A brief cognitive behavioural intervention for regular amphetamine users: a treatment guide

Phase 1: Building motivation to change

Page last updated: 2003

The goals of motivational interviewing (Rollnick et al. 1999) are to:

  1. maintain rapport;
  2. accept small shifts in attitude as a worthy beginning;
  3. promote some concern about risk (e.g. for health, legal problems);
  4. avoid increasing resistance;
  5. promote self-efficacy and responsibility; and
  6. view lifestyle holistically (each aspect usually affects the other).
Critical conditions for promoting change are empathy, warmth and genuineness. Strategies to promote motivation to change include:
  • removing barriers to change;
  • providing choice;
  • decreasing desirability of substance use;
  • practising empathy;
  • providing feedback;
  • clarifying goals; and
  • active helping.
Presenting the rationale for intervention
A typical day
Personal feedback from assessment
Impact on lifestyle
Explore the pros and cons of using speed
Explore concerns
Explore health risks
Financial costs of using
Looking back
Looking forward
Self vs self as a user
Encountering ambivalence
Summarise
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Presenting the rationale for intervention

The following is an example of what you might say:

"Before we begin, let me just explain a little about how we will be working together. You have already spent time completing the assessment that we need, and we appreciate the effort you put into that process. We'll make good use of that information from those questionnaires today. This is the first of four sessions that we will be spending together, during which we'll take a close look at your situation. I hope that you'll find the sessions interesting and helpful.

I should also explain right up front that I'm not going to be changing you. I hope that I can help you think about your present situation and consider what, if anything, you might want to do, but if there is any changing, you will be the one who does it. I'll be giving you a lot of information about yourself and maybe some advice, but what you do with all of that after our sessions together is completely up to you.

I couldn't change you if I wanted to. The only person who can decide whether and how you change is you. How does that sound to you?"

A typical day

Presenting the client with feedback from your assessment is important; however doing so this early in the first intervention session could elicit resistance and hinder engagement in the intervention program. To minimise this, an important first step in raising the issue of your client's speed use is to understand how they see their situation. Proceed with strategies for eliciting self-motivational statements about change by approaching health/lifestyle issues first and gently fit your questions about their speed use into this perspective. Miller et al. (1995), in their MET manual, suggest the following approach is a useful way to stimulate a discussion about the client's current issues:

"The information we have talked about in this session has given me a bit of an idea about what is going on in your life at the moment. But I really don't know a lot about you and the kind of life you lead. I wonder if I could ask you to tell me a little more about your life and the problems you are coping with right now? It would help me to understand the situation better if you could pick a typical day in your life and take me through it from the time you woke up. Tell me about the things you struggled with and how you felt at the time".
(later)

"Can you tell me where your using speed fits in? Can you think of a typical recent day from beginning to end? You got up..."
Allow the person to continue with as little interruption as possible. If necessary, prompt with open-ended questions:

"What happened then?"
Review and summarise, and if required ask: Top of page

"Is there anything else at all about this picture you have painted that you would like to tell me?"

Personal feedback from assessment

Once you have a reasonably clear picture of how the client's speed use fits into their typical day and their current concerns, ask the client's permission to provide feedback from your assessment in the following way:

"In getting a feel for what's going on in your everyday life at the moment, you've mentioned several things that are concerning you (summarise these problem areas briefly, using those issues raised by the client in the "typical day" discussion, w.g. quality of life, health, mood, speed use). Would it be OK if I gave you some feedback from the assessment we completed together, because I think it fits into some of these issues?"
Discuss the client's level of dependence and other salient results from the initial assessment. Talk about the diagnosis of dependence and the implications of this, including physical and psychological dependence. Check whether the client feels this is an accurate reflection by asking the following questions:

"How do you feel about this?"

"Does it surprise you?"

Impact on lifestyle

Once you have provided the client with feedback (or 'your impression' of their areas of concern), raise the issue of how their use of amphetamines impacts on their lifestyle. The MET manual suggests the following approach:

"I've been wondering what you think is the most important thing to concentrate on to improve your health and lifestyle at the moment ... What do you think the priority should be?"
If appropriate...

