Helping People who Use Substances: A health promotion perspective

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All psychoactive or “mind-altering” substances, from caffeine to heroin, involve some risk. For thousands of years, people have been using these substances for their benefits, but the risk of experiencing short- or long-term harms is always there.

Many of us can and do use alcohol, cannabis, prescription medications or other substances in ways that carry minimal risk of harm. But sometimes we may lose our way and start using more, or more often, for a wide variety of personal, social or environmental reasons. What’s more, these reasons may feed on each other, leading to an even bigger substance use problem with more risk of harmful consequences to ourselves and others.

As a general rule, when our substance use starts to negatively affect our relationships, work performance, finances or health, we have a problem and may want to think about making some changes.

Helping others

Anyone who has contact with people who may be using substances in harmful or risky ways has a unique opportunity to influence the way they think and feel about their use, and help them make changes to reduce the harms they are experiencing or causing in others.

Using a health promotion approach, helping someone make changes is less about telling them how to manage or reduce risks and harms and more about enabling them to increase control over their health. This often involves encouraging them to reflect on their own goals, desires, needs, strengths and resources.

This perspective helps us to work with people to support them in making sense of the complexity of factors that influences their health and well-being, to increase their capacity to manage those factors in achieving their goals and aspirations and, ultimately, to engage with them and their communities in creating healthier environments.

The helping path

The goal in helping people is recovery, viewed as overcoming the negative impacts of a mental health or substance use problem.

Some people use “recovery” to refer to a lifestyle that involves complete abstinence from alcohol or other drugs. To them, the use of the substance at any time after achieving a period of abstinence means “relapse.”

But a growing number of health professionals and others are associating recovery with a person’s ability to manage the normal expectations of daily life, whether this involves substance use or not. In this context, helping involves encouraging people to see themselves as an integral part of the healing process. It means both rejecting ideas of simplistic cures and discouraging people from passive acceptance of “expert” interventions. It means acknowledging that each one of us has a fundamental right and responsibility to manage our own life. A recovery perspective is about building capacity in people and communities to support self-regulation.

Getting there

For a long time, treatment experts believed that real change in people’s lives can only happen after abstinence is achieved. That is, a person must stop drinking or “get off drugs” completely in order to get their life together. But recovery management is radically changing this idea. We now understand that people often need to get their lives together in order to consider no longer using alcohol or other drugs.

Treatment, in this context, refers to any intervention that helps a person deal with the physical and psychosocial harms related to their substance use. Time-limited interventions (such as withdrawal management or counselling) are often helpful, but they represent just one part of a larger, comprehensive response.

While some experts will continue to prefer abstinence as the ultimate goal, a more respectful and fair goal is to help a fellow human take control of their life. After all, the path of recovery is varied and, for many people, abstinence may not be immediately realistic or desired, especially early in the recovery process.

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Helping another person—a motivational approach

All of us are agents of change, though we may not realize it. In our daily lives, we use language to not only share information but also to influence one another’s behaviour. This could be in asking for help or in trying to help another person make a change in their behaviour or lifestyle.

Despite our best intentions, however, we can fall into the trap of forgetting whose life it is that we are trying to help. Miller and Rollnick use the analogy of “sitting together on a sofa while the person pages through a life photo album. You ask questions sometimes, but mostly you listen because the story is the person’s own.”

Helping qualities

Truly helping a person involves a commitment to advancing their best interests. The process starts with the assumption that people are experts on themselves, and the acknowledgement that no one can be expected to have all the right answers for someone else.

Helping is not fixing. It is a partnership in which we must be attuned to our own aspirations as well as those of the other person. It involves an acceptance of what the other brings to the relationship and a respect for the other that makes exploitation impossible.

Helping also involves what Carl Rogers called accurate empathy, that is, an active interest in understanding the other person’s “inner world of private personal meanings as if it were your own, but without ever losing the ‘as if’ quality.” This is not about identification with or feelings of pity for the other person. It is about believing that the other person’s views are relevant and important. The opposite of empathy is imposing one’s own views on the other person.

