Transcript Kevin Ducray – Individual Psychotherapies

Kevin Ducray
Senior Clinical Psychologist
The Drug Treatment Centre Board
November 2006
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Individual Therapy Approaches to Adolescent Substance Misuse
Introduction
Challenging and intimidating?
In its own infancy (or "adolescence")?
Complex clinical condition
Associated with co morbid psychiatric/ psychological disorders
Client- related barriers to treatment
Interplay of biological, psychological and social difficulties
Role of politics, economics, culture and ideology in shaping attitudes?
(Disease, abstinence, confrontation, criminalisation versus harmreduction, pragmatism, collaboration, egalitarianism)
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Paucity of research on effectiveness of adolescent psychological treatments
Adult treatments well researched
Paucity of research on adolescent psychological interventions
Adolescent studies often suffer from the following methodological problems :
small sample sizes
lack of randomized sample assignment
inadequate measures and descriptions of patterns and levels of use
wide ranges of levels of participant drug use (casual / abuse/ dependence)
impact of dual diagnosis
high drop out rates
assessment tools loaned from adult treatment
researchers own/ self developed tools
scales' psychometric properties often unknown
inconsistent methodology in terms of time scales (e.g. of prior use, post treatment
outcome)
variable methods of determining level and frequency of use
what constitutes successful outcome?
(Source: Waldron and Kaminer 2004; Kaminer 2001; Muck et al. 2001)
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Tendency to extrapolate empirically validated adult models to adolescent populations.
Clinical Differences between Adults and Adolescents:
More susceptible to development of dependence syndromes
Rapid progression from casual use to dependence
Higher degree of co- occurring psychopathology
Psychopathology precedes the onset of substance use
Psychopathology often does not remit with abstinence
Greater constellation of needs and problems (often inter- related)
Dependence impacts upon developmental pathways
Developmental variability between adolescents
Need for flexible/ tailored approach?
Interventions must be sensitive to the above differences
Greater intensity and duration of treatment than adults?
Habilitative as opposed to rehabilitative strategies?
(Source: Muck, R et al, 2001)
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Adolescent Drug Abuser's Needs/ Challenges:
Psychological
Resistance/ Ambivalence
Chaotic
Disengaged
Low frustration tolerance/ Impulsive
Irritability
Emotionally Fragile
Dependency and motivation to change?
Physical
Physical illness Hep C/ HIV
Basic Needs Unmet (Maslow)
Social
No close relationships outside the context of drug use
Difficulties of relating to authority figures
Pattern of “downward social drift"
Power of peer pressure
Predilection for “testing limits”
Disruptive deviant associates disrupt/ undermine progress
Violence and harm (debts, dealers, disputes, pimps and family)
Absence of effective pro- social “reinforcers” that compete with
drugs?
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Developmental
Negative impact upon development of:
Coping skills
Pro- social identity formation
Interpersonal skills
Communication skills
Educational/ Vocational skills
Family responsibilities
Work responsibilities
In extrapolating evidence- based adult models, one needs to be
extremely mindful of:
the unique needs
characteristics
developmental issues
problems characteristic
- of young people who misuse drugs
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Individual Therapy Approaches to Adolescent Substance Misuse
Objectives:
(1)
(2)
Provide brief overview of approaches regarded suitable/ appropriate for adolescent substance
misuse
Sensitise delegates to their many existing competencies (skills/ knowledge/ attributes)
Generic competencies required to assist adolescents with drug problems.
Addiction shares principles of genesis, acquisition, and maintenance with other psychological disorders
Addiction rarely occurs in absence of related psychological problems
Evidence based approaches for treating alcohol/ drug problems are familiar to many practitioners
Cultivating a respectful relationship, accurate empathy, individual psycho education, instilling hope is
generic and is associated with positive outcomes.
