Manual test pdf2

Duncan Raistrick SGTOEIANDGY iSBNT manual

iSBNT manual Gillian Tober and Duncan Raistrick v2.2 May 2021 iSBNT manual Page 1

iSBNT manual Use this manual in conjunction with result4addiction Adapted from: COPELLO A, ORFORD J, HODGSON R, TOBER G, GODFREY C, HEATHER N, RAISTRICK D, RUSSELL I (1998) Social Behaviour and Network Therapy: A Clinical Guide for Therapists Treating Alcohol and Drug Misuse. UKATT (United Kingdom Alcohol Treatment Trial) About iSBNT principles of practice iSBNT manual Page 2

iSBNT manual Using the result4addiction website The result4addiction website is designed to accompany the iSBNT manual. It provides: iSBNT manual Page 3

iSBNT manual  Self-assessment tests and recovery tasks i SBNT demonstration videos i SBNT worksheets to download S  cienti c evidence and references  Learning materials for practitioners Good practice Collect information before treatment sessions. This saves time otherwise spent completing questionnaires and means the practitioner can open up a meaningful discourse from the start of the session. This principle can be applied before the rst session. Ask new clients to complete the self-assessment My Addiction and email the results to the practitioner. Show your client how to put a RESULT icon onto their phone... ▷mobiles and posters Introduction Integrated Social Behaviour and Network Therapy, iSBNT, is the practice of helping to bring about substance use behaviour change in a supportive network of family and friends. The person with the substance use problem is called the focal person (FP) throughout. The manual directs the practitioner to use a motivational style of dialogue to deliver behaviour change interventions with the help of a supportive network of family and friends (NMs): iSBNT manual Page 4

iSBNT manual T  he assessment, the rst session, is best seen as part of the treatment itself and should be conducted in the style of motivational dialogue I  deally treatment will be delivered in a xed number of sessions, to be agreed in the network early on, and in line with the practitioner’s resources T  he substance use goal will be based upon the assessment of the severity of the addiction and related problems, and on the motivation of the client and those around them to change their drinking or drug taking behaviour  Ending treatment is about ensuring sustainable change plans are in place.  No less than 30 minutes is recommended for the duration of each session, while an hour would be the maximum T  he overarching principle of the treatment is to think network – always think about how to involve and supportive family and friends In every treatment session the practitioner has in mind three questions for the FP. These help to keep everyone in the network focussed. 1. Where are you now? 2. Where do you want to be? 3. How are you going to get there? Use the manual flexibly The provisional treatment plan may be modi ed as treatment proceeds. Depending on the initial assessment, iSBNT can be a brief or extended intervention. iSBNT manual Page 5

iSBNT manual The key to the application of the manual is exibility, that is, agreeing and completing tasks at the pace of the FP’s and NMs’ e orts to change and actual progress. For example, a decision to change the substance use behaviour may not be achieved at the rst session; more time may be needed to resolve ambivalence. This may then be tackled again with the assistance of the network that has been recruited. This does not mean that treatment is open-ended. On the contrary, it is task and objective driven and non-completion of tasks or non-achievement of objectives does not mean endless treatment. A manual cannot anticipate all of the situations in which you are seeking to help your FP in treatment; the skill of practitioners is to apply the principles and practices outlined here to particular cases. The manual provides a framework for the delivery of structured work where there can be a strong need for structure in the face of crises and apparent chaos. Using the manual exibly means adapting to the FP’s and NMs’ particular needs. What needs to remain constant is that each session has structure and purpose, and that these are set out at the beginning of the session and summarised at the end. A combination of good clinical judgement and planning can obviate some of the problems that complex FPs can present to busy practitioners, and for whom ‘ re- ghting’ inadvertently becomes the dominant style of working. Practitioner Competences iSBNT manual Page 6

iSBNT manual E ective practitioners will have the ability to build a therapeutic alliance with their FPs and NMs. A therapeutic alliance refers to the degree of mutual respect and understanding between the practitioner, the FP and the NMs. It comes from the practitioner’s ability to communicate empathy, a non-judgmental approach and a task orientation. It will be built upon the perception of the practitioner as a source of help in the resolution of particular problems. The practitioner’s role is team leader in modelling these behaviours. Training and supervision underpin the acquisition and maintenance of practitioner competence. The basic skills on which the interventions are built derive from the well-established core skills of listening, expressing empathy, positive regard and respect, as described by Carl Rogers and demonstrated to be e ective in repeated studies of therapist characteristics. These are combined with the directiveness expressed in motivational interviewing and cognitive behavioural counselling to produce a purposeful, agenda driven, non- confrontational practice style. Watch the video of Carl Rogers talking about empathy iSBNT manual Page 7

