Distress and Increase Treatment Readiness Dr Victoria Manning and Dr - - PowerPoint PPT Presentation

Six-Step Brief Intervention to Reduce Distress and Increase Treatment Readiness

Dr Victoria Manning and Dr Jane Oakes

The team…

• Dr Jane Oakes
• Dr Victoria Manning
• Dr Simone Rodda
• Ms Mollie Flood
• Prof Dan Lubman

Developing a Brief Intervention to reduce distress

Brief Intervention Rationale

Problem Gamblers

• <10% present to treatment (Evans & Delfabbro, 2005, Horche and Hodgins,2015)
• Poor knowledge treatment options (Gainsbury et al, 2014)
• Often first (and only) point of contact
• Helpline staff influence counselling initiation

(Valdivia-Salas et al, 2014)

Problem Gamblers

• 7/10 gamblers accessing GHO report psychological distress
• 9/10 experience negative emotions – helpline
• Acute distress - common reason for seeking help(Rodda et al,

2014)

• Don’t seek help until crisis (Evans & Delfabbro, 2005)

Problem Gamblers

• 21% helpline callers experience suicidal thoughts due to

high distress (Ledgerwood et al, 2005)

• 50-75% offered referral - significant drop-out
• (TP, 2014, Weinstock et al, 2011)
• Improving tx readiness increases attendance
• Increased attendance improves outcomes (Dunn et al, 2012)

Brief Intervention: OVERARCHING GOAL

Increase successful referrals

Brief Intervention- Aims

• Alleviate distress / stabilise client
• Enable client to think clearly
• Optimise motivation to change
• Increase problem-focused coping
• Assist client to engage with appropriate help

Methodology

• Search online databases:
• to identify relevant peer-review literature
• to identify relevant resources
• Building on existing interventions
• Consultation

Caplan’s Crisis Intervention Framework

• “Transient response to circumstances arousing

anxiety to intolerable levels, undermining individual’s natural coping resources”

• Stressful situations - detrimental effect on cognitive

functioning, problem solving and erodes their belief in ability to manage

• Informal supports & formal interventions are

required to help contain emotional arousal & enhance problem solving capabilities (Caplan 1964)

Consultation

Participants Number Gambling helpline counsellors 8 Crisis helpline counsellors 4 Academic addiction specialists 5 Consumers 1 Significant others 1 Group consultation – workshop 10 Total 29

Semi-structured interviews

• What is distress?
• How do you identify distressed clients?
• How do you manage distressed clients
• What works, what doesn’t work?
• How do you get PGs to consider treatment/support?

Alleviate distress – PG can think clearer

It is important to reduce distress …….a client may continue gambling to alleviate their distress, which is likely to only increase their distress when they lose more money. ….a client in distress is not thinking straight or acting normally. Getting the client to talk is obviously important but getting them to tell the details of their story, while in a state of distress, is unlikely to make them feel better. expert

Distress in help-seekers

Lifeline’s approach Allows story telling to reduce distress, but not to the point where it immobilises practical coping

(lifeline.org.au)

The focus is on how aspects of their situation are affecting them right now.

It is helpful for a distressed caller for the person they are talking to remain calm and to use strength based approach where possible… we try to build on their own strengths and resourcefulness – review how the caller has coped in the past, where they are stuck now and how could they extend their resources and strategies for managing.

Only immediate concerns - Don’t increase distress

Lifeline counsellors

Seek sufficient understanding of what lies behind it to address immediate concerns. The focus is on how aspects of their situation are affecting them right now.

Only immediate concerns - Don’t increase distress

Lifeline counsellors

It is helpful if they remain calm and to use a strength -based approach where possible… we try to build on their own strengths and resources– review how the caller has coped in the past, where they are stuck now and how could they extend their resources and strategies for managing the situation. It’s unhelpful for the caller to be continually pouring

• ut thought after

thought with no real focus.

Distress level Time with clinician

10 9 8 7 6 5 4 3 2 1

Workable Zone

• Increased distress
• Continued gambling
• Self-harm
• Severity of situation

minimised

• Perceived permission

to continue gambling Extreme distress Relaxation

Brief Intervention Model

Identify distress Step 1: Acknowledge & Measure Distress Step 2: Normalise and Reduce Distress Step 3: Optimise motivation for change Step 4: Provide a Sense of Hope Step 5: Measure Distress Step 6: Explore Treatment/Support Options

Beginning the intervention: Identify distress

• People concerned about gambling frequently

describe experiencing a distressing event, being in crisis or “hitting rock-bottom” as reason for contacting help services

• Identifying distress - begin brief intervention

(Evans and Delfabbro, 2005)

Beginning the intervention: Identify distress

Not thinking rationally

GHL Counsellor GHL Counsellor

Are they agitated or sounding panicky?… is their speech fast or slow? whether or not they are crying….and if so are they struggling to talk?