(Obviously would not detract from the practitioner's need to obtain the necessary training
and supervision should they wish to formally apply these approaches within the context of a
defined care plan)
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Motivational Interviewing
(William R Miller and Stephen Rollnick)
“Motivational Interviewing is a directive, client- centred counselling style for eliciting behaviour change by helping clients to
explore and resolve ambivalence"(Miller, R and Rollnick, S, 1991, pg. 8)
Explicitly egalitarian and respectful
Most influential, exciting and promising recent therapeutic development within addiction?
Spirit of MI
Motivation elicited not imposed
Client's role to articulate and resolve their ambivalence
Therapist's role to highlight ambivalence impasse, guide client to a resolution that triggers change
Persuasion/ confrontation counter productive
Quiet, respectful and eliciting, never argumentative or confrontative
"Resistance and denial" not client traits but product of therapeutic interaction
Therapeutic relationship more a partnership than a expert/ recipient role
The "spirit" or interpersonal style gives rise to therapeutic behaviours
Notion of "set of techniques being used on people" is an antithesis to MI
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Recommended strategies for building motivation for change:
'Open ended' questions
Listen reflectively
Affirm
Summarise
Ascertain readiness for change
(e.g. Explore advantages and disadvantages for problem behaviour)
Elicit self- motivational statements
Goal is for client to realise cost of problem behaviour exceeds any benefits
Strengthen commitment to change
Negotiate a treatment plan
Support Self-Efficacy
-
“There is no right way to change”
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Particular Utility?
“Angry” clients
Cross cultural therapeutic relationships/ Minority groups
Low motivation, ambivalence, reluctance to change
Problem behaviours are highly rewarding
Produce/ evoke rapid, internally motivated change
No significant psychological/ psychiatric pathology
MI shown to improve outcomes of subsequent other evidence based interventions
A safe and economic starting point for one to one psychosocial therapy
May be suitable framework to initially address client motivation, who once motivated to change, can be assisted with skill
development?
(Source: Project MATCH Research Group 1999, Miller et al 1995, Miller 2006)
Motivational Enhancement Therapy
MET- 4 planned, structured and individualised check up and follow- up sessions for problem drinkers
MI is the “style”, philosophy or approach used
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Cognitive Behaviour Therapy (CBT)
Heterogeneous mix of interventions aimed at improving cognitive and behavioural skills to change drug related
behaviour
A combination of Cognitive Therapy (CT) and Behaviour Therapy (BT)
BT - seeks to inhibit maladaptive behaviour by reinforcing desired behaviour and extinguishing undesired behaviour
CT- “a system of psychotherapy that attempts to reduce excessive emotional reactions and self defeating behaviour by
modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions” (Beck et al, 1991, pg. 10)
CT- facilitates positive behaviour change by examining and changing distorted patterns of thinking.
CBT- integrates ‘cognitive restructuring' with behaviour modification techniques and skills generation
Abnormal thinking changed by:
Verbal techniques (explanation, discussion, questioning and testing of assumptions)
Behavioural actions which can be used to change the way someone thinks
(“Learn from their experience”, use real life experience to challenge faulty cognitions )
Behaviourally there is an emphasis on:
And
Increasing the ability to cope with (interpersonal and intra personal) situations that precipitate or maintain
drug use
Overcoming skills deficits
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Schema (fundamental core beliefs) giving rise to enduring assumptions, attitudes and thoughts which set in motion
problematic behaviours may be focus of attention
Drug use (according to Social Learning Theory) is also functionally related to major life problems
Addressing this broad range of problems will be more effective than addressing drug use alone
Treating concurrent disorders and other life problems seen to be a legitimate focus
Emphasis on learning and practicing a variety of coping skills (some cognitive and some behavioural).