iSBNT manual The content of treatment is as important as the style of its delivery; the evidence informs us which behaviour change techniques are associated with good outcomes. The competent practitioner uses goal setting and eliciting commitment to a goal, planning speci c behaviours that result in alternative rewards, implementing these in homework tasks, monitoring behaviour and reviewing goals. These competences may not come naturally and need to be taught in the context of continuing professional development. It should go without saying that a thorough knowledge of the e ects of alcohol and drugs on behaviour, psychological and physical health and social functioning and the outcomes of treatment is a prerequisite for the acceptance of the practitioner as an authoritative source of help who will have legitimacy for the task in the eyes of service users, their families and concerned others. Watch the slide shows on How Drugs Work and Why Drugs are Addictive. Regular supervision has been demonstrated to be essential: competences are lost without constant vigilance and supervision of recorded practice, and even the most experienced practitioners lose focus and drift away from good practice habits. The manual is no substitute either for training or supervision but forms the reference point on which to build both. Timing of Interventions iSBNT manual Page 8

iSBNT manual The starting point of treatment is determined by the motivation of the FP and NMs: there may be resistance to change, ambivalence about change, contemplation of change, or determination to change along with behaviour change plans and actions. Some FPs will be in the business of maintaining changes already made. People who are undecided about change are likely to have: 1. an overriding perception of the rewards of drinking or drug use 2. denial, rationalisation or minimisation of adverse consequences 3. low self-e cacy for change 4. low positive outcome expectancy for change As people move towards considering change, their motivation will be more evenly balanced; they may experience: 1. greater ambivalence regarding their drinking or drug use 2. recognition of actual or potential adverse consequences 3. greater concerns about their drinking or drug use 4. more thoughts about the possibility and bene ts of change Determination to change is characterised by: 1. a de nite commitment to a change plan 2. belief in an ability to carry out the plan 3. belief in the bene ts of carrying out the plan iSBNT manual Page 9

iSBNT manual Once people have changed their drinking or drug use and are faced with the tasks of maintaining the changes, they need to: 1. maintain vigilance for high risk situations 2. identify rewards for their changed behaviour 3. maintain self-e cacy for change There will be an overall goal for the intervention which should be stated at the outset of each session. Speci c and concrete goals need to be set for each step in the change process, and these will depend upon changing motivation, self- e cacy, coping ability, and the therapeutic alliance with the FP. The key is to agree that treatment is a collaborative venture – the agreement of treatment goals and treatment tasks are elements of an e ective therapeutic alliance. Basic Skills: motivational dialogue The best results are achieved by using a motivational dialogue style of treatment delivery throughout all interactions with FPs. Read Tober and Raistrick on ‘Motivational Dialogue’ chapter 12 iSBNT manual Page 10

iSBNT manual This is a purposeful way of talking with a FP and NMs, using the core skills of open questions and selective re ective listening to identify and work towards the treatment goal. Motivational dialogue is the style of choice whether building motivation to change, applying behaviour change techniques or for maintenance of behaviour change. The motivational dialogue method allows the practitioner to address the FP’s and NMs’ pace and stage of change, as well as appreciating their perceptions and thoughts and feelings about the work at hand – but it also facilitates moving the dialogue forward. This method of dialogue and exchange with the FP and their network facilitates navigation through the change process, while maintaining respect, empathy and focus on progress and strengthening self-e cacy. Basic Skills: behaviour change techniques The problem solving approach provides a framework for planning behaviour change steps. It is useful to remember 7 steps for a problem solving exercise: 1. Clearly de ne the problem (rather than ‘I don’t have enough money’, make it speci c such as ‘I need to nd £X a week to pay o my credit card bill’) 2. Think of as many solutions to the problem as you can (brainstorming) 3. Look at the advantages & disadvantages of each solution 4. Choose one of the solutions 5. Plan and agree the steps to carry it out 6. Carry out the plan 7. Review the outcome (Was it successful? Did I achieve the goal? What did I learn?) iSBNT manual Page 11

iSBNT manual Behaviour change tasks (solutions in the problem solving approach described above) are agreed in the network and carried out according to a homework plan set, then reviewed for level of success or need to modify. The structure of each session therefore consists of reviewing the questions: ‘where are you now’, ‘where do you want to be’ and ‘how are you going to get there’. In this way, the treatment goal and the goal for the session are continually reiterated. Skill rehearsal is the basis for trying out new behaviours and can occur during sessions or be planned to be carried out between sessions; the FP’s and NMs’ skill level and con dence to apply the skills in their own environment is incrementally developed. The important thing to remember is to monitor and review task completion and its impact. Setting Expectations One of the best ways to communicate commitment to the FP and NMs is to get all the planned appointments in the diary at the outset. This sets an expectation of attendance. At the beginning of treatment it is worth stating some expectations and ground rules. These may need to be repeated from time to time: iSBNT manual Page 12

iSBNT manual A  treatment goal or goals will be decided and worked towards. This may be negotiated with the FP alone or with FP and NMs and will form the kernel of the work to be done in sessions A  ttendance at all sessions is expected. With the consent of the FP, NMs will be encouraged to attend whether or not the FP does T  he treatment will be a collaborative process involving practical tasks for all during and between sessions. Skills rehearsal and between session practice are essential to success T  he content of sessions is con dential and this will be agreed with all NMs. Recording sessions for supervision and training purposes is good practice and will need the informed consent of the FP and NMs.  Drinking and drug use are the focus of this treatment; other problems often co-exist, but little will be achieved without targeting the problem drinking or drug use S  ome circumstances take precedence over the treatment plan and need urgently to be addressed, for example safeguarding children, risk of suicide or self-harm, homelessness and sustenance. Summary of Tasks for Practitioners The formula for guiding the entire treatment episode and each session, whether there is one or many is made up of the following set of questions: 1. Where are you now? 2. Where do you want to be? 3. How are you going to get there? iSBNT manual Page 13

