As Sam’s case manager or rehabilitation practitioner, how can you help him?

Step 1: Start with an assessment of Sam (Table 12.1)

This would probably be best in the form of a semi-structured interview plus the use of some standardised assessments. You will need to address the following.

Substance use

• How much has he been drinking?
  
• When does he drink?
  
• What was he doing prior to drinking?
  
• Why does he think he drinks?
  
• How long has he been drinking?
  
• Has he committed any offences while intoxicated?
  
• Has he had any withdrawal symptoms?
  
• Does he think that his substance use is out of control?
  
• Is he worried about his substance use?
  
• Does he wish he could stop?
  
• How difficult would he find it to go without?
  
• Does he want to change his substance use right now?
  
• Does he think he could change his use of substances now if he wanted to?

If you want to assess his readiness to change, the Readiness to Change questionnaire (Rollnick et al., 1992) may be useful.

Table 12.1 Assessment tools for substance use.

Diet

• What is his daily intake of food like?
  
• Does he eat three meals per day?
  
• Is he prone to eating snacks?
  
• What sort of snacks does he eat?
  
• Does he know how to cook?
  
• Does he do the cooking or is it done for him?
  
• If he cooks, what sorts of things does he cook?
  
• Is he wanting to know more about nutrition?
  
• Is he wanting assistance with meal planning and preparation?
  
• Can he identify times when he overeats?

If you want to measure food intake and to also note possible mood effects on the intake of food, then a food/mood diary can be kept for a set period of time (Table 12.2). This records all food and beverage intake, time of intake and requires the person to rate their mood at that time.

Exercise

• What amount of exercise does he do in a day?
  
• Is he interested in any team sports?
  
• Is he interested in individual sport?
  
• How long is it since he regularly participated in any sporting activities?
  
• Has he put on any weight?
  
• If so, why does he think he has put on weight?
  
• Over what period of time has he noticed his weight gain?
  
• What would he like to do about it?
  
• Is he interested in participating in an exercise programme?

Table 12.2 Food/mood diary.

To assess various physical activities, you could use the Health and Nutrition Examination Survey (National Center for Health Statistics, 1973). You could use a simple survey like the one below to give you some idea about Sam’s level of activity and what he is ­interested in. This survey has been adapted from the Active Australia Survey (Australian Institute of Health and Welfare, 2003). It is available on the internet and is free of charge.

The following questions are to find out about the different types of physical activity you did over the past week.

Table 12.3 How do you spend your leisure time?

Step 2: Deciding on a program for Sam

You will need to decide whether Sam would be best off attending a group programme in rehabilitation or whether some individual sessions would be more effective. This decision is usually based on the person’s circumstances. In this particular case, Sam has been ­feeling bored and is sitting around not doing much with his time. After discussion with Sam, you both decide that a group programme would suit him best as this would give him a chance to start interacting with other people who are similar to him. You refer him to two group programmes, one a substance misuse program and the other a healthy lifestyle programme.

The substance misuse group programme is designed for young adults under 30 years, as their issues and needs may be different from those of older adults who may have had substance use issues for a longer period of time. Between six and eight clients are included to enable a sense of group cohesion and trust to develop. This particular group programme is run during business hours over an 8-week period and each session is 3 hours in ­duration. The preferred venue for this group is a neutral community setting which is considered to be less stigmatising.

As well as information giving and sharing, clients engage in goal setting, discussions, brainstorming, role play and practical experiences. Handouts are used to reinforce content. Active participation in leisure activities provides clients with practical experiences that enhance their wellbeing and enables them to experience alternative ways of obtaining satisfaction and enjoyment. This programme may be modified if you need to conduct individual sessions with the client.

A substance misuse group programme

Session 1: Introduction

The introductory group is facilitated by the group leader(s). In this session, the facilitators introduce themselves to the group members and discuss the outline of the programme. Discuss concepts of interactive style of education and participation in positive substance-free fun/leisure activities weekly. Have the participants introduce themselves to the group. Ask what stops people from participating in leisure activities and how their substance use affects their participation.