Can be didactic in early stages
CBT- Practitioners approach drug use behaviour as a Learned Behaviour
Substance misuse and related problems are learned behaviours
Initiated and maintained in a particular environmental context
As behaviours are learned so they can altered by application of learning principles
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Operant conditioning- focus on important and particular reinforcers (+ and -)
Manage ("extinguish") urges
Explore reinforcers for competing behaviours
Classical conditioning- pairing: Paraphernalia, places, people, times, mood states, feelings associated with the
various stages of drug use
Preoccupation, planning, procurement, use
Anticipate and avoid high-risk situations (settings, times, places which serve as triggers or stimulus cues)
Social Learning Model- Modelling/ - “copying and watching others”
Incorporates classical and operant learning principles
Recognises influence of environment on behaviour acquisition
Acknowledges role of cognitive processes (how environmental influences are appraised and perceived)
Drug use and misuse thus influenced by:
Observation and imitation of parents, siblings, peers, role models
Social reinforcement
Anticipated effects/ Expectancies
Direct experience of drug's effect being rewarding
Self efficacy beliefs
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Specific techniques include:
Self Monitoring/ Diaries/ Logs/ Mood monitoring
Graded Task Assignment/ Activity Scheduling/ Behavioural contracting
Avoidance of Stimulus Cues
Distraction/ Engagement in incompatible actions
Modelling/ Role play/ Response and Behaviour Rehearsal/ Refusal Skills
Coping Skills to manage/ resist urges to use
Focus on drug effects/ expectancies/ consequences of use/ Decisional analysis
Use of Flash Cards
Communication Skills/ Conflict resolution skills/ Social skills training/ Assertiveness Skills
Problem Solving Skills
Self Image
Mood Regulation
Relaxation training
Anger Management
Clarification of role of cognitions in challenging situations/
In situ and in vivo practice to manage threatening situations
Recognition/ challenge and correction of inaccurate/ distorted thoughts
Challenge/ review maladaptive core beliefs/ schema (self, world, others, future)
(Re) lapse analysis (preparation, prevention and feedback)
Psycho- education
Progressive Muscle Relaxation/ Autogenics Training
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Positive Features
Problem- focussed; perceived as relevant to the adolescent's difficulties
Not complex or esoteric
Collaborative- the client is an active equal
Emphasis on personal responsibility for change/ Empowering
Can employ familiar, jargon free language (“homework” assignments; role play”, “practice”)
Optimistic outlook/ “Cheap and cheerful”
Clear and negotiated structure
Evidence
Indicated for severe dependence and higher “psychiatric severity”, retained drug using networks, the motivated
Relatively large and positive evidence base, esp. in treatment of alcohol and cannabis misuse
Differential effect between adult cocaine and opiate users with greater effect for opiate users
The unique mechanisms of change of CBT remain to be more fully understood
Quality of the therapeutic relationship is critical
(Source: Project MATCH 1996, Beck et al. 1979, Carroll 1996, Crits- Christoph et al. 1999; Woody et al. 1983 and 1995)
Consistent empirical evidence CBT associated with significant and clinically meaningful reductions in adolescent substance
misuse
Substantial empirical evidence supporting efficacy of CBT for adolescent substance use disorders
CBT an efficacious intervention for youths with substance use related disorders and related problem behaviours
Effectiveness with adolescent suffering from problems/ other disorders known to co- occur with drug use well established
(Source: Waldron and Kaminer, 2004)
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Relapse Prevention
G Marlatt and J.R Gordon
Relapse notoriously high
Pattern, process and circumstances for relapse are similar across addictive behaviours
RP a behavioural self control programme based on CBT strategies
Self-management program :
1) help clients maintain gains achieved in addictive behaviors treatment
2) as a stand alone programme
Strategies designed to facilitate abstinence and help those who experience relapse
Initially developed for problem drinkers, later adapted for cocaine dependency
RPT programs have also been developed specifically for co-occurring disorders
Recognizes that therapeutic progress occurs in gradual increments or stages of change
Humane and pragmatic
Emphasizes self-management and rejects labelling clients with traits like "alcoholic" or "drug addict."
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Major components
(1) Aimed at helping clients anticipate and avoid an initial slip or lapse
(2) Designed to reduce the intensity, duration, and harmful consequences of any slips
that do occur
(3) Following a lapse, to encourage clients to continue their journey and accept that
change involves both advances and setbacks.