iSBNT manual The question of how are you going to get there involves the ‘who will be there with you’ and ‘what will they do’. The following are the building blocks of your practice: F  ocus on engaging and motivating your FP and network from the outset  Treatment is collaborative and the practitioner is responsible for building the therapeutic alliance G  oals and tasks are agreed by the network T  he motivational dialogue skills of open-ended questions and selective re ective listening are used throughout T  he focus is on the present and the future, rather than the past  Use positive language; emphasise strengths F  ocus on making changes to your FP’s and NMs’ behaviour G  ive a clear rationale for homework, make it relevant and interesting, within everyone’s skill level, and manageable. Review homework at the start of the session, a rm e ort, address achievements and make di erent plans where necessary  Practise tasks and skills with your FP and NMs in the session Check out your own good practice and rate yourself using the WAI & BPRS. Bringing It All Together Good therapists will use this manual in creative ways that re ect their personal style. However, there are a number of essentials to iSBNT: Involving a supportive network to promote positive change and deal with risky situations which hold the potential for relapse Practitioner interactions with the FP and NMs are in the style of motivational dialogue iSBNT manual Page 14

iSBNT manual Behaviour change techniques involve structure, skill rehearsal and homework Essential iSBNT a social network based context In every treatment session the practitioner has in mind three questions for the FP. These help to keep everyone in the network focussed. 1. Where are you now? 2. Where do you want to be? 3. How are you going to get there? iSBNT manual Page 15

iSBNT manual Using the result4addiction website iSBNT manual Page 16

iSBNT manual You can use the online Network Task to map the FP social network and keep this for future reference. The Network Task can be completed in a treatment session working collaboratively with the FP or be given as homework in anticipation of a session. Show your client where to nd the recovery tasks. Why have a network? P  eople who have support for change do better F  amily and friends do better when they are involved in treatment  Improvements are sustained past the period of formal treatment The social network is the forum for the agreement and achievement of treatment goals. The practitioner’s role is to mobilise a social network supportive of change. This is the distinctive feature of iSBNT. The FP’s existing social situation will vary along a spectrum from total isolation to having an extensive range of people willing to o er support. The objective is to develop positive support for change and the maintenance of change, with at least one supportive person. It may be that not everybody in the FP’s existing network will support change and therefore may not be suitable NMs. Problem drinking and drug use a ects both the FP and their family and friends. NMs a ected by the FP’s drinking or drug use may well be under stress and at risk of developing problems themselves; working in the network can lead to reduced stress and increased con dence for them. The ideal NM should: iSBNT manual Page 17

iSBNT manual B  e available to the FP  Have a positive relationship with the FP  Be prepared to be rm but kind with the FP  Be able to agree with the FP about their drinking and drug use goals  Be willing to work with other members of the network, during treatment and afterwards to develop and maintain a consistent, agreed policy with regards to maintenance of change and relapse prevention They should not: H  ave an alcohol or drug misuse problem themselves B  e under 16 years of age H  ave a chaotic lifestyle or untreated mental illness Take a look at the importance of trusted family and friends in supporting recovery. Working in the network The essence of network treatment is always think network. It may be that the FP has in place a supportive and constructive network of people who are concerned and want to help bring about change. In this case simply inviting them to be part of the treatment is straightforward. Such a network can help with goal setting, behaviour change planning and management. It may be that the network is needed to help the FP reach the best goals for their particular problems. iSBNT manual Page 18

iSBNT manual Role of the practitioner  The practitioner is a member of the network too and needs to be an active agent of change. This can involve assistance and support for NMs as well as the FP, though NMs with their own problems should be advised to seek help for these elsewhere. Identify who in the network could be invited to participate in sessions and who might play a more indirectly supportive role. Allocate tasks to di erent NMs and insert these in a network map. Gather information on relationships between NMs and the FP, for example their views/attitudes about the drinking problem, the support o ered at present or in the past, the frequency of contact, activities they do or have done together. Help the FP to distinguish di erent types of support, for example direct support for nding non drinking/drug use activities, or indirect support such as looking after the children while the FP goes to the cinema. The practitioner needs to establish how the treatment plan is going to look and agree the way forward with the FP and NMs. Working with NMs in the absence of the FP should be agreed as a possibility at the outset. Research has shown that this approach can help to re-engage the FP in treatment. It is advisable to review the network periodically and consider recruiting new members to it. Speci c tasks are... iSBNT manual Page 19

iSBNT manual E  xplain the importance of social support in achieving positive outcomes to the FP and potential NMs  State to NMs the preliminary goal for which you are recruiting support C  ontinually seek to identify people who can provide positive support D  raw a network map with NMs’ roles de ned P  lan FP and NMs’ activities P  lan maintenance and renewal of the network Role of the NMs NMs are encouraged to attend as often as possible. It may be that some network members join temporarily for particular tasks. Support can vary from friendship to providing helpful information and may be o ered not just from close friends and relatives but also from the community at large. Support can also change: what starts as a contact for information may become a source of moral support or even a friendship. Dependable friendships take time to develop or recover. Here are some speci c types of support: iSBNT manual Page 20

