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SUBSTANCE MISUSE FACT SHEETS CATEGORY III – COMMUNICATION AND SUBSTANCE MISUSE detailed drug and alcohol history. All questions should be asked with: How ... ? When ....? Where ....? What ....? Which ....? Why in a non-judgemental, empathic and non-confrontational ....? Who ..? What ...? If ....? manner – this can help with developing a therapeutic e.g. relationship and facilitate disclosure. Can you tell me more about your current drinking? Actively look out for the possible interactions and patterns that can occur: What problems are causing you concern? How might these be affected by your drugs/drinking do you think? l Primary psychiatric disorders leading on to substance misuse, possibly as a form of ‘self-medication’ for What concerns do you have about your current use/drinking? distressing symptoms (e.g. increasingly drinking alcohol to Tell me more about that, can you give me an example of that? alleviate anxiety symptoms/disorders; people with 4.3 Non-verbal communication dissocial personality disorders drinking alcohol and abusing drugs from a relatively young age). Use appropriate body language yourself: l The substance being misused having a direct psychoactive l Face the person with an open, attentive posture. effect which may be a prominent feature of the l Maintain good eye contact (look at the speaker a lot, but presentation in a psychiatric assessment. don't stare all the time).

The psychoactive effects of the substances being used may l Acknowledge that you are listening (see active listening). be a consequence of: l The above are all just as important if you are observing a – acute intoxication (e.g. a toxic psychotic effect with paranoia colleague undertaking an assessment. in a prolonged binge of cocaine), 4.4 Active listening – Withdrawal from the substance (e.g. delirium tremens in l You might reflect back what the speaker is saying in other alcohol withdrawal; depressed mood with the cocaine words to clarify understanding: you paraphrase and repeat “crash”) l You can summarise and bring new interpretations to the – More chronic effects of regular use (e.g. relationship between speaker’s words as well as allowing them to add more cannabis use and psychosis). information. Remember you are co-constructing the In a chronic situation it is not always obvious what the primary history together. problem was initially. l This demonstrates that you are listening carefully and Mental state examination should be interpreted in the context checks you are understanding correctly what they are of these possibilities too. Physical examination and collateral saying allowing the speaker to confirm or correct your information should include sensitively seeking out further feedback. details about the extent of use/ complications of use. The use of l It also encourages the patient to elaborate and to define investigations, such as urine drug screen and breathalyser, is an their problems. important part of assessment. Remember that more than one substance can be used 4.5 Establishing a positive relationship simultaneously. Also, ensure that the most serious and l Develop an empathic , warm and genuine dialogue. potentially life threatening complications of drug/ alcohol use l Communicate effectively through appropriate use of which can be part of the presentation are definitively empathic statements, reflection, clarification, verbal and considered and addressed – i.e. delirium tremens, Wernicke’s non-verbal behaviours. encephalopathy, overdose, severe benzodiazepine withdrawal. l Deal with emotional content of sessions.

4.0 Components of effective communication l Be non-judgmental.

Effective communication is a core skill required in the l Be non-confrontational. assessment and care management of a patient with substance l Involve patients in decisions about the options of care and misuse problems. treatment. 4.1 Introductions and building rapport 4.6 Giving service users information about substance l Introduce yourself. misuse l Thank the patient for meeting with you. l Provide accurate information on the nature and course of l Good listening builds a rapport and understanding with drug misuse and explore the service user’s view of this the speaker and allows them to freely express their views. information. 4.2 Elicit change talk l Provide advice about the risks associated with smoking, drinking and taking drugs. l This involves recognition of a problem around drugs/alcohol, concerns about this, intention to change, 5.0 Communication approaches optimism about change and commitment to change. Once a problem with substance misuse has been identified, l It is helpful to ask open ended questions, which may start strategies to assess the extent of the problem, to explore