(4) Development of skills to increase ability to deal with these high risk situations
(5) Learn to create more balanced lifestyle (Engage in Meditation, Exercise, Spiritual
Practices)
Encouraging evidence RPT is an effective psychosocial treatment for alcohol and drug problems
Effective for poly- drug use when alcohol is one of the substances misused
Skills learnt during interventions remain after completion of treatment
Gains maintained for 12 months
(Source: Carroll 1996; Carroll et al. 1991 and 1994; Irving et al. 1999; Marlatt and Gordon 1985)
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The Matrix Model
Richard Rawson, Ph.D
Intensive 16 week outpatient “framework” for helping clients achieve abstinence (esp. stimulants)
Weekly aftercare sessions
Draws upon other tested modalities (Urine testing, family, group, social support and self- help approaches)
Focus on the fundamentals of stabilisation, abstinence, maintenance and relapse prevention
Individual therapeutic relationship is seen to be critical for client retention
Teacher and a coach
Empathic and directive, support critical
Role is to give clients the knowledge, structure and support to achieve abstinence
Clients learn about issues critical to addiction and relapse
(Early recovery skills; Drug education; Relapse prevention; Relapse analysis)
Therapeutic relationship is positive and encouraging
Realistic and direct, not parental, confrontational (or "therapy" in the classical sense)
Self esteem, dignity and self worth is promoted in sessions
Has been manualised into systematic treatment protocols
Shown to:
Facilitate statistically significant reductions in drug/ alcohol use (effective across substances)
Improve psychological indicators
Reduce high-risk sexual behaviours
(Source: Huber et al. 1997; Rawson et al. 1995)
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Supportive Expressive Psychotherapy (Adapted for heroin and cocaine abuse)
Time limited, focussed, psycho dynamic treatment
Concentrates on:
Role of drugs in relation to problem feelings and behaviours
Impact of inner struggles on behavioural/ emotional problems
Exploration of how problems and difficulties can be solved without resorting to drug use
Major features:
Use of supportive techniques to assist clients feel at ease in relating their personal experiences
Use of expressive techniques to help clients recognise and resolve interpersonal and relationship difficulties
Adult clients on MMT with mental health difficulties who were exposed to this intervention had:
1) Lower cocaine use and required less methadone for opiate difficulties
2) Improved outcomes for opiate users with psychiatric problems on MMT
3) Maintained gains for longer
Has been manualised for treatment of opiate and cocaine dependence
(Source: Luborsky 1984; Woody et al. 1987)
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Behavioural Therapy for Adolescents
Unwanted behaviour can be changed by:
Demonstration of the desired behaviour
Agreed upon sets of behaviours to be changed
Daily or weekly goals
Rewarding the incremental steps made toward achieving these goals
Equipping the client gain the following types of control:
Stimulus Control
Avoid situations associated with drug use
Increase time spent in activities incompatible with drug use
Urge Control
Help clients recognise and change thoughts/ feelings/ plans that lead to use
Social Control
Involving significant others in helping the client avoid drugs
Significant others can contribute to therapeutic assignments/ reinforce desired behaviours
Therapeutic behaviours can include:
Completing assignments
Rehearsing desired behaviours
Recording and monitoring progress
Receipt of rewards and privileges for accomplishing assigned/ negotiated goals
Urine samples are collected on a regular and structured manner to monitor chemical use
More effective than supportive counselling
Demonstrated to help adolescents attain and maintain drug abstinence
Improvements shown in related indices such as school attendance, quality of relationships, depression and alcohol use
(Source: Azrin et al 1994 and 1994)
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Solution Focussed Brief Therapy
Steve de Shazer and Insoo Kim Berg
Initially developed for low- income, socially disadvantaged clients with serious drug and alcohol problems
Treatment interventions concentrate and focus on the presenting or most immediate problem
Two essential components:
1) Potential solutions are based on “Exceptional Moments”, i.e. when the problem does not overpower,
overwhelm or incapacitate the client’s ability to function
Therapist attempts to discern what it is that the client is already doing which might contribute to problem resolution
2) A determination of what life would be like without the problem, or with it solved?
Knowledge of client’s goals, desired ‘life destinations’ increases the likelihood of success.