iSBNT manual M  oral support – giving encouragement and positive feedback to the FP  Solving problems – other people may have had a similar problem and/or be good at weighing up di erent sides to a situation H  elp with tasks - simply sharing the load and/or bringing some particular knowledge or skills to a situation  Organisational help - arranging a fun social activity, a rewarding task, or practical support such as driving to and from activities P  roviding information - making available resources or information for example about courses, jobs, leisure activities, support services, specialist advice  Emergency help – for example, nancial or equipment loans, transport. How to create a network map iSBNT manual Page 21

iSBNT manual  Describe the rationale of the network-based treatment process to the FP (and NMs if present) including the bene ts of developing a supportive network compared to working alone D  escribe the nature of the people suitable to be members of the network: that they are not problem drinkers or drug takers, that they are concerned about the FP and support their goal, that they are available to give support D  raw the network, build up an understanding of who is already in the FP’s social network, and identify who may be supportive to the FP. Do not be afraid to say that the FP’s nearest and dearest might not be suitable for this network  Agree a plan to recruit potential NMs, namely who will approach them, when and how. If the FP lacks the communication skills necessary to make this achievable, role play the dialogue that needs to take place Examples of dialogue  “Who is there who you care about and who cares about you?” “Who would be willing to do things with you which would help you to avoid drinking?” “Who would you like to spend more time with when you are not drinking/taking drugs?”  “How do you think you might describe to your friend what it is that we are doing?” “What sorts of things do you think they might want to know?”  This is what your network map might look like… iSBNT manual Page 22

iSBNT manual iSBNT manual Page 23

iSBNT manual The diagram above is one way of drawing a network map; practitioners can be imaginative in how they want to illustrate the FP’s network and NM roles. The map can be dynamic re ecting the development and actions of the network, and may be changed over time. Outcomes from networking 1. A supportive network is in place, illustrated by the Network Map, and may include carers/professionals 2. NMs understand and plan to carry out their roles 3. NMs provide support for each other 4. Plans are in place for future network support 5. The goal of treatment is agreed and restated Homework suggestions 1. Network tasks: approach individuals who have been identi ed in the session, explain the nature of the treatment, report the treatment goal and ask them if they will join the network. 2. Practise writing to people as well as speaking to them. 3. Go to the result4addiction website and complete the networking tasks Issues that may arise Here are some issues that commonly arise alongside the business of building a network – there may be others. It is up to the practitioner to use their judgement on how best to deal with these if they become a concern during treatment. 1. People can give support without being a network member iSBNT manual Page 24

iSBNT manual There are people who can give support outside the network: the local shopkeeper who sells alcohol can be persuaded not to sell alcohol to the focal person, and this can be set up by the FP helped by an NM. In cases that have a child protection or dual diagnosis dimension, and where there is active involvement from social services or health professionals, it may be useful to invite these people to some sessions. Such professionals will have a keen interest in what is happening in treatment, the FP’s response to it and the extent of their social support for change. However, the nature of the power relationship between the FP and NMs is an important one to keep in mind. The FP needs to feel support rather than coercion from members of the network. This does not preclude parents, social workers or senior colleagues being members of the network for a period of time, as long as they come in the spirit of mutual aid and support. 2. Communication in the network iSBNT manual Page 25

iSBNT manual Good communication in the network stems from the ability of the FP and NMs to tell each other how they feel and what is helpful, without fear of criticism and rejection. Network members may need to practise listening to each other and responding in turn, not interrupting, not blaming, and respecting each other’s point of view. The iSBNT therapist should be aware that the FP and NMs could have damaging communication patterns. Such patterns may contribute to the re- occurrence, maintenance or escalation of the substance misuse problem. Communication issues must be dealt with. An example of network dialogue might be: a) Michael says that when Maria tells him “I can’t cope with you going back to drinking” Michael assumes that she is threatening to end their relationship. Michael responds by saying “do what you have to do then” whereupon he leaves the house, feeling angry, hurt, let down and at high risk of drinking or taking drugs. The practitioner can ask Michael to check this understanding with Maria. This will give Maria the opportunity to tell Michael how she feels, and ask him what would be a helpful response from his point of view. The practitioner can then ask “how would you want to say this to each other? What would you do di erently in the future?” Look out for unhelpful communication styles. For instance: b) Blaming “It’s your fault that I…” c) Defensiveness “What do you expect me to say…” iSBNT manual Page 26

iSBNT manual d) Being judgemental “That’s what you always do…” e) Making assumptions “So that’s what you think…” Where communication is a problem explore current communication and responses between members of the network and plan new, constructive styles where necessary. To do this: 1. Ask the FP and NM to describe actual situations 2. Ask the FP and NMs to describe the impact of poor communication styles, and the way they a ect their relationships and behaviours 3. Make plans for new strategies, record the plans and their outcomes 4. Review and amend as necessary Communication patterns and their e ects on the FP and NMs need to be highlighted and discussed. It may be helpful to facilitate a conversation where each person present has the opportunity to say how it makes them feel and what they would prefer to happen. As a result, alternative methods of communication can be agreed and rehearsed. Here are some situations where communication di culties often arise: f) Asking for help  dealing with drinking or drug use situations w  ith practical matters  dealing with craving  recruiting additional NMs iSBNT manual Page 27

