What are appropriate counseling strategies for individuals with mental health issues or substance abuse?

Appropriate Counseling Strategies for Mental Health and Substance Use Disorders

For individuals with mental health issues, cognitive behavioral therapy (CBT), interpersonal therapy, and problem-solving treatment should be the primary psychological interventions, while those with substance abuse require brief motivational interviewing-based counseling with harm reduction principles, and both populations benefit from structured, non-confrontational approaches that address ambivalence and build on patient strengths. 1

Mental Health Counseling Approaches

Depression and Anxiety Management

• Interpersonal therapy, CBT (including behavioral activation), and problem-solving treatment are recommended as first-line psychological treatments for depressive episodes in non-specialized settings 1
• Problem-solving approaches should be used for individuals with depressive symptoms who are in distress or have impaired functioning, even without meeting full criteria for depressive disorder 1
• CBT-based psychological treatment is indicated for adults with medically unexplained somatic complaints who are in substantial distress 1
• For panic attacks, psychological treatment based on CBT principles should be offered 1
• Graded self-exposure based on CBT principles should be considered for adults with PTSD symptoms when follow-up is possible 1

Trauma and Acute Stress

• Psychological debriefing should NOT be used for recent traumatic events to reduce PTSD, anxiety, or depressive symptoms 1
• Instead, provide access to support based on psychological first aid principles for people in acute distress exposed recently to traumatic events 1
• For complex trauma with family dysfunction, create a safe, non-judgmental therapeutic environment where suppressed emotions can be expressed without fear of rejection 2
• Apply existential principles to help clients find meaning in their circumstances and life transitions 2

Severe Mental Illness (Psychotic and Bipolar Disorders)

• Psychoeducation should be routinely offered to individuals with psychotic and bipolar disorders and their family members/caregivers 1
• CBT and family interventions can be considered if adequately trained professionals are available 1
• Psychosocial interventions to enhance independent living and social skills should be provided 1
• Facilitate opportunities for inclusion in economic activities appropriate to their social and cultural environment 1

Substance Abuse Counseling Strategies

Brief Counseling Framework

Brief counseling using motivational interviewing principles is the cornerstone of substance abuse treatment in primary care, with sessions lasting 5-30 minutes incorporating individualized feedback and advice on reducing or stopping substance use 1

Key Communication Techniques:

• Use the "elicit-provide-elicit" technique when providing information or advice 1
• Avoid confrontation or pushing the patient to change, as this decreases motivation 1
• Help patients articulate their own reasons for change rather than telling them why they should change 1
• Manage resistance and ambivalence using motivational interviewing principles 1

Stratified Approach by Severity

Hazardous Use:

• Provide brief counseling and ongoing assessment 1
• Offer individualized feedback about personal risk 1

Substance Abuse:

• Brief counseling with negotiation of a specific plan for change 1
• Close follow-up monitoring 1
• If abuse continues despite intervention, refer for specialized treatment 1
• Harm reduction is an appropriate goal when patients are not committed to abstinence 1

Substance Dependence:

• Brief counseling combined with referral for specialized treatment 1
• Consider pharmacotherapy as appropriate 1
• Facilitate engagement with mutual help groups (e.g., AA, NA) 1
• Provide ongoing assessment and support using a longitudinal, chronic care approach 1

Specific Substance Interventions

Cannabis and Psychostimulants:

• Offer brief intervention comprising a single session of 5-30 minutes with individualized feedback and advice on reducing or stopping use 1
• Provide offer of follow-up 1
• Short duration psychosocial support modeled on motivational principles should be offered 1
• Refer for specialist assessment if problems persist despite brief intervention 1

Alcohol Dependence:

• Encourage engagement with mutual help groups 1
• Monitor the impact of group attendance 1
• Encourage family members to engage with appropriate mutual help groups 1

Withdrawal Management:

• Cannabis, cocaine, or amphetamine withdrawal is best undertaken in a supportive environment with symptomatic medication only 1
• No specific medication is recommended for cannabis or psychostimulant withdrawal 1
• Benzodiazepine withdrawal requires planned tapering over 8-12 weeks with conversion to long-acting agents 1

Self-Harm and Suicide Risk Management

Assessment Protocol

• Individuals over 10 years with mental health conditions, chronic pain, or acute emotional distress should be asked about thoughts or plans of self-harm in the last month or acts of self-harm in the last year at initial assessment and periodically thereafter 1

Intervention Strategies

• Advise the individual, family, and relevant others to restrict access to means for self-harm (pesticides, toxic substances, medication, firearms) as long as suicidal ideation persists 1
• Regular contact (telephone, home visits, letter, contact card) with the healthcare provider is recommended for persons with acts of self-harm in the last year 1
• A structured problem-solving approach should be used for persons with acts of self-harm in the last year 1
• Facilitate use of social support from informal and/or formal community resources 1
• Hospitalization solely to prevent self-harm is NOT routinely recommended; instead, mobilize family, friends, and community resources for close monitoring 1

Practical Implementation Considerations

Alternative Delivery Modes

• Telephone-based motivational interviewing is effective for treating substance abuse and is supported by all published RCTs 3
• Internet-based MI is effective for preventing and treating alcoholism but shows inconsistent outcomes for smoking cessation 3
• SMS-based MI appears useful for controlling tobacco and drinking 3
• Group MI has mixed findings for alcohol and drug cessation 3

Common Pitfalls to Avoid

• Do not focus solely on practical issues without addressing underlying emotional and existential concerns 2
• Do not neglect the impact of substance abuse in family systems and relationship dynamics 2
• Do not rush through grief work before establishing adequate emotional safety and regulation skills 2
• Do not overlook potential trauma responses when discussing childhood experiences 2
• Avoid unnecessary confrontation, which reduces patient engagement 1
• Do not assume all patients are ready for abstinence; meet them where they are 1

Adjunctive Interventions

• Relaxation training and advice on physical activity may be considered as adjunct treatment for depression 1
• Anti-stigma campaigns and community education may be implemented to improve attitudes toward mental health conditions 1
• Facilitate supported employment for those with severe mental illness who have difficulty obtaining or retaining normal employment 1