Chapter 24 Therapeutic interventions
Learning outcomes
Stress management
It is also important to consider what causes stress. It is not usually a particular event or situation that causes stress, but your perception of and reaction to the event. For example, two people coming across a dog in the street might experience the situation quite differently. One person might view the dog as ‘man’s best friend’ and experience pleasure in seeing the animal. The other person might view the dog as a potential threat, perhaps because of a dog attack during childhood, and subsequently experience fear and anxiety, resulting in stress. Also, although we all experience stress, not all stressful situations have a detrimental effect on us. This is because of a range of internal and external factors that help to mediate the impact of stress. Internal factors might include effective coping skills and a relaxed personal style. External factors might include strong social support and a comfortable living environment. Nevertheless, the inability to manage stress ultimately leads to difficulties in living and, for some, mental health problems.
Escot et al (2001, p 273) examined the stress levels of nursing staff working in an oncology setting and found that ‘stress is primarily related to inadequate training, lack of time to deal with the psychological component of caregiving, especially terminal care, and relationships with other medical staff’. Edwards et al (2002, p 213) found that ‘mental health workers are likely to experience stress as a result of working closely with patients over an extended period of time’. Other workplace difficulties causing stress that these authors identified included increased workload, increased administration, lack of resources and problems with management.
Once you are aware of the major stressors in your life, you can begin to think about how to manage them or, more correctly, manage the effects of the stress you are experiencing. Remember, it’s not the stress itself that is the problem; it’s how you react to the stress that is crucial. According to Battison (1997, p 24) there are four main techniques people use to manage stress. You can:
Relaxation training
Relaxing is an excellent way to manage your body’s responses to stress. It works because you can’t be both tense and relaxed at the same time. When you experience tension, relaxation is a certain way to alleviate it. It is also important to use relaxation to prevent the adverse effects of stress, not just manage these symptoms. Relaxation can involve simply setting aside some time to sit back and listen to soothing music, read a good book or take a stroll around the park (Battison 1997). Listening to music and reading might also be done from the comfort of a hot bath combined with aromatherapy. Learning to breathe more effectively will also lead to relaxation.
Progressive muscle relaxation (PMR, also known as deep muscle relaxation) can be carried out reasonably quickly and with great effect. It can be done independently or by following the instructions on an audiotape (available in a range of outlets including music stores). Because PMR is a skill, it will take practice. You won’t develop the skill overnight. Progressive muscle relaxation involves the progressive relaxation of the major muscles of the body while making a conscious effort to distinguish muscle tension from muscle relaxation. It has been found that PMR also relaxes the mind and internal organs (Romas & Sharma 1995). Ultimately, you will be able to relax groups of muscles at will, which can be done anywhere. Progressive muscle relaxation has been shown to be effective in treating a range of physical and psychological conditions such as headaches and anxiety disorders and in preventing the effects of stress (Ayers et al 2007; Romas & Sharma 1995; Rausch, Gramling & Auerbach 2006).
To begin to learn how to use PMR, you will need to set aside some time every day to practise. You can do this sitting in a comfortable chair, or preferably lying down. Find a quiet place where you won’t be interrupted. Avoid PMR immediately after food as relaxation of the stomach may occur, resulting in delayed digestion (Patel 1991). If lying flat on the floor or bed, be sure that you let your feet flop loosely and, if in a chair, let your arms hang loosely. Above all, be sure that you are comfortable or you will find it difficult to relax. You can either follow written instructions until you have memorised them or you could record the instructions on an audiotape and play it through each day. This way you can devote your attention to relaxation.
Before beginning muscle relaxation, it is important to take a few slow, deep breaths to prepare yourself. Progressive muscle relaxation involves working the major muscle groups, starting with the lower limbs and working through to the head (although some authors don’t follow this directional flow). Begin by flexing the feet, holding the flexion for a few seconds, then releasing the tension. Focus on the difference between the tension resulting from flexion and the relaxation resulting from releasing the muscles. Repeat this action for each muscle group and take a short break between each action. Alternatively, tense and relax the calves, thighs, buttocks, back, chest, shoulders, hands, arms, neck, jaw, eyes (face) and forehead (Battison 1997). Finishing the session should involve acknowledging freedom from tension, resting quietly for a few minutes and counting backwards from ten. Then take a deep breath and get up quietly. To effectively help others develop relaxation skills you need to be able to do this well for yourself. This will also lead to a belief in the benefits of relaxation.
