Interventional Strategy to Prevent Relapse and Enhance Motivation

Its great how you embraced the assessment task and carried out the session with a real service user. You opened up the session well, and this allowed the service use to share openly with you. You clearly have a good rapport. You have a gentle manner and your open body language reflected your openness to hear the person’s story. You have quite a natural, conversational style and this created a safe space for the service user to talk freely. You asked appropriate questions about the service user’s AOD use – these are excellent skills to have as a mental health nurse working in the inpatient setting. You are a good listener as it was evident that you heard what he was saying. Consider balancing the over-focus on questioning to practice more core counselling skills (OARS). This is key to enhancing motivation to change and to empower the service user as it reinforces that they have the skills to change. For example, you used the opening words .

“You need to…” many times in the discussion. Consider instead which micro-skill you might have used which would have affirmed his ideas, or empowered him to explore his own answers/solutions (see 12.40, 12.55, 12.58mins “You need to…”). At one point when talking about his goal to be a peer support mediator, he said “I could be quite good at it as well” (6.49mins). Consider reflecting on the missed opportunity to take some time to affirm this statement and explore all the reasons why he might have been quite good at this role. Another example was at 12.12mins when you said “You really need to develop some skills”, when he had already told you about some skills he had/was using. This may be perceived as missing an opportunity to validate the skills he already has when the statement is made like this.

A further example was at 13.46mins where when talking about refusal skills you said “You need to…”, consider instead asking him to reflect on his own refusal skills, how might he do this in the situations that he might be in? There could have been role-playing, where he practised his refusal skills. Giving advice might undermine his own strengths and skills that he already has. By moving away from questions or advice giving you are avoiding the ‘counsellor trap’ that motivational interviewing speaks to.

The intervention:
You stated that you were applying CBT using the functional analysis. There was very little evidence in your session that a functional analysis was being used. There was, however, many good examples of relapse prevention in the session, therefore I would recommend using relapse prevention as the intervention, and using motivational interviewing to mobilise the relapse prevention discussion.

The session with the service user

Recommendation 2: Change intervention to be relapse prevention with motivational interviewing.  

Recommendation 3: Make brief reference to his motivational position (planning/action?) and bring in Prochaska and DiClemente literature to validate with service user quotes to demonstrate.

Relapse prevention as the intervention:
He identified wanting to be a peer support mediator, remember to link this to your goal for the session, that you are focusing on relapse prevention to support his goal of abstinence which also enhances his prospectus of achieving his career goals. 

 Recommendation 4: Identify a clear goal that aligns to his AOD-related goal, motivational position and his personal career goal.   

The service user identified boredom (4.47mins), anxiety, memories and flashbacks related to PTSD as his triggers. Explore these more integrating related literature.

Recommendation 5: Integrate research related to the service user’s specific triggers and link this to your rationale for choosing relapse prevention. 

He spoke about his mother, how she can be both supportive and a trigger. He also spoke about his friends, how some are good supports and others are drug-using friends (8.57mins). He also spoke of hobbies (8.17mins). Consider reflecting on the missed opportunities to explore these important factors further, where the relapse prevention could have focused on ways of being that drew out the positives from his relationship with his mum and his non-AOD using friends. Bring in literature.Recommendation 6: Use relapse prevention research and ideas to critique how you might have explored the role of supports and hobbies/alternatives to using to support his recovery.

Use relapse prevention techniques to identify triggers and cravings. At 9.23mins he said to you “I’ll be honest, I’ve experienced wanting to have a drink.” whilst being on the unit. This provided an excellent opportunity to identify triggers and explore ways of managing triggers. At 10.11mins he also spoke about how his “over-protective” mum was a trigger sometimes, and his flashbacks and memories of his traumatic event also. At 14.54mins he talked about how he relieves boredom, he explained his alternatives to using – consider pausing the conversation to acknowledge these skills. In the video at 14.54-15.28mins he spoke about gaming as a distraction method/alternative to using. At this time you focused on gaming being addictive too. While this is true, at this time it seemed like a large leap as he was mentioning it in a functional way and there was no indication that it was problematic. You then recommended that he go to the gym instead, I wonder how realistic this was for him?

He gave no indication to you that this was something he was interested in doing, other than being polite and letting you continue to offer him advice. Consider instead exploring his ideas, rather than yours.  It was great how you kept returning to the conversation around his triggers (11.32mins). At 18.08 you introduced the “3 D’s” and explained this to him. This was really useful and appropriate - consider inviting him to explore his own ideas about what would work for him.

Recommendation 7: Use relapse prevention research and ideas to critique how you might have explored managing triggers and cravings. 
o    Discuss the rationale for why you kept returning to the conversation around triggers (ie why its so important to identify). What skills did you use? Bring in literature to validate.
o    Reflect on how you might have explored these ideas (ie 3 Ds) in a way that uses motivational interviewing – that bring out his ideas rather than offering yours.
o    Consider also the idea of referring him to further counselling for his PTSD (or if he’s already engaged in this, say so).