treatment from specialized services.
  
  
• M - Menu refers to the provision of alternatives from which clients may exercise personal choice and commitment in pursuing change.
  
  
• E - Empathy is used to create a climate conducive to empowering clients to undertake positive changes.
  
  
• S - Self-efficacy involves service providers' belief in the potential of the client to make positive treatment gains.

The goal of motivational interviewing is to help clients explore their ambivalence about their substance use. In applying this approach, service providers use empathic statements that reflect discrepancies in the client's experience of current substance use patterns and associated consequences. Service providers help clients examine the costs and benefits of substance use, and come to their own conclusions about its effects and consequences. In contrast to heavy "confrontation," concern is communicated, and clients self-evaluate current circumstances and make choices. Service providers then help the client examine the behavioural steps necessary to make changes, what supports are needed, the anticipated challenges and the measures of success (Miller & Rollnick, 1991; Royal New Zealand College of General Practitioners, 1999; Yahne et al., 2002). Table 3 provides examples of motivational interviewing questions that correspond to the various stages of readiness to change (Burge & Schneider, 1999; Rollnick, Healther & Bell, 1992).

* Adapted from Burge and Schneider (1999) and Rollnick, Heather and Bell (1992).

2.5.5 Brief Negotiation Interview

D'Onofrio et al. (1998b) identified the brief negotiation interview as "an extension" of the motivational interview. This strategy focusses on assisting clients to recognize and modify substance use behaviours that pose significant health risks. This interview involves a joint evaluation of the client's motivation to change. The term "negotiation" reflects the deliberations undertaken between clients and service providers to determine the client's level of readiness to pursue treatment options.

Similarly, treatment options are elaborated on and generated in collaboration with the client. The process of negotiation is used to tailor treatment alternatives to the needs of the individual. A key concept is the notion that it is the client who possesses the necessary capacity and knowledge from their own experience to set the stage for change. The client's participation in pursuing lifestyle changes is as important as the experience and expertise that the service provider brings to the interview (D'Onofrio et al., 1998b).

The process of negotiation is described as a "meeting between experts" comprising five key steps:

• establish rapport;
  
  
• ask for permission to discuss the pros and cons of continued substance use;
  
  
• be open to allowing clients to self-identify potential evidence of problematic substance use;
  
  
• invite clients to assess their readiness for change; and
  
  
• negotiate a potential strategy for change, taking into account clients' perception of their readiness to change (D'Onofrio et al., 1998b).

D'Onofrio, Bernstein and Rollnick (1996, cited in D'Onofrio et al., 1998b) described a range of key principles for effective use of negotiation strategies. These guidelines underscore the importance of service providers respecting and promoting the autonomy of clients and their choices. Clients are viewed as the expert in identifying their need areas and in formulating decisions, while service providers are active in providing information and verbal support for actions undertaken by clients.

2.5.6 Family Participation in Early Intervention Approaches

The concern of family members is an important factor that can motivate clients to seek treatment. Eliciting the collaboration of family members and significant others can play a key role in encouraging clients to initiate and remain involved with intervention services or programs (Copello & Orford, 2002).

The Community Reinforcement and Family Training Approach (CRAFT) emphasizes establishing working relationships with family members of those experiencing problem substance use (Meyers, Miller, Hill, & Tonigan, 1999; Meyers, Miller, & Smith, 2001; Miller, Meyers, & Tonigan, 1999).

This family-oriented approach has three key objectives: to enhance the health, safety and well-being of the family; to engage the family member who is experiencing problem substance use in treatment services; and to reduce the harm associated with continuing substance use. In a 6 month evaluation by Meyers et al. (1999) of 62 significant others, 87% completed their treatment and 74% successfully involved their unmotivated family member in treatment. Improvements were also noted in family members receiving CRAFT whether or not the person with the substance use problem engaged in treatment, with noted reductions in internalizing clinical features (e.g. anxiety and depression). Drug abstinence days also increased. Similar outcomes have been replicated in other randomized clinical studies (Miller, Meyers, & Tonigan, 1999).