Being a helper is like being a friend. By learning and practising the spirit of helping (what Miller and Rollnick call the spirit of motivational interviewing), you can become an expert friend. And no matter what level of professional training you have, you can be a friendly expert.

Spirit of helping

Using a motivational approach (based on the principles of motivational interviewing articulated by Miller and Rollnick) means drawing out and strengthening the other person’s internal readiness to change. It means relating to them in a way that is collaborative, not confrontational and coercive. And it involves affirmation of the person’s self-efficacy—building their confidence to face a task and succeed. Instead of trying to fix or solve things in their life, the emphasis is on helping the individual express and reach their goals. It is essentially steering a conversation toward possibility and action. The steps below reflect this spirit of helping.

Step 1: Building a Partnership

Every relationship begins with engagement—a process of establishing a partnership. Helping a person manage their substance use behaviour is not a matter of an expert doing something to the person, like giving medicine. Rather, it is a collaboration between experts. Factors about both parties and the context and culture in which they interact can affect the level of engagement. Informal chatting may help create a level of comfort, but the conversation must move to a focus on personal concerns and goals if it is to be truly engaging. Along the way, attention to several basics is helpful.

Profound acceptance of the other person is essential. This does not mean approving the person’s behaviour or choices. It does require a belief in the worth and potential of the other. It involves trying to understand the person‘s point of view while drawing out their reflections about their situation and deciding together if and what they would like to change. And it means a commitment to the person’s right to self-determination—the freedom to be and to choose. Without such a respectful relationship, it will be difficult to help a person move toward positive changes.

Good listening is fundamental. The most powerful forces for change are within the individual. Good listening helps a person explore their own experience and reflect on how to move forward. It also helps in avoiding the tendency to dispense expertise. But good listening is also active. It shows sincere curiosity and involves reflecting back the meaning the person is communicating in a way that helps the person clarify thinking and focus on issues that might promote positive change.

Affirmation is another essential ingredient. To affirm is to accentuate the positive, to acknowledge what is good. This includes acknowledging the person’s worth and autonomy. To affirm is to support and encourage, to express confidence in the individual’s ability. People are more likely to trust someone who recognizes and affirms their strengths, and are more willing to attempt change when they can buy into a positive assessment of their own abilities.

Step 2: Nurturing Change Talk

Most people who need to make a change are aware of reasons to change and reasons not to change, and sometimes they get stuck. This is known as ambivalence. One of the best ways to help people is to help them explore this ambivalence and to evoke “change talk,” any speech that favours change. Change talk comes in many forms. Some forms signal a growing willingness to change (I want to, I can, or I need to). Others express a commitment (I will) or identify actions or orientations toward such a commitment. Engaging in change talk encourages change. So how can we evoke change talk?

Open questions invite a person to think a bit before responding. Open questions do not often have “right” answers, meaning it is not easy to predict how the person will respond. Closed questions, on the other hand, ask for specific information or short answers. When used in response to change talk, open questions encourage further reflection and more change talk.

Discrepancy is the feeling that a behaviour is out of line with a goal or value. People are more likely to be motivated to change a problematic behaviour when they see a difference or discrepancy between the way their life is right now—for instance, their current use of alcohol or other drugs and the related problems—and the way they‘d like their life to be. When you sense a discrepancy, posing open questions about it, or drawing attention to it by restating what was said, might encourage further reflection and clarity.

Dealing with discord means avoiding arguments with a person who rejects the need for change. It means acknowledging that the person is ultimately the one who‘ll make decisions about their health and well-being. Showing respect for what the person thinks is more helpful than trying to force or convince them. Sometimes you can agree with the person but reframe the issue slightly in a way that opens up new possibilities

Step 3: Supporting Change

Change happens when someone wants to change, feels able to change and develops a plan to change. There are many models for developing a change plan. In a motivational approach, the plan must be developed by the person who will be doing the changing, not imposed by an expert. Supporting change involves helping someone develop and implement a change plan using all the principles of engagement discussed above.