This model stresses that the problem and solution may not necessarily be related
The type of drug used is not viewed as a critical determinant in choice of treatment
Model is designed to help clients exploit their own unique strengths and resources in problem resolution
Approved by Office of Mental Health and Addiction Services (US) as an Evidence- based Practice
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Integrated Dual Diagnosis Treatment (IDDT)
Robert Drake, Susan Essock, Andrew Shaner, Kenneth Minkhoff et al
Many people with addictions have co- occurring mental illness
(>60% of adolescents: Bukstein et al. 1992)
IDDT offers concurrent mental health and addiction interventions in same setting
Hope, optimism, and a positive atmosphere are core beliefs
Other’s recovery is used to promote a positive expectation
A personalised treatment plan for both mental health and addiction problems
Individualised treatments are determined by stage of recovery
Interventions are structured in a stage- wise fashion given their relative significance to treatment
(Some services are important during the earlier phases of treatment and vice versa)
Interventions are comprehensive and long- term
Interventions include:
Psycho- education about client’s illnesses and conditions
Relationship counselling and living skills
Help with budgeting and money management
Employment advice
Specialised counselling focussing on symptom management
Approved by Office of Mental Health and Addiction Services (US) as an Evidence- based Practice
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Individualised Drug Counselling
Emphasis on stopping or reducing drug use
Focus on short term behavioural goals
Strategies and tools to help attain and maintain abstinence
12 Step participation is strongly encouraged
Also addresses areas of impaired psycho- social functioning salient to drug use:
involvement with negative peer groups
criminal activities
interpersonal and family relations
education
Twelve Step Facilitation (TSF) Therapy
(Joseph Nowinski)
Facilitates active participation in AA/ NA
AA seen as primary factor responsible for recovery
Widely used internationally
Addiction/ alcoholism a spiritual and medical "disease"
Must be managed through- out life
Recovery equated with abstinence
Brief, structured, manual driven approach
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Implemented on an individual basis in 12- 15 sessions
Treatment based on spiritual, cognitive and behavioural principles that form the basis of AA and NA fellowships
Template: 12- Step Programme- stepped sequence of treatment and lifestyle goals
Honesty
Decisions regarding cessation of drug and alcohol use
An action plan for lifestyle change
Correction of past wrongs where possible, continue a recovery plan for the rest of life)
Increasing scientific attention:
Greater abstinence at 12 months than other approaches (Project MATCH 1996)
AA/ NA enhances outcome when component of ongoing formal interventions
Beneficial effect “additive” rather than independent
Stand-alone AA/ NA attendance does not improve outcome
“Dose effect” found
Merit in encouraging 12 step attendance as an adjunct to formal treatment.
Increasingly accepted by clinicians?
(Source: Project MATCH 1996; Alford et al. 1991; Fiorentine1999; Fiorentine and Hillhouse 2000; Winters et al.
and 2000)
1999
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Contingency Management Treatments
Nancy M. Petry
Widely used in substance misuse research
Gaining popularity despite some attitudinal resistance
Clients awarded tangible positive reinforcers for objective behaviour change
Vouchers for negative urine samples
Clinic managed account
Staff purchase requested items (audiovisual equipment, sports goods, clothing, cinema tickets etc.)
Positive effects unambiguously demonstrated when compared to traditional treatments
Almost doubles average period of abstinence when added to psychotherapy
Barriers
- cost
- attitudes, esp in parts of the world where abstinence orientated, confrontational approaches dominate
Prize Contingency Management
Some political and ideological criticisms
- as efficacious as the voucher system
- costs reduced by two thirds
- “ the technique "mimics gambling"
- “why pay addicts what they should do anyway?”
