Dr Barbara HedgeConsultant Clinical Psychologist

Is there more to risk prevention than MI?Flavour of the month

Relaxation therapyCognitive behaviour therapySolution focused therapyMotivational interviewing

Why recommendedLooks to be effective but cheapNever mind the problem

NICE guidance 2007

One to one interventions to reduce the transmission of sexually transmitted infections (STIs) including HIV, and to reduce the rate of under 18 conceptions, especially among vulnerable and at risk groups

May 2007

Implementing NICE guidance

NICE public health intervention guidance 3

Putting therapy into contextSexual health setting

A normal, universally practised behaviourRisk

Probability of danger and/or undesired outcomes Individual Partners and families Society

Undesired outcomes Sexually transmitted infections Pregnancy

Aim to change behaviours to reduce riskIdentify useful psychological therapies

What factors are associated with risk?Lack of knowledge or understandingResourcesSkills

CommunicationAbility

Conceptualisation of personal riskMotivation to reduce riskLack of care for self or others

Low moodShame

Power differentialCulturalCoercive

Sexual health expert knows best

AssumptionsPatients are always rational so act on knowledgeThe goals of patients are the same as goals of

sexual health practitionersAll patients want what is best for themselves

UK national guidelines on safer sex adviceBASHH 2011

ConclusionsGiving knowledge is all that is necessaryTelling people what to do is the same as giving

advice

They just don’t listen!Repeated STIsHIV transmissionUnwanted pregnanciesRepeated requests for PEP

Information is necessary but not sufficient

Theory of reasoned actionFishbein, 1979

Which therapy?What, who needs to change?Who wants or doesn’t want to change?What are the risk factorsGoal to be achievedHow to bring about change

Learning theories Skinner’s Operant Conditioning theory Bandura’s Social Learning theory

Risk reduction

Behaviour change therapiesCognitive Behaviour TherapySystemic TherapySolution focussed TherapyMotivational InterviewingPeer InfluenceNudge

Cognitive behaviour theories

Personal risk cognitionsNot want to transmitNot want to discloseNot want to use a condomNot want to become infectedNot want to think about itNot want to confront

Self-serving attributionsConstructed narratives that allow

justification of our behavioursBefore and/or after action or non-action

ART means I have no virus to transmit PEP is available if need it If partner is willing to have unprotected sex they

are probably already positive Partner wouldn’t suggest unprotected sex if they

were positive Can trust negotiated safety agreement

Cognitive behaviour therapyAddresses non-adaptive cognitionsReplaces with adaptive

Can confront the issueCan plan to remain uninfected

Raises moodLowers anxietyIncreases self-esteemAdoption of self affirming behaviours

AssertivenessAcceptance of rejection of the behaviour rather

than of the self

Learning new behavioursOperant ConditioningReinforcement

Positive repeat of behaviour Great sex with a condom

Remove negative Finally agree to sex when agree to condom

Negative Fail to keep erection with a condom

Remove positive No sex as no condoms

Nudge theorySuggestion + positive reinforcementAddress one element of behaviour in the

chainIf positively reinforced by others or internally

Repeat behaviourReinforce additional elements in chain

Gradually approach goal of protected sex

Solution focussed therapyNot concentrating on the problemUses resources patient already has

Encourages trying a course of action (possible solution) Strengths patient already has

AdvantagesQuickCheapPatient generated

Builds self esteem and self efficacyDisadvantages

Failure for complex issuesKey factors may not be identifiedDifficult engagement when depressed

Cycle of change – Prochaska and Diclemente

Changing behaviours

“After all, when you seek advice from someone it’s certainly not because you want them to give it. You just want them to be there while you talk to yourself”

Terry Pratchett

Changing behaviours

“After all, when you seek advice from someone it’s certainly not because you want them to give it. You just want them to be there while you talk to yourself”

Terry Pratchett

Motivational interviewingDirective, client-centred

counselling style to resolve ambivalence (Rollnick & Miller, 1995)

Motivation = Importance + Confidence + Readiness

Aims to elicit and boost these factors

NICEQuickCheapCatch people on first

visitEvidence of

effectivenessA stand alone

interventionPossible service

approach

Peer interventionsUse of a peer educator

Group leaderIntroduce safer sex into conversationSet up group norm

‘cool to use condoms’ Social learning theory + Nudge + MIEfficacy

Some support? Culturally specific

Review: Simoni et al, AIDS Behav, 2011, 1589-95

When do I need systemic therapy?Risky sex is rarely an individual practice

What is the influence of the partner?What is the perceived influence of the partnerIs there a power in-balance?

CommunicationNegotiationAgreement between partners to change

SummaryMotivational interviewing a good place to start

Finding out the whole picturePatient suggests the next step

Moves to action from pre-contemplationMore commitment to meet their own challenge

Ready to address cognitions and beliefs and learn skillsAble to identify when there are greater unmet needs

Pathways for onward referral to meet general needsAppropriate use of therapeutic techniques brings

best results