Explore group participants’ expectations

List participants’ goals and expectations from attending the group.

Getting acquainted

Use warm-up activities to enable participants to get to know each other and to explore their strengths and areas they want to work on.

The recovery journey

Identify where participants are in the journey by providing them with a diagram of a road where one end represents the achievement of their desired goal and the other represents the beginning of the journey. Ask participants to indicate where they are on the road and encourage them to explore where they are in relation to others in the group.

Stages of Change Model

Explain that change may occur when the costs versus benefits of behaviours are considered. Explore the pros and cons of substance use with participants. Identify discrepancies between the pros and cons to understand the participants’ decisional balance. Discuss the Stages of Change Model and determine the stage participants are at.

Baseline assessment

Use standardised measures.

Session evaluation

Ask participants to circle words that describe how they felt about the session, things they enjoyed the most, things they would like to change and one thing they will take away from the session.

Leisure activity

Participate in an activity selected by the group, for example bush walking.

Session 2: Coping with cravings

The introduction and warm-up exercise are facilitated by the group leader.

Effects of intoxication

This is an information-giving section facilitated by the group leader. This addresses the effects of intoxication and withdrawal and the influence of substance use on mental health.

Awareness of cravings

Ask the group members to describe their cravings, if they have them. Brainstorm and discuss ideas about delaying cravings. Emphasise the importance of distraction and engaging in activities not connected with using.

Changing negative self-talk

Discuss how negative self-talk and beliefs can often lead to lapsing into substance use. Provide a handout on steps to changing thinking, challenging negative thinking, demanding evidence, reasoning it out, substituting with a better option, replacing the word ‘should’ with ‘could’, giving oneself permission to feel good. Ask participants to tell the group one positive thing about themselves or their progress.

Session evaluation

The evaluation of the session is the same as for session 1.

Leisure activity

Participate in an activity selected by the group, for example swimming.

Session 3: Communication

The introduction and warm-up exercise are facilitated by the group leader.

Communication

Brainstorm ideas about effective communication. Discuss how people’s perceptions of an event can be masked by their substance use. Discuss communication differences when using and not using substances.

Problem solving

What is a problem? How do problems affect participants? How do they currently solve problems? Discuss problems experienced by group participants and possible solutions. Provide a handout on steps to solve problems – identify thoughts and feelings about the problems, define the problem, identify alternatives, choose an option, create an action plan and practise. Role play an exercise in problem solving.

Session evaluation

Complete the session evaluation as for session 1.

Leisure activity

Participate in an activity selected by the group, for example volleyball.

Session 4: Planning for high-risk situations

The introduction and warm-up exercise are facilitated by the group leader.

What to do in high-risk situations

Brainstorm ideas.

Skills to cope with relapse triggers

Discuss signs and signals of stress reactions and coping skills. Ask group participants to identify stressful situations. Discuss how these situations can be reframed. Discuss ­positive affirmations. Practise relaxation techniques.

Session evaluation

This is the same as for session 1.

Leisure activity

Participate in an activity selected by the group, for example canoeing.

Session 5: Setting goals

The introduction and warm-up exercise are facilitated by the group leader.

Goal setting

Information giving facilitated by the group leader. Brainstorm what goals are and how to set them. Provide a handout on principles of goal setting, making goals observable, ­realistic, achievable and action oriented. Look at the steps involved in successful goal ­setting. Practise setting a goal. Ask the group to say one positive thing that they have achieved since the group started.

Time use

Discuss time use. Complete a time pie. Discuss good time management.

Session evaluation

This is the same as for session 1.

Leisure activity

Participate in an activity selected by the group, for example basketball.

Session 6: Substance refusal skills

The introduction and warm-up exercise are facilitated by the group leader.

Drink refusal skills

Information giving by the group leader. Ask participants to describe situations in which they had problems refusing substances. Brainstorm more assertive responses. Role play refusal of substances. Discuss what it was like for participants in the role play and for those watching. Provide a handout on drink refusal skills, for example verbal strategies (‘not for me, thanks’), non-verbal strategies (using body language and eye contact), alternatives (change the subject, request that the other person stop asking them to use).