Payments to drug users have rarely induced drug use and have not led to an increase in gambling
Improves retention and stimulant use abstinence in non- methadone settings
Increases proportion of drug negative samples submitted in methadone settings
(Source: Petry 2006)
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Adolescent Community Reinforcement Approach (CRA) with Vouchers
Developed as individual counselling approach (alcoholism)
CRA with Vouchers is an extensive 14- 24 week out patient therapy
Initially designed for cocaine addiction
Used for cocaine dependent clients who use alcohol/ MMT patients who use cocaine
Goals:
Achieve abstinence for sufficient duration to develop life skills to sustain abstinence
Reduce alcohol consumption
Clients attend one- two psychotherapeutic sessions weekly aimed at:
Improving family relations
Developing skills to reduce drug consumption
Vocational/ educational related issues
Developing new recreational interests, activities,social networks
Vouchers received for drug (esp. opiates and cocaine) negative samples (various systems)
Vouchers are exchanges for goods which are consistent with a drug (esp. opiates and cocaine) free lifestyle
Cocaine or Heroin positive urines reset value of voucher to initial baseline level
Focus on fostering engagement and a systematic gain in periods of abstinence
Voucher- Based Reinforcement Therapy in Methadone Maintenance Therapy (MMT)
Very similar to above model
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Dialectical Behaviour Therapy (DBT)
Modified for Substance Abuse (DBT- S)
DBT adapted for adolescents
Marsha Linehan
DBT increasingly extended to older adolescents with addiction, dual diagnosis and mental health issues
(Suicidal concerns, deliberate self harm, poor emotional and impulse control,dramatic interpersonal styles and impaired
interpersonal skills)
Included as:
Adolescent alcohol use disorders predictors of adult borderline personality disorder (Thatcher et al, 2005)
Individuals with BPD often suffer from alcohol and substance abuse (Benjamin, 1993 *)
A complicated reciprocal relationship exists between BPD and drugs (Stone, 1993 *)
Individuals with BPD are characterised by drug seeking behaviour (relief and escape)-( Millon,1996 *)
Individuals with BPD are "the best candidates for developing addictive disorders" (Richards, 1993 *)
The treatment of any character disorder is the road to recovery for addiction (Khantzian et al, 1990 *)
"...borderline patients pose tremendous challenges to therapists who are working diligently to help them overcome
addictions to drugs" and
"As separate identities, substance abuse and...the borderline syndrome are difficult to treat. In combination, the clinical
picture becomes extremely challenging indeed" (Beck et al, 1993)
*Cited in Ekleberry, 2000
The borderline schema "I'm bad and deserve to be destroyed" supports self harm, self sabotage and hatred
- would run contrary to the goals of self interest which commonly appeal to most other clients
- motivate avoidance of treatment strategies aimed at personal achievement, recovery or wellness
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Primary strategies to promote validation (acceptance and understanding) and problem solving (change)
Modes of therapy:
1) Individual psychotherapy (the main basis of treatment)
‘Patient and Therapists Agreement’ is significant
Accepting but encouraging of change
Centred and firm, yet flexible when required
Nurturing but benevolently demanding
Clear about their personal limits
Treat with respect
Implicit- not able to stop the client from harming herself
Techniques include
Contingency management
Cognitive therapy
Exposure based therapies
2) Group skills training
3) Telephone coaching between sessions
Skills taught/ imparted
Mindfulness (focussed attention and awareness to the here and now, Zen meditative techniques)
Emotion regulation (changing and reducing distressing emotional states)
Distress tolerance (tolerating intense emotional states that cannot be changed)
Interpersonal effectiveness (maintain sound relationships, self esteem and asserting needs and objectives)
With modification DBT has been shown to be effective in treating addiction disorders for women and has also been adapted for
adolescents (Linehan,1997)
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Brief Interventions
(Heather1995)
Frequently used for maladaptive drug use (esp. alcohol, cannabis)
Clients not yet dependent, few problems
Goal moderate drinking as opposed to abstinence?
