Mental Health Addiction Intervention
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Introduction to the essay
This essay critiques the work of a video session using sensory modulation as an intervention in an acted session. Throughout the essay I will highlight therapeutic counselling skills within a brief intervention session. Focus however, will be on the use of sensory modulation.
Introduction to the tangata whai i te ora
This is the second session with Samantha (pseudonym). Samantha is a 31-year-old pakeha woman who was referred to the addictions service by her general practitioner. In the first session, Samantha was assessed as having a moderate to severe alcohol use disorder and anxiety. Samantha believes that she has always been an anxious person however her anxiety (and drinking) escalated three years ago when her mother and stepfather were in a serious car accident. Her stepfather died in the accident and her mother has ongoing health problems because of her injuries. Samantha is very close with her mother and has become fearful that she or her mother could be harmed in a car accident again. Over the past year, her anxiety has become progressively difficult to manage, causing considerable impairment in her daily functioning. Her anxiety has impacted her ability to sleep, drive, work and participate in activities that occur outside of her home environment. She lives alone in a small basement unit; has sold her car and either walks to the supermarket or takes the bus to work. Samantha forces herself to go to work at her part-time job as she has a strong desire to live a normal life. While doing so, she often experiences panic attacks and other symptoms such as shaking and nausea. When returning home, she feels exhausted and highly anxious and drinks alcohol until she falls asleep. Her anxiety appears to have heightened due to financial worries related to not being able to work because of her anxiety, and ongoing ruminations about her breakup from her fiancé 18 months ago. She believes she is solely responsible for the break-up due to her fears around leaving the house other than to go to work or get groceries. Samantha’s overarching goal is to be able to manage her anxiety so that she can independently leave the house (other than go to work) when she wants to without consuming alcohol.
AOD use
Samantha consumes alcohol daily. Drinking cask wine, her daily use can fluctuate, but she goes through about one and a half, 3 litre casks over a week (approximately 45 SDs per week, equalling about 6.4 SDs per occasion). On assessment, she met criteria for moderate to severe alcohol use disorder (APA, 2013). She reports a strong desire to live life without relying on alcohol, she drinks alcohol despite her anxiety being exacerbated by the effects of drinking, she has given up full-time work and seeing her family as much as she would like to due to her desire to hide her drinking (and knowing that she cannot see them without drinking), and increased tolerance, where she reports needing to drink more and more just to get her grocery shopping done. Samantha reports no other current substance use. In her late teenage and early adulthood years she used to consume cannabis but found that as her anxiety increased, she became too paranoid when she got stoned and no longer uses cannabis. Mental Health Addiction Interventionv
Intervention approach: Sensory modulation
Goal/plan for session
The aim of the session was to introduce sensory modulation so that Samantha could recognise anxiety early and respond with sensory strategies. By engaging in sensory strategies, Samantha might feel like she does not need to consume alcohol to manage her anxiety. Using the client worksheet ‘Using your senses to cope’ (INSIGHT, 2020), the initial focus of the sensory modulation brief intervention session involved some brief psychoeducation of sensory modulation and the worksheet. We then explored Samantha’s sensory preferences and everyday sensory strategies that she could use to manage anxiety, and consequent urges and cravings to consume alcohol.
Intervention approach
Sensory modulation can be defined as “The ability to self-organise and regulate reactions to sensory input in a graded and adaptive manner” (Champagne, 2011, p. 252). The sensory approach can be particularly useful when working with people who have anxiety. Anxiety often manifests as a response to a perceived threat that involves the arousal of the person’s central nervous system (Smith & Randall, 2012). When a person receives sensory input that is startling, their nervous system sends a fast message across the amygdala which releases a burst of adrenalin (Lane et al., 2010; Le Doux, 1996). The body releases the vagal brake and switches the autonomic nervous system from a parasympathetic state (‘rest and digest’) into a sympathetic state, triggering the ‘fight, flight, freeze’ response (McCorry, 2007). Kinnealey et al. (2011) found that the activation of the sympathetic nervous system can cause hyper-sensitivities to sound, visual stimuli and movement. Over-responsiveness to sensory stimuli contributes to avoidance behaviours, social withdrawal, reduction in work productivity and an increase in pain perception (Ben Alvi et al., 2012; Dempsy, 2016; Wallis et al., 2017).