Conflict resolution, assertiveness and anger management

Information giving by group leader about verbal and non-verbal behaviour, assertive behaviour and anger. Brainstorm personal experiences of anger. Provide a handout on anger management solutions, for example taking time out, changing the focus, addressing one’s thinking (don’t personalise or jump to conclusions), and go through it with the group. Look at what is assertive behaviour. Role play an alternative way of expressing anger using recent scenarios provided by a participant. General discussion about how they felt about the activity.

Session evaluation

This is the same as for session 1.

Leisure activity

Participate in an activity selected by the group, for example ten-pin bowling.

Session 7: Lifestyle changes

Introduction and warm-up activity are facilitated by the group leader.

Finding alternatives to substance use

Identify interests and current activity levels. What are the participants interested in? List participants’ desired lifestyle changes. Identify barriers to making changes and discuss barriers to making changes. Explore ways to overcome barriers.

Community resources and services

Provide a handout on resources and services in the local area. Get group members to identify one positive aspect of joining community groups by the end of the session.

Changing negative self-talk

Discuss negative self-talk and the importance of positive affirmations.

Session evaluation

This is the same as for session 1.

Leisure activity

Participate in an activity selected by the group, for example tennis.

Session 8: Leisure

Introduction and warm-up activity are facilitated by the group leader.

Importance of leisure

Discuss the benefits of leisure participation and planning for the future. Discuss the importance of keeping active.

Leisure activity

Participate in an activity selected by the group, for example a BBQ.

Readminister baseline assessment and complete overall evaluation of the group. It may be useful to evaluate the leisure component of the programme with the Leisure Motivation Scale (Beard & Ragheb, 1983).

Celebrate completion of the group programme. Hand out certificates of attendance.

Healthy lifestyle programme

In addition to the substance misuse programme, you decide that a lifestyle group would be beneficial for Sam. Lifestyle groups are useful for any clients for whom poor lifestyle habits have been identified. Clients with psychotic disorders comprise the majority of clients in these programmes because poor nutritional intake and physical inactivity are significant issues for them (Catapano & Castle, 2003; McLeod et al., 2009).

This particular lifestyle group is run over 9 weeks, with 2-hourly sessions twice weekly. Clients are given the opportunity to continue in the group for the following 9 weeks to consolidate their skills and lifestyle changes.

This programme requires a venue with a sizeable group room and ready access to ­cooking facilities for the nutritional component. If these facilities are not available, ­individual work may be more effective. Other practical components take place at a local supermarket and gym. It is important that Sam is checked out by the GP to make sure he doesn’t have any physical problems that would be compounded by attending the fitness programme.

This group programme assists clients to set goals with regard to their nutritional intake, spending habits and physical activity levels. In the nutritional and budgeting sections of the group programme, the principal approach involves the use of a proportional spending model, which means demonstrating that the nutritional quality of a person’s diet can be improved by changing the proportion of funds available to spend on various types of foods. Clients are assisted to balance their diet and food budget and to understand how good nutrition and physical activity work together to achieve a healthy lifestyle.

Fitness

The fitness component of the group programme consists of a 15-minute warm-up, a 30-minute circuit or exercise class and a cooldown session. Clients are also involved in developing an activity plan and setting goals. So even though people do exercises in the programme, there is a need to emphasise that exercise needs to be incorporated into ­everyday activity. It may be useful to talk to Sam about getting involved in some of the programmes sponsored by local authorities. You could help Sam search the web for free or low-cost programmes offered by city councils or other organisations. He can also locate his nearest park or other places where he would be able to engage in healthy ­activities. Sam might also consider trying out an activity he has never done before by ­joining a beginner’s group. Many activities are offered at minimal cost and some are free. The sessions offered by the council cater to all ages and fitness levels.

Explain that physical activity is something that everyone can enjoy and point out that making activity a regular part of your day has lots of benefits to health and wellbeing.

Box 12.1 lists of some of the activities that might be available.