Assertiveness training
Assertion is about being able to communicate clearly to others and avoiding misunderstandings that might contribute to stress. Assertiveness, therefore, is a communication skill that will enhance your interpersonal effectiveness and make social situations more comfortable (Gambril 1995). As our personalities develop, we tend to learn a pattern of responding that is aggressive, passive or assertive (see Table 24.1). The passive person’s rights are often violated by others. Being taken advantage of inevitably leads to frustration, anxiety and unhappiness. At the other end of the continuum, the aggressive person violates the rights of others and takes advantage of them. The aggressive person is generally defensive and humiliating, perhaps resulting in social isolation. The assertive person, however, protects the rights of each party and achieves goals without hurting others. This results in self-confidence and the ability to express oneself appropriately in emotional and social situations.
Table 24.1 Comparing passive, assertive and aggressive styles
| Passive | Assertive | Aggressive |
| Communicates indirectly; can have human rights violated | Communicates directly and clearly; protects own rights and the rights of others | Communicates critically and explosively; violates the rights of others |
| Does not achieve goals | Achieves goals without hurting others | Achieves goals at the expense of others |
| Allows others to make choices or decisions | Chooses for self | Intrudes on others’ choices |
| Doesn’t manage problems | Addresses problems and negotiates | Unwilling to listen to others and acts on problems too quickly |
Source: adapted from Davis 1989.
Central to these ways of responding is the consideration of basic human rights. We all have the basic right to be treated with respect, for example, and the right to say no without feeling guilty. Making your situation understood by others in a non-aggressive way enables you to feel comfortable without violating the rights of the other person. It is important that your verbal and non-verbal behaviours match. Appropriate non-verbal behaviour to support your verbal message includes good eye contact, a firm voice (don’t apologise or shout), and open body posture to show sincerity (Patel 1991). So, what is your communication style?
Critical thinking challenge 24.1
Decide which of the following responses would best describe your pattern of responding.
If it’s okay with you … If it’s not too much trouble … um, would it be okay … this essay that’s due … I’m sorry …
There are many types of assertion skills that can help you to handle situations you will encounter either personally or professionally. Some difficult situations can include making or refusing requests, accepting and giving compliments, expressing opinions, giving negative feedback or being confrontational, initiating conversations, sharing intimate feelings and experiences with others, and expressing affection. Examples include conveying a nursing assessment to other members of the multidisciplinary team, and refusing a request to care for a client with complex needs when you are a novice nurse. Indeed, nurses’ concerns about advocating on behalf of clients have been found to be a factor that supports the use of assertiveness skills in the workplace (Timmins & McCabe 2005). Many of us find it hard to refuse unwanted requests and this can make life difficult. Just as often, a person might be unable to accept a compliment without countering it by minimising it. For example, when someone says, ‘You look nice today’, it is important to say ‘Thank you’. It’s quite a different response to say, ‘Thanks, but this old dress/suit belongs in a clothing bin’.
Teaching assertiveness skills to others is usually done in groups involving people who need to develop assertion skills. There are a number of workbooks available that can be used to work through and learn how to develop assertiveness skills. A simple and easy text by Davis, Robbins Eshelman & McKay (2000) can help you to assess your inter personal style and your difficulties before guiding you though some strategies for changing your behaviour if you see the need to do so. Once you learn some of these skills, you’ll be able to support others to recognise their non-assertiveness or aggressiveness and help them to learn new ways of behaving.
Risk assessment
Risk assessment involves determining whether a person has the potential for self-harm, either actively or passively, or is considered to pose a risk for hurting someone else. Whenever a person with a mental health problem seriously hurts or kills another person, this usually elicits a strong reaction from the media and the public. When the result is an official enquiry into organisations and individual mental health practitioners, the outcome is usually a tightening of risk assessment and risk management strategies as well as considerable anxiety among staff. Where the client involved in violent behaviour has been treated in a secure environment such as a forensic psychiatric unit, the need for accurate risk assessment skills is heightened (Kelly, Simmons & Gregory 2002). Risk assessment is designed to prevent rather than predict self- or other-directed violence. It is a continuous and dynamic process that is affected by the person’s changing mental state and the environment at the time. Therefore, risk assessment is a critical clinical skill in practising as a competent beginning mental health nurse.
