Counselling is the form of drug treatment most commonly provided in response to VSM by Australian drug and alcohol treatment services (National Inhalant Abuse Taskforce, 2006), although there is little research literature on which to build an evidence-base for VSM counselling interventions. US treatment protocols, cognisant of possible effects of long-term VSM on the user's brain, advise that counselling sessions be short and 'a slow rate of recovery' anticipated (Beauvais, 1997; Beauvais, Jumper-Thurman et al., 2002; Substance Abuse and Mental Health Services Administration, 2003). However, many young people using inhalants have not consumed these substances for long enough to acquire serious brain injury; indeed one study which tested both volatile substance users and other drug users for neuropsychological impairment on admission to residential treatment found no cognitive difference between these groups (Sakai et al., 2006).
Early psychological and psychiatric approaches to VSM treatment are outlined in Morton (1987). A 'biopsychosocial' approach to VSM therapy is advocated by McCartney (1999). This entails attention to transference and counter-transference in the therapeutic relationship, behavioural and cognitive approaches to increasing self-awareness and self-control, and negotiating the inside–outside boundary.
Victorian VSM management guidelines recommend a range of counselling and support approaches. The guidelines advise that clients should be clearly advised of the harms to which they are exposing themselves. Motivational interviewing (to enhance the client's enthusiasm to change their behaviour), self-monitoring strategies (assisting them to achieve greater insight) and relapse prevention (recognising and managing their response to triggers for use) should form part of any long-term individual counselling strategy. Recommended therapeutic techniques include goal setting, developing contracts with clients in relation to consequences of inhalant use, and skill development in managing emotions, decision making and communication. Family-based interventions are also advised, as are assertive outreach and follow-up, and provision of diversionary activities and other means to ameliorate social isolation. Clients should be referred to other drug or mental health services as needed and co-occurring poly drug use should also be addressed (Department of Human Services, 2003, pp. 21–27 & 35–37).
Some research considers how counselling might be provided for Indigenous clients in remote settings. San Roque et al. note that one of the primary needs of petrol sniffers is for 'psychological or personal attention, i.e. the chance to be listened to and "tell their story"' (San Roque et al.1999, p. 20). Researchers found that among a sample of ex-petrol sniffers in a remote community in northern Australia, the most commonly identified reason for giving up petrol sniffing was advice or encouragement from family members (Burns, Currie et al., 1995). The authors conclude that interventions addressing petrol sniffing might support the role of Aboriginal families.
Franks (1989), a member of the Healthy Aboriginal Life Team (HALT), has provided a useful account of the application of counselling techniques in two Central Australian communities. Central to the HALT approach was the combination of individual and family counselling with community development techniques. The twin goals were to promote the community's capacity to control petrol sniffing at the community level, and to help kin networks to regain their capacity to care for and control their members. The particular role of counselling in this context was to 're-include the sniffers within the extended family group from which they had become alienated' (Franks, 1989, p. 17). Another important aspect of the HALT approach was the presence in the team of a respected Aboriginal member, who worked in close cooperation with the counsellor.
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Franks describes two types of individual counselling, as well as family counselling. Simple support counselling was used where the family was strong and could mobilise support; the counsellor's role was one of helping persons to reach decisions and giving encouragement. Where family functioning had become distorted, in-depth counselling was appropriate. Counselling involved 'validating feelings; clarifying the problems; setting and prioritising goals; and actively moving towards the achievement of these goals by agreeing to undertake specific tasks' (Franks, 1989, p. 19). Individual counselling was used in conjunction with family counselling, in which the Aboriginal member of the team played a major role, identifying family and community supports which could be mobilised.
Other evidence supports the importance of including families in counselling interventions with Indigenous volatile substance users. Mosey (2000) adapted HALT's technique of 'family mapping', and drew also on work by Orford and his colleagues on 'family coping' (Orford et al., 1998). Mosey's intervention aimed to reduce the shame families felt about petrol sniffing. She concluded that when families functioned better overall, the drug-using member would also become more able to alter his or her own behaviour. In an evaluation of a petrol sniffing program in Kaltjiti, family counselling was viewed as a successful means of making families more responsive to the needs of petrol sniffers (Shaw, 2002).
Outside the Indigenous context, family therapy has been recommended (McCartney, 1999). In 1982 a psychiatrist argued that families of children misusing volatile substances shared certain pathological dynamics. Therapeutic interventions with 41 families resulted in 26 young people ceasing VSM (assessed at six months post-treatment) (Framrose, 1982). Another study reported by Morton (1987) found that individual treatment combined with provision of diversionary activities and family intervention was more effective than individual treatment alone.
Working with users of volatile substances poses particular challenges, sometimes leading to despondency on the part of workers. A youth worker contributing to the Victorian Inquiry into Inhalation of Volatile Substances argued that few options were available to him in encouraging and assisting clients to modify their inhalant use:
A twelve, thirteen, fourteen year old person possibly doesn't even have the cognitive development to undergo insight-based therapy. That's how a lot of our services are funded. We really don't have anything else to offer these people. (Quoted in Youth Affairs Council of Victoria Inc., 2001, p. 12)
Volatile substance users are likely to require intensive after-care and monitoring for relapse (Butt, 2004; Jumper-Thurman et al., 1995). In one Canadian residential treatment centre an after-care plan is devised before clients are admitted and community members are required to pledge support to the young person concerned (Dell et al., 2005). Efforts should be made to assist young people to cope with peers who continue to use volatile substances.
After-care is often provided though an outreach model, focusing on monitoring and reinforcing skills learned in treatment. Shaw et al. suggest that after-care services for people in remote communities should include:
- personal support for individuals;
- working with families to reintegrate the client into community life; and
- making changes to communities so that there are alternative activities available, and fewer people sniffing. (Shaw et al., 2006, p. 45)