iSBNT manual g) Managing criticism  exploring feelings that result from criticism b  uilding self esteem t  urning it into a positive, helpful experience h) Listening and conversation skills  talking in turn a  cknowledging feelings t  alking about things other than drinking 3. Problem NMs Where the concerned others present are angry, frustrated, or do not share an appropriate treatment goal, their presence in the network will be unhelpful. The network approach is not an opportunity to sort out NMs’ problems and they may need to be steered elsewhere for this purpose. Example dialogue: “Now may not be the right time for you to give support to your brother; perhaps if you are still feeling angry with him, it might help you to speak to someone, a friend or a professional person, and we can come back to it at a later date.” 4. FP resistant to networking iSBNT manual Page 28

iSBNT manual Some people see their drinking or drug use as their own problem and believe they should be self-reliant when dealing with it. However, the most common reason for this kind of resistance is that the FP is reluctant to change their drinking or drug use. While the practitioner respects the FP’s reluctance to involve others they may: E  licit from the FP their thoughts on what their concerned others would say in response A  ssess the motivational state with reference to changing drinking or drug use, and nd an area of the FP’s life that they do want to change W  here the FP says she/he does not want to involve anyone else, think about a virtual network where the FP is getting positive support without those people knowing that the support is to avoid drinking or drug use 5. Alienated potential NMs and absence of NMs iSBNT manual Page 29

iSBNT manual The FP may not be using their NMs in a supportive way or may lack sources of support: for example they may have alienated potentially supportive NMs or may lack the skills to communicate with them. There may be potential NMs who may have become distant due to the FP’s drinking or drug use. Possible action: i) consider those with whom relationships have become strained or distant, to explore whether they might be suitable NMs in the future ii) discuss ways of contacting potential NMs that are acceptable to the FP, for instance by message or email rather than more direct phone call or face-to-face encounter iii) if there are no identi able NMs it may be necessary to look at recruiting alternative support from outside the FP’s network, for example support groups or other professionals. 6. Ensuring support for the FP and NMs The point of network treatment is that everyone is supported – the FP, the NMs and the practitioner and no one person carries all the responsibility. It is shared in the network. If there are indications that the FP or NMs are not feeling supported then this needs to be explored. Example dialogue... To the NM “What sort of support do you think would be useful? Have you got a friend or family member who can support you? Have you tried Al-Anon (or other mutual support group for family members)?” iSBNT manual Page 30

iSBNT manual To the FP “What do you think you could do to make things easier for your mother, in understanding what is going on, what would be helpful?” “Is there something you could do in return?” Possible action: AA/NA , Al-Anon and carers’ groups can o er high levels of easily accessible support, as can other befriending agencies/day- centres/community support services. It is important to convey optimism about the possibilities of developing positive social support, even if the current network is limited. It is good to give out lists of support agencies. 7. Bad in uences Where some or all of the FP’s social contact is still with other problem drinkers or drug takers, they are exposed to attitudes and behaviours that are unhelpful to, or at odds with, attempts to make positive changes through treatment. The challenge for the practitioner is to make and elicit suggestions about how to minimise this contact and its e ects whilst ensuring the FP does not feel even more socially isolated and unsupported. If this is not handled carefully, the FP could withdraw their consent to receive this intervention, believing that it is doing more harm than good. Example dialogue “What is going to help in avoiding person x in the future?” “What sorts of things can we think of putting in place to build a network that will help communicate to them that you are not going to be drinking/taking drugs in the future?” “Can we try out some things that you might say to them?” iSBNT manual Page 31

iSBNT manual “Let’s have a look at what sort of support groups for abstinence are available. Let’s get some information on activities that are planned for service users who are abstinent”. “What sorts of things can we think of that would bring you into contact with new (non-drinking/non drug-taking) people?” “What would you feel comfortable trying out?” “Who could we ask to go to this with you?” Possible action: At this point think about the available community resources for employment, training, alternative pleasurable activities. The practitioner might suggest recruiting a housing support worker, a health care assistant or other available support worker to accompany the FP to get them engaged in identifying new sources of social support and alternative activities. All AA and NA groups hold open meetings to which a NM could accompany the FP. Watch the videos of Gillian Tober demonstrating building a network. Essential iSBNT the drinking/drug use goal and the coping skills plan In every treatment session the practitioner has in mind three questions for the FP. These help to keep everyone in the network focussed. 1. Where are you now? 2. Where do you want to be? 3. How are you going to get there? iSBNT manual Page 32