Risk assessment is not straightforward and it is inevitable that mistakes will be made. According to Doyle & Dolan (2002, p 651), ‘clinical risk predictions are only slightly above chance and the competence varies greatly between clinicians’. This means that risk assessment depends on the skills of individuals rather than on the outcome of focused education. A recent review of clinical risk management practices in New Zealand found that only 25% of mental health service providers had good practices in place (Mental Health Commission 1998)—there is a tendency to assume that risk assessment practices are ‘natural’, when in fact they need to be made explicit in policy documents for all to understand and follow. Because nurses spend more time with clients than do other health professionals, we are able to gather important information that will inform the multidisciplinary team regarding a person’s risk. So, if during your interactions with a client you feel concerned about the person’s potential risk, acknowledge your role and responsibility to report this to the team and write about it in the client’s file.
Risk for violence
Some risk factors for violence identified by Doyle & Dolan (2002) include a history of violence, recent verbal threats, a lifestyle that is violent (such as belonging to a gang or trafficking illicit drugs), and being a victim of childhood physical and sexual abuse. The presence of alcohol or other substance-use problems and/or personality traits that are antisocial, explosive or impulsive also increases the risk for violence. Although many believe that marijuana is a safe drug, a belief assisted by its description as a ‘recreational drug’, it has been found to contribute significantly to violence (Mullen 2002). Fear, hallucinations, agitation, anger and suspiciousness revealed through a mental status examination will also alert you to an increased potential for violence. There has been considerable research into specific diagnostic groupings (Axis I disorders) considered to have a greater or lesser potential for violence, with significant variation among the results (Monahan et al 2001). However, an Axis II diagnosis of antisocial personality disorder is predictive of future violence (see Ch 17 for more information about personality disorders). A tool might be useful in helping to predict the risk for violence, depending on your level of expertise. Abderhalden, Needham & Miserez (2004) offer a tool for use in the acute inpatient setting, while Murphy (2004) points out that community mental health nurses tend to rely more on their experience than on the use of an assessment tool.
Self-harm and suicide
Some people carry out acts of deliberate self-harm without aiming to commit suicide. Some attempt suicide unsuccessfully and may therefore fall into the category of self-harm. Risk factors for self-harm or suicide include: the presence of suicidal ideas, feelings of hopelessness, having a plan for committing suicide and having the means to carry out that plan. Demographic factors such as age (younger than 25 or older than 65), being male, being single and having no social support increase
Case study: An avoidable death?
A report on the care provided by a public mental health service in New Zealand was released in October 2002. This followed the case of a client who was discharged from inpatient treatment without a thorough risk assessment and ultimately without a risk management plan, resulting in tragedy. The client was a young man with schizophrenia who also abused alcohol and marijuana. He had made threats to kill his younger brother and his mother based on his (incorrect) belief that they had sexually abused him. He also believed (incorrectly) that the family had taken large amounts of his money. The family’s concerns reportedly had not been listened to and, therefore, not acted upon. Evidence of episodes of aggression, drug use and paranoid thoughts towards his family recurred throughout his inpatient clinical notes. Nevertheless, he was permitted to leave hospital to live independently. Following one week’s leave and after three home visits by the social worker, which revealed substantial alcohol use, and two visits by the client to the mental health service, he was officially discharged from hospital. That same evening, he drank bourbon and beer and drove to his parents’ house, taking with him a knife, a plastic container of petrol and a change of clothing. He confronted his mother at around 3 am and ‘stabbed her some 56 times, resulting in her death’ (Health & Disability Commissioner 2002, p 39). He then used the petrol to set fire to the house and his mother’s body.
the risk for suicide. Young people have their own set of risk factors, largely related to what is going on in their home, school and social environments (Murray & Wright 2006). Diagnoses of depression or borderline personality disorder carry with them an increased risk for self-harm and suicide. In addition, 10% of people with schizophrenia will commit suicide and 15% of people with alcohol- or substance-dependence problems will also kill themselves, although alcohol is implicated in up to 65% of successful suicides (Varcarolis 1998). Ultimately, being mentally ill increases the risk for suicide (see Chs 10, 11 and 23). Using a tool to guide your suicide risk assessment is suggested, particularly for novice nurses (Cutcliffe & Barker 2004).