Strategies from sensory modulation can help to stimulate the vagus nerve which increases parasympathetic arousal and decreases the sympathetic response (Porges, 2003). Sensory modulation strategies can lead to a reduction in anxiety and can empower people to take control over their responses, enhancing daily functioning (Dempsy, 2016; Kane et al., 2010; Wallis et al., 2017). The interventions are preparatory and aim to provide a sense of safety and grounding (Champagne, 2011). Sensory strategies may include the integration of external and internal senses. External senses include olfactory (smell), gustatory (taste), auditory (sound), tactile (touch, pain, temperature), and visual (sight) systems (Scanlan & Novak, 2015). Internal senses, also known as the “powerhouse senses” include vestibular (body orientation, balance, orientation), proprioception (joint position and movement) and oral motor (mouth, jaw, tongue, and lips) systems (Dempsy, 2016; Scanlan & Novak, 2015; Wallis et al., 2017).
Rationale
Coexisting anxiety and alcohol use disorders are highly prevalent (Gilpin et al., 2015; Schneier et al., 2010). Research has found that anxiety disorders often precipitate alcohol-related problems (Kushner et al., 2011; Schneier et al., 2010). Furthermore, the withdrawal of alcohol produces anxiety-type physiological symptoms (Kushner et al., 2011). Both anxiety and alcohol use disorders have overlapping and compounding effects on amygdala structure and function (Gilpin et al., 2015). This means that converting emotionally relevant sensory information about the external and internal environment into behavioural and physiologic responses will be significantly sensitised due to the coexistence of these two disorders (Gilpin et al., 2015).
Alcohol and other drug (AOD) use and AOD cues are multi-sensory (Jasinska et al., 2014). Research has shown that people with AOD problems might present with higher sensory-seeking patterns of behaviour than compared to the general population (Quadling et al., 1999). Quadling et al. (1999) found that 80% of people with AOD problems (n64) showed significant sensory seeking or sensory avoiding behaviour in one or more sensory systems. Just over half of the participants (56%) in Stols et al.’s (2013) study (n84) engaged in sensory-avoiding patterns and these participants found ways to limit their sensory stimuli.
Excessive anxiety is associated with overwhelming physical sensations, avoidance of feared situations, and reduced functioning (Makovac et al., 2006). Reduced functioning can be seen in withdrawing from social activities and impacts on work productivity (Ben Alvi et al., 2012; Dempsy, 2016; Wallis et al., 2017). These issues are consistent with Samantha’s presentation as her anxiety has prevented her from participating in full-time work, everyday tasks, connecting with family and friends, and other activities that occur both inside and outside of her home environment. In response to these situations, she presents with a strong physiological experience of fear in the form of panic attacks, shortness of breath, shaking, nausea and headaches. Wallis et al. (2017) recommend using sensory modulation to target these sympathetic responses.
Strategies used in the intervention
This being a follow-on session from the initial assessment, it was important to consider whakawhanaungatanga (establishing the relationship). At the beginning I was concerned with Samantha’s mauri ora (wellbeing) and asked if she would like a drink of water or a cup of tea before the start of the session. I enquired as to how her last week had been and opened the space for her to share. Using appropriate communication skills in a timely manner throughout the session, I incorporated micro-counselling skills of open questions, affirmations, reflective listening, summarising, and used body language and facial expressions to demonstrate listening and interest. These micro counselling skills, both verbal and non-verbal, position the clinician as a helper and validate the tangata whai i te ora and their experiences (Rushton & Davis, 1992).
At one stage I used a double-reflection to acknowledge the ambivalence she had around changing. Samantha said, “I rely on drinking to give me courage, but I want to feel like I’m not bound to it.” I reflected back and said, “so on the one hand alcohol gives you courage but you also don’t like that you feel bound to it live the life that you want for yourself.” Samantha responded by nodding her head in agreement and went on to share some of the worries she had about her current situation. I acknowledged how difficult things must be for her and promoted hope by suggesting that we turn our attention to some strategies that might be useful for her.
Integrating the client worksheet ‘Using your senses to cope’ (INSIGHT, 2020), I guided the conversation to managing anxiety using sensory-informed strategies. The worksheet contains basic psychoeducation on sensory modulation, an activity to identify helpful sensory inputs as well as a range of general tips and ideas for coping with a crisis or cravings (INSIGHT, 2020).
Engel-Yeger and Dunn (2011) recommend using psychoeducation when implementing sensory modulation as it supports the person to gain self-awareness and empowerment to take control over their responses. To increase Samantha’s understanding of how she interprets sensory information we looked at a simple diagram of the brain which I had printed out earlier. I explained how our body perceives and responds to threat (Le Doux, 1996) and I also talked about how alcohol and anxiety work together. Samantha responded by describing her physiological responses when feeling anxious and seemed to be relieved when she could identify that these sensations were her body’s way of responding to anxiety. She said, “so I’m not mad then!” and laughed. I acknowledged Samantha’s response and reiterated that she likely experiences heightened anxiety due to the coexisting issues. By normalising Samantha’s physical response to stress, she was able to observe that her experience was normal given her body’s sensitisation to go into ‘flight, fright or freeze’ to a perceived threat.