iSBNT manual Using the result4addiction website iSBNT manual Page 33

iSBNT manual You can use the online Substance Use Task to map the FP alcohol & drugs pro le and keep this for future reference. If the FP is taking prescribed drugs, also use the Medication Task. These tasks can be completed in a treatment session working collaboratively with the FP or be given as homework in anticipation of a session. Take a look at the summary of homework tasks you can give - you might ask your client to complete a substance use pro le or check out the appropriateness of their medication. Why set goals? Research tells us that e ective therapists are more likely to maintain focus by agreeing and stating a goal at the outset, and re-stating it throughout treatment. The problem solving approach is a good way to set goals, which should be decided at the outset, providing the starting point for behavioural planning.There are good practice guidelines for deciding the substance use goal. An abstinence goal is best for both drinking and drug use where there is physical or psychological harm, pregnancy or safeguarding concerns. Practitioners cannot condone or sanction illegal or harmful behaviours. Moderation goals may be appropriate to pursue where FPs have shown some ability to control their substance use, have good social support for control and an absence of physical damage and mental illness. Practical guide to goal setting Aim iSBNT manual Page 34

iSBNT manual 1. Understand the FP’s current substance use 2. Establish substance use harms 3. Agree where the FP wants to be in relation to their substance use 4. Elicit commitment to change by setting a goal or goals Action 1. Get an account of the recent substance use behaviour 2. Elicit concerns about the behaviour and its consequences 3. Explore the motivation for change and the self-e cacy for achieving a concrete plan 4. Agree a change plan accompanied by optimism about the outcomes of change It is important to be thinking about eliciting change talk and commitment: concerns, problem recognition and disadvantages of drinking or drug taking; advantages of change; setting a goal; making a plan. In eliciting concerns, be mindful of the FP’s own concerns and try to establish the most worrying to them. If dealing with complex cases, integrate mental and physical health concerns or pregnancy and parenting issues alongside those about the drinking or drug use. Commitment talk is an important predictor of behaviour change, so the practitioner needs to tune into this type of FP speech, recognise it and re ect it. The strength of commitment talk is also important: “I’m going to stop drinking on Monday” has greater strength than “I think I might try to stop”. iSBNT manual Page 35

iSBNT manual The skill is to adapt the dialogue to suit the individual FP and NMs. Practitioners should be familiar with the FP’s circumstances and previous history accurately to identify potential areas of greatest concern and ask what the FP wants to do about it. Eliciting concerns is about getting the FP to tell you what these are, as the practitioner may have di erent concerns. Examples of dialogue to elicit concerns ... “Describe a typical day when you drink/take drugs”  “What kinds of things happen when you have been drinking/taking drugs?”  “You have seen the impact of your drinking on your liver function test results; tell me what this means to you?” Get the NMs to contribute their perspective. “What is the worst thing that has happened?” and continue with “Tell me more about that” when problems or worries are mentioned by the FP. Once the FP has expressed a concern or concerns that sound as if they really matter, ask “how would you prefer things to be?” and then “What do you think would help you to get there?” Feedback of test results iSBNT manual Page 36

iSBNT manual If the FP has completed some tests before or during a treatment session then give feedback as soon as possible: the aim is to inform the discussion and secure a commitment for change. You will need to seek consent for this to be done in the presence of NMs and to ensure at each step that everyone understands the results and their implications… E  xplain the tests administered and check the understanding of FP and NMs F  eedback all available results and elicit concerns H  ighlight those results that are likely to change as a result of changes in the substance use E  licit expressions of optimism for the consequences of change  Set a change goal if appropriate A  ssess motivation for the change goal using sliding scales I  dentify areas of motivation to work on, for example self-e cacy or positive outcome expectancy M  ake a change plan in the network  Elicit commitment to the plan with all members of the network If motivation to change substance use is strong, proceed to making a behaviour change plan. If motivation to change is weak, spend more time exploring where the weakness lies: is it in belief in ability to change, or is it in optimism for the bene ts of change? iSBNT manual Page 37

iSBNT manual If the FP has decided that they want to stop drinking or taking drugs, then the assessment results are used to strengthen their resolve and to elicit optimism for the outcome of change, and not to explore concerns about drinking or drug taking that have already been established, as this would be a backward step. If the FP expresses a wish to moderate drinking or drug use and where the assessment indicates this is not likely to succeed, they are to be discouraged from this course of action and encouraged to explore abstinence. This would be the case where the FP has physical damage or illness related to drinking or drug use, where there is unacceptable occupational risk, where there is a co-existing mental health problem or pregnancy, or where family and friends do not support a moderation goal. Share your opinion with the FP and the NMs, who may all need education on drugs and alcohol harms at this point. “Tell me what you think might happen with your blood pressure/liver function if you carry on?” It is sometimes expedient to go along with a moderation goal on the clear understanding that if it is not successful then total abstinence is the next move. “If you think it is too di cult to stop now, how about we could all agree to cutting down over the next two weeks and seeing how this goes?” Alternatively a goal of abstinence can be planned for the short term only, to be reviewed once it has been achieved. iSBNT manual Page 38