Factors that protect against violence or self-injury include a safe environment, strong social support, a good relationship with staff and an acceptance of the current treatment approach (Doyle & Dolan 2002). Clearly, nurses have a role in preventing violence or self-harm. Given that nurses are in the best position to assess and manage risk, we need to be sharpening our risk assessment skills. But these are skills that tend to be taken for granted and learned ‘on the job’ rather than formally. Understanding risk factors and protective factors will help you to better assess risk. However, more accurate risk assessment comes from deeper knowledge and extensive experience.
Crisis intervention
What represents a crisis for one person might not have the same impact on another person, but no one is immune to crisis (see Ch 10). Situational life crises such as unwanted pregnancy, death of a loved one, serious physical illness and assault are frequently the cause of emotional disequilibrium or imbalance requiring crisis intervention. Being able to intervene effectively during a crisis is a critical clinical skill required by the mental health nurse.
We invariably respond to crisis with our usual ways of coping. However, because of the magnitude of the problem or a distorted perception of the problem, our usual coping behaviours might fail to resolve it. As a result, we might try other means of coping (such as alcohol or other drug abuse, eating excessively or not eating at all) and these are usually even less effective. Crisis intervention involves interrupting a maladaptive or ineffective pattern of responding and supporting the person to return to the pre-crisis level of functioning (Greenstone & Leviton 2002). Therefore, the focus is on current difficulties and the time frame is brief.
Crisis intervention is quick, short term and based in the here and now. ‘Management of the crisis, not resolution, is the goal of crisis intervention’ (Greenstone & Leviton 2002). Crisis intervention helps the person in crisis to locate or develop the resources from within or externally in order to return to the pre-crisis level of functioning (Myer 2001). At times, following resolution of a crisis, an individual may actually develop new coping skills that will help him or her deal more effectively with future crises. Conversely, lack of resolution of a crisis may result in more disabling psychological problems and subsequent crises will not be well managed.
In order to work effectively in crisis intervention, it is important to have a model to direct your actions. The model will ensure that no relevant information is missed, so the best possible outcome is achieved for the client. There are many available models (for example,
see the work of Slaikeu (1990) and the model offered by Greenstone & Leviton (2002)) but they all reflect the need to act quickly and to base interventions on an accurate assessment of the situation and of risk. Aguilera (1994) offers a simple model for assessing and managing crises. She asserts that there are three factors that, when present, defend against the development of crisis. These are the presence of social support, intrinsic coping skills (such as the ability to solve problems), and a realistic perception of the event, resulting in the belief that you can manage. Consequently, if your assessment reveals a lack in any of these areas, you would direct your interventions to meet the area of need.
Well-practised communication skills, particularly listening and helping the person to tell their story, are fundamental to crisis intervention. Without being clear about what the problem is, it is unlikely that you will be able to intervene effectively in a crisis. Crisis intervention is one time when you, as the helper, take some control and provide direction because the person in crisis is usually unable to do so for him or herself. Myer (2001) suggests that we take control and determine the direction of the therapy without causing dependence. ‘The more severe the reaction to the crisis situation, the more active the crisis worker must be’ (Myer 2001, p 6). The focus is on ensuring both physical and psychological safety.
Telephone counselling
Counselling by telephone is designed to support people in crisis, so it usually involves a single session. It often occurs after-hours and at no cost to the recipient. In addition, telephone counselling affords anonymity to the caller at a time when the person is experiencing vulnerability. As with any counselling session, the telephone counsellor helps the person cope with the crisis by working through feelings and by problem solving. Outcomes include resolution of the problem, referral for further treatment or, if the counselling is unsuccessful, lack of engagement. Interestingly, it has been found that most calls to crisis centre call lines are from people seeking social support rather than crisis intervention (Watson, McDonald & Pearce 2006), which may require an adjustment to the way that telephone services are offered. However, telephone counselling might also be set up for the convenience of the client—for example, for people with physical disabilities who might otherwise have difficulty accessing an office. In addition, some counsellors might augment face-to-face counselling sessions with telephone sessions (Sanders 1996).