Designed for use by professionals not specialised in addiction
Little time/ few resources
Includes:
Provision of self help materials
Brief assessment
Provision of advice (in a one off session),
Assessment of readiness to change (motivational interview),
Problem solving
Goal setting
Relapse prevention, harm reduction
Follow- up
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Brief Interventions
(Heather1995)
Major elements summarised by acronym FRAMES
Feedback
Responsibility
Advice
Menu of strategies
Empathy
Self efficacy
Restricted to 5 or less sessions, ranging from a few minutes to an hours duration
Not considered suitable for clients with:
more complex problems
psychological/ psychiatric issues
severe dependence
poor literacy skills
difficulties related to cognitive impairment
Can result in significant gains at minimum cost
Does not replace the need for specialist alcohol and drug treatments
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Individual Psychoeducation
Seldom an independent intervention
Inherent to good care, engagement, establishment of therapeutic alliance
Provision of information at appropriate level or detail
Stress client is not alone
Describe what improvements can be expected
Instill hope
Describe the treatment modalities that work
Suggest and recommend treatment plan
Invite questions and discuss concerns
Reinforce and repeat
A major component of all good clinical care and all self help programmes
Evidence that understanding about condition/ treatment related to adherence
Knowledge has been shown to improve outcome
(Craighead et al, 1998)
Treatment that harms or is of little positive effect
Boot camp (etc.) popularised by the media
Politically, societally and economically popular (faddish and cost effective)
Data suggests these approaches do not work but also increase problematic behaviours
(Dishion et al. 1999)
Confrontational Counselling/ Psychoanalytic Therapy seen to have little or no effect
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Meta- Analysis
Major systematic review of alcohol interventions (Miller et al. 1995)
MI; Skills based Cognitive Approaches, Community Reinforcement- effective
Confrontational Counselling, Psycho- analytic approaches, lectures of little use
CBT and 12- Step Approaches achieved equal results
Irrespective of pure or dual diagnosis or mandated to treatment
(Source: Ouimette, Finney and Moos 1997)
Project MATCH 1996 (largest addiction trial ever conducted)
12 Step Facilitation, Cognitive Behavioural Skills and Motivational Enhancement Therapy were
equally highly effective
Project MATCH 3 year follow- up (1999):
Standardised, manual based protocols, and
High level supervision and training
- optimises outcome, irrespective of intervention
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In 2000 NIDA released the first ever science-based guide to the treatment of drug addiction. Based
on a 30 year review. Findings included:
No single treatment for everyone.
Treatment needs to be readily available.
Effective treatment attends to multiple needs, not just drug use.
Treatment and services plan must be assessed continually and modified to ensure plan
meets changing needs.
Remaining in treatment for an adequate period of time is critical for effectiveness.
Counselling is critical for treatment of addictions.
Mental health and substance problems should be treated in an integrated way.
Treatment need not be voluntary to be effective.
Recovery frequently requires multiple treatment episodes.
(National Institute on Drug Abuse (2000). Principles of Drug Addiction Treatment.
Washington, D.C.: NIDA. )
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Effectiveness versus efficacy
Controlled psychological treatment outcome studies for children and adolescents treatment done
in real life representative clinics (effective) shows far more modest effects in comparison to
those done in pure laboratory (efficacy) settings.
Many studies of clinic based adolescent treatments have found no significant effects.
(Weisz et al. 1992)
This is a concern in psychological treatment research and why it is recommended that clinicians
engage in routine and systematic monitoring of the outcome of their clinic based work.
It has been repeatedly suggested that the similarities rather than the differences between
psychological treatment approaches may be primarily responsible for change. (Wampold, 2001)
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What seem to be the common features of models discussed in relation to the
above:
Quality of the therapeutic relationship is critical
Engagement and retention emphasised
Respectful and non- confrontational
An optimistic expectation of positive behaviour change
A focus on skills generation
Didactic in nature
Imparting of knowledge and understanding
Clear focus on readily identified and explicit drug use related goals
Unpretentious and jargon free
Focus on observable behaviour change (increases or decreases)
Inclusion of homework and other exercises
Emphasises the support and involvement of significant others/ family
(i.e. social network based interventions)
Encouragement of more effective communication with others
Focus on relevant quality of life- related problems
Drug and psychological difficulties treated in integrated manner
Structured, standardised, manual based approaches
Emphasis on self efficacy
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Thank You
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