iSBNT manual If the FP is resistant to change, it may be that the FP still enjoys drinking or drug use and is reluctant to say so, and even more reluctant to stop. It may be that the FP is not very concerned about the consequences of drinking or drug use and more discussion of this is necessary, or they may be unsure about the bene ts of change. Continue using motivation-building strategies, likely to be based on concerns about the consequences of drinking and drug use. Continue using commitment-strengthening strategies, building on the bene ts of change, especially those that have resulted from some experience of change. Everyone in the network has a contribution to make. “Can you describe some nice times you had before things got di cult?” If a change in substance use cannot be agreed, it can be helpful to discuss speci c situations. The focus is on deepening concerns. The practitioner can get the FP to describe the downside of drinking or drug use and elicit a description of how they would have liked things to be di erent. Explore what would help to make things di erent, with the aim of eliciting an intention to avoid drinking. Remember to include the NMs in these discussions. “What will you want to do di erently next time?” “Who will be able to help you?” “What sorts of things would be helpful?” iSBNT manual Page 39

iSBNT manual The practitioner needs to be sensitive to the reasons for resistance to change. The FP might express strong desire and reasons for change, yet have no belief in their ability to change. This lack of self-e cacy may need to be addressed, rather than repeating reasons for change or bene ts of change. The network is an important source of enhancing self-e cacy for change by o ering help and expressing their belief that change can occur. A rm commitment to change is a concrete plan that can be agreed once resistance to change is overcome. To explore self-e cacy, ask about situations when the FP was tempted to drink or take drugs but did not do so. Reinforce self-e cacy by asking the FP and NMs to clarify what they did to cope successfully in these situations. Elicit positive thoughts about achievements, however small. Since the aim is to enhance the FP’s self-e cacy and self-esteem, emphasise achievements over and above the setbacks the FP might have experienced. The network is included in the conversation by asking the FP what would help and asking NMs what help they can give. Try to get a rm commitment to the treatment goal, the reasons for change, hopes for the future as a result of making a change, the ways in which the FP and NMs will know that things are improving and their vision of how everyone will feel as a result their involvement. Examine potential barriers that may hinder progress. Outcomes of goal setting iSBNT manual Page 40

iSBNT manual There are three possible goals: i) abstinence ii) moderation iii) harm reduction and ideally the practitioner will have achieved: 1. A de nite commitment to the goal from the FP and the network 2. A completed Decision Making worksheet 3. A completed Daily Activities worksheet 4. Summary of areas for change agreed by all 5. Decision Matrix and Daily Activities worksheets can be downloaded from You might want to explore some examples of worksheets and online tools. Homework suggestions 1. Complete the Daily Activities task 2. Complete the Nice Things To Do task 3. Complete a Decision Making worksheet 4. Keep a Drinking or Drug diary if goal is not abstinence or if preparing for detoxi cation Decide and agree which NMs will do these tasks with the FP. Take a look at the summary of homework tasks available in RESULT.  Coping skills What are coping skills? iSBNT manual Page 41

iSBNT manual Coping skills are commonly understood to be the way the FP and NMs respond to high risk situations for drinking or drug use. There are two aspects of coping skills that need to be addressed: there is the question of whether the FP has developed the ability to resist drinking or drug use in high risk situations, and there is the question of how NMs respond to the risk of drinking or drug use, or its occurrence. Whether the chosen goal is abstinence or moderation, the FP will need to apply coping skills to deal with high risk situations. There are situations where the temptation to drink or use drugs is strong, whether during a period of abstinence or where use has already commenced. Di erent people will experience di erent high risk situations and these can be identi ed by FPs and NMs working together. Once high risk situations have been agreed in the network, coping skills can be described, with strengths and weaknesses identi ed. Practice guide FP coping skills Aim  Identify high risk situations for drinking or drug taking  Agree a coping strategy for each situation To do iSBNT manual Page 42

iSBNT manual  Education to understand the nature of high-risk situations C  reate a network based coping strategy  Practise coping in high-risk situations S  election of topics to address, coping with craving and refusal skills as indicated High risk situations It is usually easy to identify several of the most important risk situations for drinking or drug taking or you may have used the result4addiction Substance Use Task in anticipation of this work. The practitioner’s aim is to get to the heart of what it is that makes a speci c situation a high-risk one. The detail that comes from the use of very focused questions – the ‘what, when, where and with whom’ aspects, can be valuable to the FP and NMs in helping them to see that such situations do not just happen, but can be explained in terms of the relationship between thinking and acting. This being a practical intervention, the learning that comes from understanding the link between thoughts, feelings and behaviour can present some concrete ideas and options for coping with such situations without recourse to drinking or drug use. The network brings the collective minds of the FP, NMs and the practitioner together in deciding what will be most helpful and when. iSBNT manual Page 43

iSBNT manual 1. Rank all high-risk situations identi ed in order of risk. Riskiness is assessed by asking the FP to rate how con dent they feel in terms of coping with each one right now 2. Agree with the FP and NMs the plan and tactics for coping with each high- risk situation 3. Where there are skills de cits, the network can suggest coping responses and role play or otherwise explore them until con dence grows to apply them 4. Agree the role of each member of the network in helping the FP to cope 5. Once coping strategies are agreed they can be recorded and rated for con dence to strengthen self-e cacy The scope for high risk situations is limitless. For some situations the solution is obvious, for others use the problem solving approach to come up with a solution. Here are a couple of common examples: 1. Refusal skills example Being able to refuse drink or drugs is an important skill regardless of whether the agreed substance use goal is abstinence or moderation. This is a case where avoidance is a good strategy – simply stay away from people who might want the FP to drink or take drugs. If avoidance is not an option:  Discuss the di culty of using refusal skills – how is it for the FP?  Practise adopting the right body language  Practise an example of refusal iSBNT manual Page 44