"I think it would help a lot if you could have a closer look at your use of speed ... How does it seem to you?"
In conjunction with the client and using the information gained from the assessment, discuss their pattern of amphetamine use (regular, binge, etc) and any concerns they have about this.

Explore the pros and cons of using speed

Now, begin to explore further the client's concerns about their speed use. Ask about their reasons for using speed, the pros and the cons, writing these down together as you go (Exercise 1).
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Exercise 1: Grid to explore the pros and cons of using speed

  1. Provide the client with the following grid (the grid contains 4 quadrants):
    • Good things about using quadrant / less good things about using quadrant
    • Good things about using less quadrant / less good things about using less quadrant

  2. Elicit from the client all the positives they associate with using speed and write them down in the relevant quadrant. Use the following questions as a guide:"Tell me about your speed use. What do you like about it? What's positive about using for you?"
  3. Consider with the client how important these positive aspects are, and ask the client to write their importance rating next to the relevant aspect. Use the following questions as a guide:"How important is this to you personally? If '0' was 'not important' and '10' was 'very important' what number would you give this aspect of your speed use?"
  4. Repeat this exercise with the less good things associated with speed use and assess how important these are to the client. Ask the client to write these issues down in the relevant quadrant of the grid. Use the following as a starting point:"And what's the other side? What are your concerns about your speed use?"
  5. Finally, continue with a discussion of the good/less good things the client associates with changing their speed use. Record the issues raised in the relevant quadrant. For each issue raised, discuss the importance to the client.
Establish whether the positive reasons outweigh the negative in terms of the number of issues listed for and against change, but also the importance ratings provided by the client for the positives and negatives. This is an important step in assessing the need to continue with motivational interviewing during this session.

If at this stage the good things associated with using speed at the current level and the less good things associated with cutting down/quitting outweigh the other quadrants (i.e. the perceived benefits of using still outweigh the perceived costs), use the following techniques to tip the balance in the other direction. If however, the client determines that the costs associated with continuing to use outweigh the perceived benefits, proceed to Phase 2: Strengthening commitment.

You may encounter resistance during this discussion. Miller and Rollnick (1991) have identified four categories of resistance behaviour in clients:
  • arguing about the accuracy, expertise or integrity of the therapist (challenging, discounting, hostility);
  • interrupting in a defensive manner (talking over, cutting off);
  • denying or unwillingness to recognise problems, take responsibility or co-operate (blaming, disagreeing, excusing, claiming impunity, minimising, pessimism, reluctance); and
  • ignoring or not following the therapist (inattention, non-answer, no response, sidetracking).
If you pick up on this, use the following techniques in response (Miller, Zweben, DiClemente and Rychtarik, 1995, pg 24):
  • reflection – simply reflect what the client is saying;
  • reflection with amplification – reflect but exaggerate what the client is saying to the point where the client is likely to disavow it. (However do not overdo this and elicit hostility);
  • double-sided reflection – reflect a resistant statement back with the other side (based on previous statements made in the session);
  • shift focus – shift attention away from the problematic issue; and
  • roll with resistance (rather than opposing it) – gentle paradoxical statements that will often bring the client back to a balanced perspective.
Once the client raises a motivational topic, it is also useful to ask them to elaborate on it (Miller & Rollnick, 1991). This will reinforce the power of the statement and can often lead to more motivational statements about change. Miller and Rollnick (1991) suggest that one useful way to do this is to ask for specific examples and/or for the client to clarify why this particular issue is a concern.
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Explore concerns

"You've said that these are the less good things about using speed (relate to grid), do these things concern you?"

"What other concerns do you have about speed?"

"I wonder how you feel about using speed ... What can you imagine happening to you?"

"How much does that outcome concern you?"

Explore health risks

"Can you tell me some reasons why using speed may be a health risk (check psychological and physical health)?"

"Would you be interested in knowing more about the effects of speed on the body (or on the brain)?"

"Some people find that changing their speed use can improve their depression. What do you think?"

"How does your use of speed affect your mental health?"