There are many models for crisis intervention by telephone (Egan 1998; Lester 2002; Slaikeu 1990) but they all follow a similar problem-solving plan. There needs to be initial engagement or the development of rapport through a caring, honest and open approach before the problem can be explored and analysed. The same counselling skills used for face-to-face counselling are used, but with greater emphasis on listening. Following engagement, it is important to determine the person’s safety before moving on to explore their needs. Once the person’s needs have been thoroughly explored, a plan of action would be developed that includes a follow-up appointment.
When working on the telephone, more frequent verbal responses are necessary. It is important to let the client know that they are being heard and that you are there, listening to the story. Typical verbal encouragers include: uh-huh, yes, sure, go on, mmmm, right, okay, I see, Do you want to say more about that? and Please tell me more about that. These verbal encouragers let the client know that they are being listened to, and this enables further elaboration of the story about the current crisis.
Listening carefully is also very important. When telephone counselling, there are no visual cues to attend to so you must focus your listening skills more acutely. This enables a more accurate assessment of what the client is thinking and feeling, which enables you to reflect that understanding to the client in a truly empathic way. The telephone counsellor needs to listen for voice tone, pitch and volume, and breathing noises that might indicate anxiety, grief or anger. It is important to listen for crying and other noises like snorting, groaning, grunting, sighing, laughter, sarcasm and silences (Sanders 1996). These will need to be interpreted in the context of what is being said.
Psychotherapy
Once extremely popular, psychotherapy now has to compete in a world where the biomedical approach to diagnosis and treatment prevails. The biological model focuses on chemical treatment and limits the consideration of a person’s historical trauma. Psychotherapy, on the other hand, is concerned with ‘the complex messy nature of the human experience. This includes the problematic domains of the aesthetic, the ethical, and the spiritual’ (Petchkovsky, Morris & Rushton 2002, p 330). The term psychotherapy is used to describe a number of interpersonal models, each with its own individual philosophy and set of techniques. Examples of psychotherapeutic models include individual psychotherapy, planned short-term psychotherapy, cognitive behavioural therapy, motivational interviewing, and dialectical behaviour therapy. To be able to practise any of these psychotherapies, you would need to undertake a specialised program of study that might include supervised practice, but nurses can and do conduct psychotherapy.
Individual psychotherapy
The early work of Sigmund Freud (1938/1965) revealed that much of what motivates us and influences our behaviour occurs at an unconscious level. Despite some of his work being challenged over the years, this tenet still holds true and it is this understanding that underpins psychotherapy. Although psychotherapy can occur in groups, it most commonly occurs individually. The goal of psychotherapy is to effect change in the person’s character, as difficulties of living are viewed as linked to childhood development of the psyche. ‘Psychodynamic theory is rooted in the belief that we develop a sense of self during childhood’ (Gallop & O’Brien 2003, p 216) (see also Ch 8 for information on psychotherapy).
Psychotherapy occurs between client and therapist, usually over a lengthy period of time (time-unlimited). It provides the client with opportunities to examine the historical experiences that have shaped who they are and influenced their life decisions. This happens when the client brings those past experiences into the present relationship with the therapist and re-enacts them (transference). Transference is an unconscious process, that is, the person is unaware that he/she is doing it. According to Evans (2007, p 191), ‘transference is about one’s fundamental ways of relating to those one loves, fundamental ways that repeat throughout one’s life, although new experiences do provide the possibility for change in this pattern’. The person may begin to relate to you as the nurse in one of these patterned ways, for example, as someone who can be trusted, loved and respected. From this place, the client might be able to talk more deeply about the things that concern them. Alternatively, the client might respond to you as someone who is unlikeable and untrustworthy, reflecting that person’s earlier experiences. This negative transference is quite common and needs to be immediately recognised as such rather than taken personally.
The therapist is also responsible for recognising what he or she brings to the therapeutic relationship and the counter-transferences that support the client’s re-enactment of earlier relationships. For example, it is important to recognise that reciprocal love or dislike for the client is counter-transference and that expressing this would be counter-therapeutic and potentially destructive. Counter-transference can be viewed as a natural and expected response in some instances (for example, responding as the caring and nurturing mother), but it is important to recognise this response as counter-transference, as it has the potential to be damaging to the client. For example, an adult who struggled as a child to get confirmation of love from a parent might re-enact that struggle in the client–therapist relationship (transference). The therapist who doesn’t recognise the transference and allows the client to continue to seek affirmation (without challenging it), is demonstrating counter-transference. So, the therapist is responding to a situation that is rooted in the client’s past and causing the situation to be repeated in the present. The appropriate response on the part of the therapist would be to explore the client’s need for love and to help the client gain insight into how this is related to experiences from an earlier time in his or her life. Counter-transference can be viewed as a natural and expected response in some instances (for example, responding as the caring and nurturing mother), but it is important to recognise our response as counter-transference, as it has the potential to be damaging to the client (see Ch 23 for more information on these terms).