I then explained sensory modulation and how it works with the senses. Turning to what helps for her, Samantha identified that she appreciates being in nature. She enjoys observing the beauty, listening to birdsong, and smelling the scent of fresh earth. Being in nature is multisensory. The ability to have direct sensory experiences with nature provides a meaningful opportunity for intimate interaction with natural objects and living creatures (Taylor, 2013).
When exploring aspects that she found calming in her home environment, Samantha said she used to enjoy smelling lavender, and used to put lavender on her pillowcase at night. The relaxing effects of lavender oil are well known (Buchbauer et al., 1993; Kuroda et al., 2005; Shaw et al., 2007). Essential lavender oil has a sedative effect on the autonomic nervous system (Cavanagh & Wilkinson, 2002). In the session Samantha talked about “feeling silly” for enjoying the smell so much and again seemed reassured that there was a reason for feeling good when she went to bed at night. Samantha talked about how she used to enjoy listening to music. Predictable music can also regulate mood by adapting the arousal state (Canbeyli, 2010; Champagne et al., 2010; Lepage et al., 2001). We discussed Samantha listening to music with her headphones before and as she was walking out the door for activities or shopping.
It seemed that sensory modulation was effective for Samantha as she was quite animated when we were exploring the different sensory ideas. She seemed to be hopeful about being more strategic regarding how and when she used the strategies, and at the end of the session she said, “I can’t wait to try these things out.” As we were going through different sensory options, she was excited to try new sensory ideas, and made mention of how affordable (or free) many of the ideas were. I acknowledged her innate intelligence to know the strategies that work for her. I reiterated that using these strategies in a planned way will help her to feel more in control of her response to perceived threats.
By using these sensory tools Samantha might begin to feel less anxious and less likely to reach for alcohol to calm her. The sensory strategies aim to empower her to improve her quality of life (Scanlan & Novak, 2015). Additionally, by exposing herself to situations she fears she is more likely to become physiologically habituated to the experience (Wallis et al., 2017). With its roots in cognitive behavioural therapy, gradual exposure, or repeated exposure toward fear provoking stimuli, has shown to be effective for people with anxiety disorders (Craske et al., 2014). Therefore, the more that Samantha can address her fears without using alcohol, the more that this behaviour will be reinforced as an activity that she can do without experiencing a highly anxious state.
Reflection
I need to improve my volume and pace as I found myself being ‘loud’ and at times saying a lot in a short timeframe. At times, I rushed in with different ways of questioning, not waiting for Samantha to process and answer. This is because I was aware of time pressure, and there was a certain amount of tension I was feeling that came through in my over-questioning approach. Asking too many questions impacts the power balance between client and clinician in a negative way (Miller & Rollnick, 2013). Instead reflective statements should be made to avoid stepping into the ‘expert’ role (Britt et al., 2014).
As far as using the intervention approach was concerned, I felt moderately confident to implement sensory modulation with Samantha because I had spent a large amount of time preparing myself with readings and the worksheet. I practiced using the worksheet with my flatmate to familiarise myself. I need additional practice to expand my knowledge and skills to confidently use it again. Azuela and Robertson (2016) argue that developing a high standard of skills and knowledge is one of the most important steps that clinicians can take to assist tangata whai i te ora in using sensory modulation strategies.
I believe I missed an opportunity to explore Samantha’s disclosure about deep-pressure touch. At one stage Samantha spoke about how as a child she used to love being under lots of blankets. I assumed that she enjoyed the weight and talked about weighted blankets. Making assumptions is another clinician trap. Clinician assumptions may create conflict and hinder therapeutic effectiveness (Cowan & Presbury, 2000). Counsellors are better to ask the client what they mean or their interpretation of their statements or experiences (Miller & Rollnick, 2013). I should have asked her what she enjoyed about the experience and allowed her to share more about her preferences as it might not have been the weight at all. Identifying sensory preferences is important when offering sensory modulation interventions. Sensory preference refers to the type of sensory data that registers most quickly and intensely in the person’s brain (Brown et al., 2019). People tend to feel affirmed, comfortable, and understood when they receive sensory data within their sensory preferences (Meredith et al., 2018). Therefore, understanding this is an important skill when using this intervention.
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