In a study by Kirby, Marlowe, Festinger, Garvey, & LaMonaca, 1999, 32 concerned family members and significant others were recruited through newspaper advertisements offering free treatment to families of drug users. The families were randomly assigned to either the CRAFT or a 12-step support group intervention. The families receiving the CRAFT approach made treatment gains equal to the families assigned to the 12-step support group intervention. The CRAFT model, however, was significantly more effective in sustaining family members' involvement in treatment (85.7% compared to 38.8% for the 12-step) and in facilitating client entry into rehabilitation programs (64% compared to 17% for the 12-step) (Kirby et al., 1999).

Miller (2003) emphasized including family members in early intervention and treatment processes, and when clients do not have such support, reconnecting them with their family or building positive social support systems may be critical for engagement in treatment.

2.5.7 Self-help Resources

Self-help resources can be of benefit in addressing problem substance use. These resources should be tailored to reflect individual or gender-related issues. Written resources identified as helpful employ cognitive behavioural and harm-reduction methodologies. Self-help materials provide a range of relevant information and strategies on setting self-limits, using self-monitoring and recognizing and preparing for high risk problem substance use situations (CAMH, n.d).

Internet recovery services (IRS) can be used as a communication tool for early intervention, and components may include:

• individual e-mails or instant messaging systems;
  
  
• bulletin boards or interactive Web pages;
  
  
• chat rooms; and
  
  
• video conferencing (Hall, Wendell & Tidwell, 2003).

An Internet survey of 1000 users with a usable data analysis sample of 928, focussed on the demographic profile of clients with problem substance use who accessed IRS. This study found that, for the 70 different recovery programs being used, twice as many females as males accessed Internet services and most women users (76%) were under the age of 51. As well, it indicated the diversity of people using the Internet, including all ethnic groups and age levels. Internet options may be viable for those who have access to the Internet, and who are uncomfortable discussing their problems face-to-face with a health professional. Additional research is needed to assess the effectiveness of IRS for early intervention strategies or treatment (Hall, Wendell & Tidwell, 2003).

2.5.8 Settings for Early Intervention

Settings for early intervention are often found outside established addiction treatment facilities or programs. Haver and Franck (1997) indicate that women experiencing substance use problems often seek assistance for other conditions related to their addiction. Support may be sought in a variety of community-based settings, including primary health care centres and workplace programs (Samet, Friedmann, & Saitz, 2001). Previous research suggests that between 2% and 18% of women who seek assistance from medical services or health settings show hazardous levels of alcohol consumption (Haver & Franck). In addition, women who develop substance use problems often have co-morbid features, such as anxiety and depression, which prompts them to seek support from other counselling or mental health facilities. In many instances, women may conceal their problem substance use at health appointments or when they meet community service providers. If health professionals do not include questions in their screening practices related to problem substance use, many women may not receive adequate treatment or any treatment at all (Haver & Franck).

In a Swedish program, the Karolinska project for Early treatment of Women with Alcohol Addiction (EWA), women without prior treatment were encouraged to seek assistance for their problem substance use. Participants were contacted through health-related organizations and services in the community. The treatment intervention involved a short inpatient stay followed by frequent outpatient appointments for a minimum of 6 months, maintaining a stable client-therapist relationship over the course of the program. These appointments included medical evaluations, counselling and therapeutic services, and the development of a "total life situation" treatment contract addressing social support, vocational concerns and a range of physical and mental health issues. There is a research program attached to the EWA and a 2 year outcome study, involving 84 of the first 100 women treated, showed that two thirds of the participants experienced positive outcomes, including drinking within recommended guidelines, and improved occupational functioning and social relationships (Haver & Franck, 1997).

Health appointments with primary care physicians are an opportunity for both screening and brief interventions for problem substance use (Welte, Perry, Longabaugh & Clifford, 1998). To determine the effectiveness of the Health Care Intervention Service (HIS), 673 hospital patients experiencing or at risk for alcohol dependence were recruited for an attempt at follow-up. Two intervention groups and one control group were formed. Six months post intervention, with a follow-up rate of 75%, the full intervention group showed a reduction in problematic substance use and were more likely to accept a referral for additional assistance; the risk-reduction group also showed a reduction in substance use compared to the control group. Brief intervention focussing on risk reduction was found to render positive effects in reducing alcohol consumption and associated consequences. The results support the notion that "less intensive interventions" may be effective in modifying substance use behaviours and even people who exhibit features of dependence may benefit from such interventions (Welte et al.).