2 SUBSTANCE MISUSE FACT SHEETS CATEGORY III – COMMUNICATION AND SUBSTANCE MISUSE

readiness for behaviour change and to involve the patient in l Identifying and responding appropriately to patients cues. managing the problem will all be more effective if the l Use of questions with a psychological/emotional focus. appropriate communication approaches are used. Again, l Eliciting and responding to concerns about physical and dealing with these sensitive issues can be made easier if there mental health. is a chance to discuss and experiment with different approaches in a safe environment. The ability to communicate effectively l Identifying, acknowledging and responding appropriately with other health-related professionals and agencies, for to difficult emotions. example, pharmacists and community drug teams, is also l Reflection. important. Linking effective communication with motivational l Summarising. interviewing and health behaviour change models is a useful 7.0 References and further reading approach. Bien TH, Miller WR, and Tonigan JS (1993) Brief interventions for alcohol Once a problem is disclosed, patients may take a passive problems: a review. Addiction 88:315-35 approach and expect the doctor to “cure” it, sometimes seeing D'Amico, E. J., Houck, J. M., Hunter, S. B., Miles, J. N. V., Osilla, K. C., & Ewing, B. A. the concept of “detox” as a complete remedy. It is particularly (2015). Group motivational interviewing for adolescents: Change talk and important in complex disorders like substance misuse to alcohol and marijuana outcomes. Journal of Consulting and Clinical facilitate full patient involvement in all treatment, from a brief Psychology, 83(1), 68-80. http://dx.doi.org/10.1037/a0038155 intervention/advice to complex care planning. Assessment and Douaihy, A.; Kelly T.M; Gold, M; (2015) Motivational interviewing: A guide for intervention often overlap. Building on the components of Trainees Oxford University Press communication, the “FRAMES” model of brief intervention is Dunlop, A., Perry, N. and Robinson ,M. (2015) ‘ Therapeutic Relationship’, in Haber, P. Day, C. and Farrell, M. (ed) Addiction Medicine Principles and Practice, commonly used for alcohol misuse, but can be applied more Australia, IP Communications, pp104-113. generally. Galasi ski, D. (2018) Language and psychiatry The Lancet Psychiatry 5(3) It is an excellent example of the essential role of effective p200–ń201, DOI: https://doi.org/10.1016/S2215-0366(18)30040-3 communication in diagnosis and management: Green, M.; Parrott, T.; Crook, G. (2012) Improving your communication skills BMJ Careers. Feedback: about personal risk or impairment http://careers.bmj.com/careers/advice/Improving_your_communication_skills Responsibility: emphasis on personal responsibility for Lloyd M & Bor R. (2009) Communication Skills for medicine, Edinburgh: change. Churchill Livingstone Advice: to cut down or abstain if indicated because of severe Miller WR, & Rollnick S. (2003) Motivational Interviewing: helping people to dependence or harm. change. New York, London, Guilford Press. NICE (2007) Drug misuse in under 16s psychosocial interventions. Clinical Menu: of alternative options for changing drinking pattern and, Guideline 51. http://guidance.nice.org.uk/CG51 jointly with the patient, setting a target; intermediate goals of Rollnick S (2010) Motivational interviewing, BMJ 2010; 340 reduction can be a start. http://www.bmj.com/content/340/bmj.c1900 Empathic interviewing: listening reflectively without cajoling Seppa K, Lepisto J. and Sillanaukee P(1988). Five-shot questionnaire on heavy or confronting; exploring with patients the reasons for change drinking. Alcohol Clin Exp Res 22: 1788-1991 as they see their situation. Thistlewaite JE, & Morris P. (2006) Patient-doctor Consultations in Primary Care: Theory and Practice. London: Royal College of General Practitioners Self efficacy: an interviewing style which enhances peoples’ Washer P (ed) (2009) Clinical Communication Skills. Oxford: Oxford University belief in their ability to change. Press. (Bien et al, 1993) 8.0 Resources NICE (2007) recommends that treatment and care should take Alcohol Use Disorders Identification Test (AUDIT) into account service users’ needs and preferences and that https://patient.info/doctor/alcohol-use-disorders-identification-test-audit individuals should have the opportunity to make informed CAGE Questionnaire https://patient.info/doctor/cage-questionnaire decisions about their care and treatment, in partnership with IRETA Motivational Interviewing Toolkit http://ireta.org/improve-practice/ their healthcare professionals. addiction-professionals/toolkits-for-practice/mitoolkit/?utm_ There are a range of tools than can be used in the delivery of content=bufferfc2bc&utm_medium=social&utm_source=twitter.com&utm_c ampaign=buffer treatment interventions. Paddington Alcohol Test ‘make the connection’ (2011) 6.0 Hints and Tips https://www.alcohollearningcentre.org.uk/_assets/PAT_2011_Paddington_Alc Useful communication strategies when addressing possible ohol_Test.pdf substance misuse: March 2018 l Introducing and asking difficult questions in a sensitive manner. l Use of open directive questions. l Conveying empathy, respect and a non-judgemental attitude. l Not making assumptions because of race, religion, sexuality – keep an open mind. 3