Mental health articles

OF mental health care and mentally ill

Engagement on substance misuse

This stage concerns the development of a therapeutic alliance between client and professional. Persistence may be needed to engage the client and techniques associated with assertive outreach, such as visiting the client at home and helping sort out practical issues (for example, getting benefit payments, dealing with housing difficulties, providing clean injecting equipment) can serve to promote continued contact between client and nurse. Focusing on substance misuse is not the main aim at this stage.

However, there may be scope for enhancing motivation and minimizing the harm associated with use. Harm minimization is a specific approach to working with substance misusers which evolved in the 1980s, primarily in response to concerns about the transmission of HIV through the sharing of injecting equipment. Many substance misusers may not want, or may be unable to achieve abstinence, so the goal is to reduce associated harm – to the person themselves, their family and friends, and the wider society. A key component of harm minimization is providing information and advice. This might include: safer injecting techniques, transmission routes of blood-borne infections, sexual health issues, recommended safe drinking limits, and the effects that various substances can have on physical and mental health. It is hoped that the client will respond by using substances in a safer way and take steps to live a more healthy lifestyle (for example, using condoms, having a hepatitis B vaccine). Needle exchange schemes have played an important part in this approach by giving out clean injecting equipment and providing for its safe disposal. Substitute prescribing on a maintenance basis (for example, methadone for heroin) has been another strategy. People can also be encouraged to use substances more safely by reducing the quantity and/or frequency of use, changing the route of administration (for example, from injecting to smoking), and reducing the intake of additional substances (for example, benzodiazepines and alcohol).

Although the goal for this stage is engagement, the nurse and client may only meet on one or two occasions. ‘Minimal’ or ‘brief’ interventions in which verbal and/or written information and advice about substance misuse is given may be appropriate (there is some overlap between brief interventions and harm minimization). The acronym FRAMES has been used to summarize the elements of brief interventions.

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