Screening patients who access emergency hospital services can be of benefit (D'Onofrio et al.,1998a). D'Onofrio et al. report that some studies of emergency departments have found that as many as 38% of patients are legally intoxicated when they seek assistance. Given this high prevalence, effective screening and referral services in emergency departments may reduce further morbidity and mortality from substance use. The authors suggest that screening and early intervention services are often not available in emergency departments because of insufficient time and resources, and a lack of education and training for personnel.

Evidence supports the effectiveness of work-place programs in improving health (Lapham, Gregory & McMillan, 2003). Messages received in workplace settings about problematic substance use can be linked with general health, diet and exercise themes. Successful workplace health programs use general screening and intervention approaches for all employees, with special attention given to those at-risk (Pelletier, 1999, cited in Lapham et al., 2003). Positive outcomes have included reduced rates of absenteeism (Stein, Shakour, & Zuidema, 2000), decreased medical costs, and increases in healthy behaviours by employees (Goetzel et al., 1998).

Lapham et al. (2003) undertook a controlled 3 year study of a worksite early intervention program for health care professionals addressing binge drinking and the intent to reduce alcohol use. The program, entitled Project WISE (Workplace Initiative in Substance Education), involved substance misuse awareness training for managers and application of various health risk appraisals with employees. These measures were supported by showing educational health videos on issues related to problem substance use. The study compared 3442 participants receiving Project WISE at one site to 2032 participants at satellite sites who did not receive the intervention. After three years, outcome analysis indicated that binge drinking rates did not change substantially in either group. Changes were reported, however, in motivation to reduce alcohol consumption, with binge drinkers who received Project WISE being more than twice as likely as those in control sites to indicate a desire to reduce their alcohol intake.

Cardiovascular risk prevention programs implemented in the worksite are often well attended by employees, and may offer a unique opportunity to address alcohol consumption in the context of overall health. Heirich and Sieck (2000) conducted a controlled trial of a worksite alcohol abuse prevention program, comparing 2000 employees randomly assigned to either the individual outreach and personal counselling group or to the control group where clients received group health education classes. Re-screening after three years indicated that reductions in various cardiovascular risk behaviours, including alcohol use, were noted for both groups, however, more clients improved in the group receiving individualized counselling than those participating in the education classes, and 43% of those who had been assessed as at-risk drinkers were abstinent or had reduced their consumption to safe levels.

Richmond, Kehoe, Heather and Wodak (2000) evaluated a workplace brief intervention program for excessive alcohol consumption, where 1206 self-selected employees were randomly assigned to either the brief intervention or comparison group. The intervention was delivered in the context of a broader health and wellness program. After 10 months, significant reductions in alcohol consumption were reported among women who received the intervention, but not among men. Richmond et al. indicated that in many studies, brief interventions yield positive results for men but not for women. In this study, women showed reductions in alcohol consumption at follow-up regardless of whether they were in the intervention or comparison groups. The authors speculated that the process of conducting screening and assessment processes with women might have facilitated self-reflection about their substance use behaviours, which in turn may have resulted in the decision to reduce their consumption of alcohol or other substances.

2.5.9 Specialized Consultation and Training for Health Care Providers

It is important to have addiction specialists inform health professionals about the wide range of features associated with problem substance use (Haver & Franck, 1997). Specialized addiction counsellors can act as consultants to educate a wide range of service providers responsible for health care services for women in areas related to:

• pregnancy and early childhood development;
  
  
• general medical practice;
  
  
• psychiatry;
  
  
• gynaecology; and
  
  
• workplace health services.

Welte et al. (1998) noted that to ensure successful implementation of early intervention programs in health care and medical settings, a commitment by health organizations and senior personnel to provide in-service training for their health staff is required. Health professionals who receive specialized training will be more effective at detecting problem substance use and providing clients with focussed interventions.

Considerable research is still required to enhance the effectiveness of screening and early intervention programs for women with problem substance use in health care or other related settings. As well, research is needed to examine the impact of health care facilities detecting and referring women to treatment services (Haver & Franck, 1997).