Rationale and principles of intervention
Goals of intervention
Format of therapy
Initial assessment

Rationale and principles of intervention

Throughout this guide the term 'speed' is used to encompass all forms of amphetamines.

This intervention is based on the assumption of the motivational enhancement therapy (MET) approach that the responsibility for change lies within the client (Miller, Zweben, DiClemente & Rychtarik, 1995). The therapist's task is to create a set of conditions that will enhance the client's own motivation and commitment for change. The therapist does this by following the five basic motivational principles:
  1. Express empathy;
  2. Develop discrepancy;
  3. Avoid argumentation;
  4. Roll with resistance; and
  5. Support self-efficacy.
Following the development of the client's commitment to change, the therapist assists the client in learning skills that will help him/her achieve change.

Goals of intervention

The main goal of intervention is to reduce the level of drug use and harm, e.g., mental and physical health, financial, social, occupational, associated with regular amphetamine use. The client will be assisted to identify specific goals. If the client has a concurrent mental health problem, such as depression or a psychotic illness, then an important goal is to enhance the client's understanding of possible interactions between their use of amphetamines and other other prescribed or illicit drugs, current psychiatric symptomatology and potential for relapse. Top of page

Format of therapy

Guidelines for the delivery of the intervention sessions are given for each of the interventions in this guide. These guidelines are general and a practitioner can modify the guidelines to be consistent with his or her own counselling experience. The suggestions for practitioner statements throughout this guide are taken from the MET manual (Miller et al., 1995).

This publication presents the guide for a four-session intervention; however the decision to offer either a two- or four-session intervention may be made by the practitioner in accordance with individual client needs.

The content of the four sessions is listed below and each session should last approximately one hour. The first session will begin following the initial assessment.
  1. Motivational interviewing (Session 1).
  2. Coping with cravings and lapses (Session 2).
  3. Controlling thoughts about amphetamine use and pleasurable activities (Session 3).
  4. Amphetamine refusal skills and preparation for future high-risk situations (Session 4).
Although weekly sessions are preferable, there will be occasions when clients cannot attend or forget their appointment. In this case, an attempt should be made to reschedule for the same week in an effort to maintain engagement and the client's motivation to change drug use behaviours. If this is not possible, the session should be carried over to the regular time the following week.

Initial assessment

The assessment package that was developed for the evaluation study would not be practical in the context of routine clinical care. However, specific elements are required in the initial assessment so the sessions can be tailored to individual needs. This assessment should be incorporated into routine assessment procedures already in place. The essential elements of the initial assessment include:
  1. A thorough alcohol and other drug use history that includes use of amphetamines and other drug classes, quantity, frequency, route of administration and associated risks, duration of current use, age of initiation, severity of dependence, experience of previous intervention, and history of withdrawal symptoms.

  2. A thorough mental health assessment including past mental health history and assessment of current symptoms (presence and severity) with an emphasis on psychosis, depression and suicidal ideation (see Figure 3 for suggested questions for assessing suicidal ideation). The reader is referred to the recently published Review of diagnostic screening instruments for alcohol and other drug use and other psychiatric disorders (Dawe, Loxton, Hides et al., 2002) for a review of relevant screening and assessment instruments.

  3. Client's readiness to change amphetamine and other drug use (see Figure 4, Client self-assessment tool on speed use below).
A practitioner's initial assessment will inform the decision regarding which aspects of the four-session CBT intervention to emphasise with each client. For example, if the client is assessed as being in the action stage of change (Prochaska & DiClemente, 1986), session 1 which concentrates on motivational interviewing may be kept to a minimum in order that more time is available for other issues that require emphasis such as coping with cravings to use amphetamines. Top of page

To enable the development of a thorough assessment and case formulation, the following assessment instruments are recommended as an adjunct to routine assessments: If you feel that a client is at high risk of suicide, follow the suicide policy in place at your workplace. If a decision is made to manage a high-risk suicidal client, the client should be given written information about how to seek 24-hour assistance if required, and they should be closely monitored throughout the intervention.

Figure 2. Severity of Dependence Scale

Figure 2 is presented as text in this HTML version for accessibility reasons. It is presented as an image in the PDF version.
  1. Have you ever thought your speed use is out of control?

    Never (0) Sometimes (1) Often (2) Always (3)

  2. Has the thought of not being able to get any speed really stressed you at all?

    Never (0) Sometimes (1) Often (2) Always (3)

  3. Have you ever worried about your speed use?

    Never (0) Sometimes (1) Often (2) Always (3)

  4. Have you wished that you could stop?

    Never (0) Sometimes (1) Often (2) Always (3)

  5. How difficult would you find it to stop or go without?

    Never (0) Sometimes (1) Often (2) Always (3)

Gossop, Darke, Griffiths et al. (1995). Note: A cut-off score of greater than four corresponds to a diagnosis of severe amphetamine dependence (Topp & Mattick, 1997)

Figure 3. Questions for assessing suicidal ideation

Top of page Figure 3 is presented as text in this HTML version for accessibility reasons. It is presented as an image in the PDF version.
  1. Have you been feeling depressed for several days at a time?
  2. When you feel this way, have you ever had thoughts of killing yourself?
  3. When did these thoughts occur?
  4. What did you think you might do to yourself?
  5. Did you act on these thoughts in any way?
  6. How often do these thoughts occur?
  7. When was the last time you had these thoughts?
  8. Have your thoughts ever included harming someone else as well as yourself?
  9. Recently, what specifically have you thought of doing to yourself?
  10. Have you taken any steps toward doing this? (e.g. getting pills/buying a gun?)
  11. Have you thought about when and where you would do this?
  12. Have you made any plans for your possessions or left any instructions for people for after your death such as a note or a will?
  13. Have you thought about the effect your death would have on your family or friends?
  14. What has stopped you from acting on your thoughts so far?
  15. What are your thoughts about staying alive?
  16. What help could make it easier to cope with your problems at the moment?
  17. How does talking about all this make you feel?

Reproduced with permission from the Treatment Protocol Project (2000), Management of Mental Disorders, pp. 22-23, Third Edition, Sydney: World Health Organisation Collaborating Centre for Mental Health and Substance Abuse.

Figure 4. Client self-assessment tool on speed use

Text equivalent below for Figure 4. Client self-assessment tool on speed use
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Text version of Figure 4

Figure 4 uses a ladder to represent five stages of speed use. Above the image of the ladder is the following text:

The rungs on this ladder can be used to represent where you are now in regard to your speed use. Tick the rung that best describes where you are right now.

From bottom to top, the rungs are as follows:
  • Pre-contemplation - I'm happy using speed and don't feel the need to quit or cut down
  • Contemplation - I think I might need to quit or cut down but I'm not sure I want to
  • Preparation - I have made real plans to quit or cut down
  • Action - I have recently started to quit or cut down
  • Maintenance - I have already cut down or quit some time ago

Adapted from Biener and Abrams (1991). See footnote 6 for an explanation of the readiness to change model.

Footnotes

6 The readiness to change model (see Prochaska & DiClemente, 1986) provides a framework to understand and identify a client's readiness to change drug use behaviours. The model describes six broad categories of the change process, and relapse can occur at any stage:

1. pre-contemplation: not considering change
2. contemplation: thinking about change
3. determination: has made a decision to change
4. preparation: getting ready for change
5. action: is in the early stage of change
6. maintenance: is maintaining changes made