A word about culture

The spirit of helping crosses cultural boundaries. The processes for engaging may differ across cultures, but respectful listening and accurate empathy provide a universal foundation. By recognizing people as experts on themselves, we can avoid the presumption of superiority implicit in many cross-cultural discourses.

Cultural competence, when it comes to helping to explore change, is less about having a pre-understanding about the other person’s culture and more about awareness of the cultural norms of politeness and the conventions of discourse related to negotiating and planning. Some of these communication skills may affect the ability to build a partnership and to support effective action. But even these cultural communication skills can often be learned in the process when one begins with a deep sense of respect for the other person.

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Shaping the community environment

Every ecosystem, whether a geographical community like a municipality or region or an institution like a school or workplace, is unique. But there are some common factors that influence the health promotion potential of the environment.

Inclusion

To thrive, people need to belong to, and be an active part of, a community. Healthy communities provide a rich variety of means and contexts promoting connectedness and social inclusion. Building relational capacity is not only about providing opportunity, but also about nurturing skills. A focus on enhancing relationships (e.g., parent-child, child-school, family-neighbourhood, staff-clients, dialogue between various sectors or among faith communities, etc.) builds capacity for comprehensive community health by coordinating the assets of the entire community.

When we develop policies that promote the interests of some members of the community at the expense of others, we weaken the community. So, for example, a zero-tolerance policy, meant to protect the well-being of some, may cause harm to others who do not currently have the capacity to comply. Not only our policies, but our practices too, need to reflect this commitment to inclusion. When programs operate on a one-size-fits-all model, or when system components operate in isolation, they are unlikely to meet the diverse needs of many clients. Rather than seeking to fix clients, service providers need to engage clients in processes of discovery and growth.

Policies that shape environments

Policies operate at many levels. Policies to regulate access and availability of alcohol or other drugs will influence community norms and individual behaviour. For example, age restrictions for purchasing alcohol and graduated licensing programs draw attention to how alcohol affects people differently at different ages, and shape the standards of acceptable behaviour within the community.

Policies also play a role in how communities identify and support citizens who are at risk of developing problematic substance use patterns. Policies related to early childhood development, for example, can promote resilience. Likewise, policies that reduce isolation and build connectedness can increase social capital. In either case, the result is a reduction in problems and a greater sense of shared experience. Community policies can also ensure that those who are experiencing problems have ready access to a range of supportive services.

Multiple strategies and approaches

Matters of health and wellness are as complex as human beings themselves, and there is no “one way” to achieve well-being. Multiple strategies and approaches are needed to meet the needs of different individuals. So while some people may need highly structured environments in order to cope and maintain healthy patterns, others may find such environments overly stressful. Multiple strategies are also needed to ensure that various contributing factors are addressed.

A well-crafted policy that sets clear expectations can shape community norms. Using restorative practices with those who fail to act in accordance with those norms will increase commitment to the norms by linking people, who might be tempted to opt-out, back into the community. Likewise, programs that support individuals to be active participants by creating opportunities or by developing skills increase the social capital of the community.

Each of these strategies is important in its own right, but it is in working together that they have their greatest impact. Recent reduction in tobacco use—influenced by increasing knowledge about cancer risk, sales restrictions, efforts to limit secondhand exposure, and changing social attitudes—is a case in point.

Substance use problems in a community are like frogs behaving strangely in a pond. It is obvious that we need to consider what in the community or “pond” is contributing to the behaviour. Managing substance use, risk and harm is always about more than providing treatment to individuals. It is about regulating the conditions in the community, whether the community is a social housing program, a school, a workplace or a larger community. It is about the frogs and the pond.

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Dealing with difficult situations

Substance use problems typically present in the form of an incident related to the substance use of an individual or group of individuals. For example, a school administrator may be faced with a group of students who show up for class under the influence of cannabis. Or a shelter supervisor has to deal with an intoxicated patron who is threatening others.

When people are intoxicated, they are not usually able to engage in thoughtful conversation about their behaviour or their willingness to change. A helper’s first concern is to determine what needs immediate attention and what can be better addressed later on. So asking a person who is drunk to deal with their alcohol issue is pointless. But getting them to a quiet and safe location to sober up could be immediately helpful and provide an opportunity to explore the alcohol use later.