Lifeline counsellor

Crying, sobbing loudly, pressured speech, heightening anxiety, breathless, anxiety ridden

Beginning the intervention: Identify distress

Distress causes powerless

In my experience anxiety is steeped in the future and creates a feeling of

• powerlessness. Therefore, it is always

helpful to bring the client back to the here and now. Consumer

Step 1: Acknowledge and measure distress

Clients feels heard/understood Shows empathy

Step 1: Acknowledge and measure distress

Measuring distress at this point:

• baseline distress level
• Allows clinician to later check distress has reduced so

client can engage constructively

Step 1: Acknowledge and measure distress

The Subjective Units of Distress Scale (SUDS) (Wolpe, 1969) Valid measure of emotional discomfort (Tanner, 2012) Scale rating from: ‘0’ No distress…. to….. ’10’ Extreme distress

Step 2: Normalise and reduce distress

Avoidant coping strategies common among people with gambling issues (Yi, 2012). Normalising distress important Encourages clients to tolerate feelings of distress Stabilises emotions, make positive changes, rather than relying on avoidant coping strategies A crisis state is inherently time-limited (Caplan, 1964; Kalafat, 2002)

Step 2: Normalise and reduce distress

Relaxation/breathing control skills reduces anxiety

(Townshend et al, 2014)

Reduce distress by completing a breathing exercise Suggested breathing exercise

(Centre for Clinical Interventions. The Calming Technique: Breathing)

Importance of breathing exercises in reducing distress

Mindfulness-based strategies could be helpful to reduce the client’s arousal. There are a number of breathing techniques that are designed to bring the client into the here and now. Expert

Step 3: Optimise Motivation for Change

Light bulb moment - client realises current distress is the result of behaviour that needs to change Turning Point “transformative moment” a state of weakness to a state of empowerment

Step 3: Optimise Motivation for Change

Teachable moment when client has a concern directly related to unhealthy behaviours, a link is made by clinician between concern and behaviour in attempt to motivate change (Cohen et al, 2011) “Cueing events” naturally occurring health events/circumstances that leads individuals to make health behaviour changes (McBride et al, 2003)

Step 3: Optimise Motivation for Change

Empathic curiosity to facilitate change/decision making

(McEvoy et al, 2013)

Evoking change talk for clients who are ready to change

(Miller, 2015)

The Readiness Ruler

To determine "How important is changing gambling behaviour to client right now, on a scale from zero (not at all important) to 10 (extremely important)

Step 4: Provide a sense of hope

Hope is required for contemplation of change (Bradshaw et al.,

2014)

Self-efficacy is an important predictor of positive behaviour change (Kadden and Litt, 2011) Information on how others have tackled gambling problems and simple statistics on tx outcomes can empower people to start dealing with own problems

(psychology.org)

Congratulate client for taking first steps helps instil hope

I always make sure to congratulate them for having gotten in touch, for having taken the first steps to dealing with their problem.

Expert

Step 5: Re-measure distress

Re-measuring distress allows the clinician to determine if distress has reduced enough for client to engage constructively in considering treatment/support

Step 6: Explore support and treatment options

Encourage the client to reflect on their strength and social supports

Step 6: Explore support and treatment options

Referral is complex- involves providing information and helping the client make an informed decision with all

• f the facts

Step 6: Explore support and treatment options

Cost, time & location of options Amount of disclosure Likelihood of shame and embarrassment Cultural needs

Step 6: Explore support and treatment options

Preferences - telephone, online or face-to-face Type of intervention/s

Step 6: Explore support and treatment options

• Having an appointment within 72 hours of initial

helpline call predictive of attendance (Ledgerwood et al,

2013)

• May need for intermediate support whilst waiting

for face to face appointment

Brief Intervention Model

Identify distress Step 1: Acknowledge & Measure Distress Step 2: Normalise and Reduce Distress Step 3: Optimise motivation for change Step 4: Provide a Sense of Hope Step 5: Measure Distress Step 6: Explore Treatment/Support Options

Strengths

• Developed from

literature

• Combined with

expert knowledge

Summary

Don’t encourage history telling – it can overwhelm the client Elicit motivation and encourage change talk Facilitate tailored access to continued support/treatment

Intervention

Counsellors GHL

To acknowledge and validate someone’s distress and normalise their feelings. It really works !!! every time I have lost count of the number of times I have calmed someone down simply by validating their distress and normalising their feelings

Intervention – significant others

I have found the distress model really helpful when talking to affected others about talking to their partners about their gambling Coaching them how to keep their partner at a level of tolerable distress helps them to understand how to best get through to them Many affected others will feel more confident about this as they have tried countless times to talk about the issue, and have reached dead ends. Counsellor GHL

Limitations Inherent in qualitative methodology Evaluation of 6-Step BI needed Needs testing in different environments to determine the uptake of subsequent support/treatment

Acknowledgements

• Clinical Development Grant
• Participants - counsellors, consumers and

addiction clinicians, academics and other experts

Gambling services co-ordinator P: 03 9418 1035 F: 03 9418 1012 M: 0432224939 E: janeo@turningpoint.org.au

Dr Jane Oakes