Record those risks that the client is most concerned about. Avoid the use of terms such as 'problem', 'abuse' etc. as these can elicit resistance from the client at this early stage.

If appropriate, ask the client for permission to provide them with some information about the health risks associated with using speed. You may like to print the "Information about speed" section for the client to review.

Information about speed

  • When you take speed, it goes into your bloodstream and is carried to your brain. Once in the brain, speed joins to certain sites called receptors. These receptors will trigger brain cells to start or stop different brain and body tasks.

  • Speed joins to receptors in the brain that trigger the release of dopamine and adrenaline in the body. Dopamine and adrenaline are chemicals that produce positive feelings when released. When speed enters the brain, it causes the artificial release of these chemicals, leading to short-term feelings of satisfaction, well-being, relief, increased attention, lots of energy etc. But these effects are not without cost. The problem is that when the effects of speed wear off, they can leave a person with the opposite feelings – radical mood swings, depression, lack of energy, confusion, total exhaustion, uncontrolled violence etc. The greater the stimulation effects of speed, the greater the negative effects (or rebound) from speed.

  • Speed is a stimulating drug. It quickens activity in many parts of the body, including the messages sent from the brain to the body. But, because it does this unnaturally, it must 'borrow' from the energy reserves of the brain and body rather then creating new energy for you to use. That's why you can get the rebound effects after taking speed.

  • As you continue to use, your body needs to work harder to burn up the speed that you put into it. It also starts to cut down the amount of dopamine and other chemicals it releases from the receptors in the brain. This means that your body won't give you as good a feeling as when you first started to use speed, and you'll rebound harder each time.

  • Frequent, heavy use can cause hallucinations, paranoia and bizarre behaviour (psychosis). Your appetite may be reduced, and you may be less likely to eat properly, making you run down and more likely to get infections. Heavy speed users may become violent for no apparent reason, and you may also experience constant sleep problems, anxiety and tension, high blood pressure and rapid, irregular heartbeat. Another common side effect is depression.

  • Because speed quickly fires up pleasurable feelings, you may gain confidence in being able to feel good just by using it. You may lose confidence in the people, places and activities that used to give you these feelings, because the effects don't happen so quickly. You may find yourself spending more time trying to get speed, being with people who also use, and resenting those people and activities that don't fit in with using speed. The problem, however, is that speed only gives you a false sense of well-being, along with serious side effects.
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Information taken from these publications:
High Times on the marijuana library website (www.marijuanalibrary.org/)
What is crystal methamphetamine? on the KCI website (www.kci.org)
Amphetamine facts on the DrugInfo website (www.druginfo.adf.org.au)
A primer of drug action. By Robert Julien

Financial costs of using

If the client raises the cost of using speed as a factor in their decision to quit/cut down, ask the client:

"Do you have any idea just how much you think you would save if you didn't use speed?"
If appropriate, calculate how much money they will save in one month or one year by quitting, and with the client determine the important things that could be purchased or bills paid with the money saved.

Looking back

"What were things like before you started using?"

Looking forward

"How would you like things to be different in future?"

"What's stopping you from doing what you like now?"

"How does using affect your life at the moment?"

"If you decide to quit/cut down, what are your hopes for the future?"

Self vs self as a user

This step helps to develop discrepancy.

"What would your best friend/mum say were your best qualities?"

"Tell me, how would you describe the things you like about yourself?"

"And how would you describe you as a speed user?"

"How do these two things fit together?"
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Encountering ambivalence

If the client is ambivalent, attempt to explore the reasons that underlie this. Re-establish the initial reasons for wishing to quit/cut down. Incorporate information on health and psychological effects of continued use. Guide the client through a rational discussion of issues involved, and carefully challenge faulty logic or irrational beliefs about the process of quitting. Positive reinforcement and encouragement are crucial. You may be able to tip the balance in favour of the positives of quitting/cutting down and the negatives of using speed, but if you encounter resistance from the client, don't push them. Remember, the client needs to argue for his or her own change. A "yes but..." statement from the client may indicate you have met resistance and is a sign to gently redirect the conversation to other relevant issues.

Summarise

Briefly summarise all of the information gained from Phase 1.
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