iSBNT manual Elicit a risky situation and ask the FP to play the person o ering alcohol or drugs. This will help for two reasons 1) the network will get an idea of how the other person o ers the alcohol or drugs so you can play it realistically later and 2) the FP can see members of the network successfully modelling the skill steps. Role- play and discuss then change roles. Break down the skill into manageable steps for the FP (including body language) ensure that all participants get a sense of success at each step. Feedback and repeat as necessary, adding additional skill and pressure until it feels realistic and the FP feels they have some mastery of the skill. Remember to reinforce positive approximations, and provide coaching to strengthen the skills. Plan to do this in real life situations with one or more network members present. Set practising the skill with a network member and then in high-risk situations as a homework task. 2. Craving example Another common problem is how to deal with cravings. It is di cult to avoid every situation that might trigger cravings and di erent coping strategies might be needed for di erent situations. D  iscuss the nature of craving – how is it for the FP E  ducate on the circumstances of craving I  ntroduce the Risk Situation worksheet and de ne the craving in detail D  evelop some coping skills E  ducation – the nature of craving iSBNT manual Page 45

iSBNT manual The experience of craving is an indication that abstinence is at risk, and this risk should be taken seriously. Motivational strategies are useful here to rea rm the abstinence goal and the importance of maintaining abstinence. Craving is experienced as a physical state accompanied by feelings of discomfort and thoughts of use to relieve discomfort. Cravings are normal and are likely to occur. The important thing to remember is that they don’t tend to last very long. So if your FP can employ a strategy to replace drinking or taking drugs, the craving is likely to subside after a short time. The Risky Situations Worksheet is to be used as a way of understanding the circumstances in which craving is more, and less, likely to occur. Situations which tend to evoke craving can then be explored and addressed – and some of the coping with craving strategies can be adopted where needed. This will be a monitoring record for both FP and NMs for the purpose of reviewing progress. The following are examples of coping skills. Use professional judgment, FP and NM preference to decide which might work best, and always think about the way NMs might be available by phone or other means : a) Talk about your cravings Discuss with the FP options for talking to someone when they feel they are experiencing a craving. Decide which NM might be best placed for this. b) Distract yourself iSBNT manual Page 46

iSBNT manual Agree things to do which will distract the FP from the craving. This needs to be something a person can do instantly, for example, some quick exercise, meditation or talking to the NM or other friend. c) Escape the situation Discuss with the FP options around how to remove themselves from the situation they are in if a craving is developing. For example leave the area, nd a safe place or a safe person. Then use another skill to bring the urge down. d) Change thoughts about drinking or drug taking Help the person to challenge the thoughts. For example say: “I can’t have just one drink/one hit and then stop” or “If I give in I’ll have to start all over again.” Think about all the bene ts of abstinence and think about the negative consequences of relapse. Encourage the person to try not to make catastrophic predictions about cravings, like: “there’s no way I can stand this, so I might as well just drink/take drugs and get it over with”, “I keep having cravings, so I must be an alcoholic/addict, I can’t beat this…”. Cravings usually subside fairly quickly anyway, so think about saying: iSBNT manual Page 47

iSBNT manual \"this will pass\". Restructuring these thoughts and developing strong self-e cacy beliefs will reduce the risk of drinking or drug taking, so they need to practise saying “the craving won’t last long…. I can deal with it.” e) Coping ashcards When the FP is in the grip of a strong craving, it can be hard to think rationally and remember all the things they’re supposed to, so writing some instructions on a phone alert can be useful. The priority is for the FP to be convinced that they can cope with the situation. Here are a few examples of things they might write: T  hings are going well right now, I don’t want to mess it up  This craving will pass if I do something else (recite a poem, count to 100)  I’m not helpless here, what action can I take?  What are the pros and cons right now? R  ing one of the network It is helpful to keep a photograph of a loved one, or favourite activity in a wallet or purse, something the focal person usually carries with them. This can help to refocus on the desired goal. Also having a list in a place where it can be seen every day can help to keep focused and vigilant (for example, the fridge door). Keeping photographs of important others (such as children) may also provide good visual imagery to protect against relapse. iSBNT manual Page 48

iSBNT manual 3. Plan ahead to prevent avoidable triggers Ask the FP and NMs to plan ahead to avoid places and people likely to stimulate craving. Introduce a fteen minute rule so that when craving is experienced, the rule is not to act on the craving for fteen minutes, using distraction, escape, talking about it to someone or any of the above strategies to complement this rule. The idea is that after 15 minutes the craving may have passed, especially if another strategy is used. The 15 minute rule can be extended to suit the FP, however within this time period the craving tends to wear o . a) Activity If the FP has had an addiction for a long time, they may not have many interests left. Quite often, drinking or drug use are the only activities they have done for fun. So when trying to stop, boredom can be the biggest hurdle and can evoke craving. New activities can be planned for times most likely to evoke craving. An iSBNT essential is life style change designed to minimise craving risks. b) Relaxation iSBNT manual Page 49