Gallop & O’Brien (2003) argue that nurses need to deepen their understanding of psychodynamic theory, not just at the cognitive level, but at the affective level—the level of emotions. We need to be aware that our own developmental experiences determine who we are and that we re-enact our personal histories in everyday relationships, professional or personal. Much of this occurs unconsciously and puts us at risk of behaving inappropriately. ‘Our history that creates the self is replayed in every interaction and decision throughout our lives. So that when we respond to our clients and they respond to us, we in the present bring with us our past’ (Gallop & O’Brien 2003, p 219). This is particularly important to acknowledge when we are working with people who are already distressed by mental health problems and are vulnerable.
Planned short-term psychotherapy
Initially known as brief psychotherapy, this group of psychotherapies is now more commonly referred to as planned short-term psychotherapy. This title differentiates it from short-term therapies that are not planned. The brief therapies began in the 1960s when efforts were made to make the psychotherapeutic model of counselling available to greater numbers of people. Access to psychotherapy was limited due to the time-unlimited nature of early psychotherapy. However, the brief therapies expanded as it became clear that they could be very effective (Bloom 1997). Brief psychotherapies include interpersonal psychotherapy, cognitive behaviour therapy and motivational interviewing. Effectiveness, efficiency and economy have therefore led to an explosion in planned short-term psychotherapies.
The goal of planned short-term psychotherapy is to manage problems in the here and now (the present). The duration of the short-term therapies ranges from a single session through to around 20 interviews, as compared with individual psychotherapy, which occurs regularly over at least a two-year period. Short-term therapists believe that the person’s presenting complaint is symptomatic of deeper psychopathology, so that ultimately, in managing current difficulties, significant psychological change also occurs (Bloom 1997). This, of course, matches the goal of the original, time-unlimited psychotherapy. Given today’s fiscal environment in healthcare services across Australia and New Zealand, improved access to less expensive forms of treatment is welcomed. Furthermore, ‘planned short-term psychotherapies are, in general, as effective and long lasting as time-unlimited psychotherapy’ (Bloom 1997, p 7).
Motivational interviewing
Motivational interviewing (MI) is a relatively modern psychotherapeutic model, having been conceptualised in 1982 by Bill Miller and Steve Rollnick. It is an intervention that was initially developed for work with people with substance abuse and dependence problems. Indeed, Miller (1998) defines addiction as fundamentally a problem of motivation. You may be aware that many people with these problems tend to use the defence mechanism of denial—that is, they initially refuse to acknowledge that a problem exists. Once the person begins to acknowledge that there may be a problem, they may still be reluctant to engage in treatment. This indecision is known as ambivalence and MI essentially aims to change the substance-use problem by helping people to explore and resolve this ambivalence (Rollnick & Miller 1995).
Rollnick & Miller (1995) differentiate what they call the spirit of MI from the techniques they recommend to support it. Central to MI is the need for the therapist to resist persuading the client to make changes in behaviour. Motivation to change is determined to come from the client. Readiness to change, however, is a result of interpersonal interaction rather than being a personality attribute of the client (trait). Any attempts to persuade or coerce the client will only lead to increased resistance. The counselling style is described as quiet and involves guiding the client towards considering the options and their consequences. It is not confrontational. The therapist would never tell the client what he or she should be doing. According to Rollnick & Miller (1995):
It is inappropriate to think of motivational interviewing as a technique or set of techniques that are … ‘used on’ people … rather it is an interpersonal style. It is a subtle balance of directive and client-centred components, shaped by a guiding philosophy and understanding of what triggers change. If it becomes a trick or a manipulative technique, its essence has been lost (Rollnick & Miller 1995, p 326).
The wheel of change or transtheoretical model developed by Prochaska & DiClemente (1983) is used to support the philosophy of MI. The model outlines five stages related to the readiness to change behaviour—in this case, abstaining from addictive substances like alcohol:
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