Sometimes the problem, while related to an individual’s substance use, has as much to do with certain environmental factors. For example, a program that works with clients who often use alcohol and that requires them to line up in a crowded space in order to access an important service is likely to experience significant disruption from agitated clients. Of course, getting clients to stop using alcohol might help, but redesigning the way clients access the service could also help solve the immediate problem.

Preventing violence

At times, the immediate issue is to reduce the risk of violence or aggression and ensure the safety of others. This may include calming one person down or keeping the peace among several people.

The factors that influence disruptive behaviour are multi-faceted and unique to each individual situation. Strategies can range from those that are supportive and promote autonomy to those that are boundary- and limit-setting.

Decisions regarding the approach to manage the situation should be based on knowledge of the person and the context in which the behaviour is taking place. Factors to consider include variance from the person’s normal behaviour, level of danger of the behaviour and potential impact on others.

Early intervention before escalation occurs is critical. Interventions should be proportionate to the risk of harm. Some of the basic elements of preventing violence are summarized below.

Connecting and engaging with the person demonstrates mutual regard and trust. This shows the person they are valued and respected. It helps the person feel safe, listened to and cared for, thus reducing the need for aggressive behaviour.

Expressing empathy gains the person’s trust and protects their self-esteem. Empathy is about taking a respectful and non-judgmental approach. It involves trying to understand the person’s point of view, expressing concern and acknowledging their experience.

Shared problem solving helps establish the reason for the agitation and ways to resolve the issue. The focus is on establishing rapport, answering questions and trying to find areas of agreement.

Restrictions should be minimized as much as possible as this shows trust and promotes positive emotions and self-control. However, knowing when to take an authoritative approach and move toward boundary- and limit-setting is an important aspect of managing disruptive behaviour. If the person is threatening or violent, an authoritative approach should be taken. The focus is on escorting the person to a safer area, combined with other measures such as crisis intervention.

Diffusing difficult situations should not be considered in isolation from other strategies and policies to help reduce risk and maintain safety. It is important to consider measures such as identifying and addressing sources of agitation, teaching coping mechanisms, encouraging open communication about feelings and emotions, and identifying and discussing feelings of anger and frustration.

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Health promotion in practice

Helping people who use psychoactive substances must begin with a commitment to helping them take control of their own lives. This involves attention to both healthy settings and the health capacity of individuals.

Healthy settings are nurtured by careful action that ensures policies and procedures contribute to a wellfunctioning community. This means building a sense of inclusion so that all members of the community (including those who use substances) feel they can contribute in meaningful ways. Everything should be examined against the health promotion goal of enabling people to increase control over their own health. Auditing a community’s programs to determine how policies and practices might influence risk and making adaptations to minimize the risk potential is a useful ongoing exercise.

Healthy people develop in contexts that support personal responsibility and nurture individual and social capacity. When people behave irresponsibly, systems need to be in place that diffuse immediate risk and then address the underlying issues. This latter task should employ the principles of a motivational approach. This involves engaging the person in a collaborative conversation aimed at strengthening the person’s own motivation and commitment to change. In a context of discord, this can be challenging. But active listening and careful reflection can help the person consider their own choices and their place within the boundaries of the community.

Sources:
  1. Health Council of Canada (2010). Stepping It Up: Moving the Focus from Health Care in Canada to a Healthier Canada. Toronto. http://www.healthcouncilcanada.ca/rpt_det.php?id=162
  2. Miller, W.R. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change, 3rd ed. New York: Guilford.
  3. Price, O. & Baker, J. (2012). Key components of de-escalation techniques: A thematic synthesis. International Journal of Mental Health Nursing, 21(4), 310–319.
  4. Rogers, C.R. (1965). Client-Centered Therapy. New York: Houghton Mifflin.
  5. Stokols, D. (1992). Establishing and maintaining healthy environments: Toward a social ecology of health promotion. American Psychologist, 47(1), 6–22.
 
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