Transcript Psychosocial Treatments for Substance Use

Amalia Bullard Ph.D.
Kansas City VA Medical Center
“Sobriety is
more than
not using –
It is creating
a new life
that
supports it.”
Objectives
 Psychosocial
interventions with
empirical support
 Treatments with promise
 Integrated treatment of co-occurring
disorders
 Mechanisms of change
 Role of therapeutic alliance and
therapist characteristics
 Importance of continuation of care
Psychosocial Interventions with
Empirical Support
Motivational
Interviewing
Cognitive Behavioral Interventions
Contingency Management
12-Step Facilitation
Community Reinforcement
Approach
Behavioral Couples and Family
Therapies
Motivational Interviewing (MI)
A goal-oriented, client-centered
counseling style for eliciting
behavior change by helping
patients to explore and resolve
ambivalence.
Motivational Interviewing
Having more
effective
conversations
about
changing
substance use
Patients don’t do what they
should because:
Don’t know what they
need to be doing
Solution = Tell them
what to do
Lazy or weak willed
Solution = Tell them
why doing what I say is
so important
Denial or don’t believe
what I have to say
Solution = scare,
convince, persuade,
them to do what I say
The Righting Reflex
 The
desire to fix what seems
wrong with people and to set
them promptly on a better course.
 What
could possibly be wrong
with that?
Ambivalence - getting stuck on
the road to change

Simultaneously wanting and not wanting
something, or wanting both of two
incompatible things
 Change talk and sustain talk
 Getting stuck in ambivalence
○ Think about changing… think about not
changing… stop thinking about it
Ambivalence the Internal
Committee

What happens when an ambivalent person
meets a provider with a righting reflex?
 Argue for one side and the person is likely to
take up the other side and defend the opposite.
 Most people tend to believe themselves and
trust their own opinions more than those of
others.
 If you are arguing for change and your patient is
arguing against it, you’ve got it exactly
backwards.
Tug of War
Pt: “I know I should quit drinking, but it’s the
only way I can sleep through the night without
the nightmares.”
Dr.: “You’re right. You really need to cut back
on the alcohol. If you don’t then…”
Pt: “I know all of that, but if I don’t drink to
sleep, I wake up with my heart racing out of
my chest and I feel like I’m back over in Iraq.
And then there’s no way I can get back to
sleep.”
An Alternative MI
Pt: “I know I should quit drinking, but it’s the
only way I can sleep through the night without
the nightmares.”
Dr.: “If it weren’t for the nightmares, you
would be okay with cutting back.”
Pt: “Yeah, I’d be fine with it. I know that much
alcohol isn’t good for me and it will probably
just make things worse in the long run.”
The Spirit of Motivational
Interviewing
“If you treat an individual as he is, he
will stay as he is, but if you treat him as
if he were what he ought to be and
could be, he will become what he ought
to be and could be.”
Johann Wolfgang Von Goethe
The Spirit Mind-set/Heart-set
 Partnership
 Acceptance
 Compassion
 Evocation
Key Principles of MI

Express (sincere) empathy

Develop discrepancy

Roll with resistance

Support Self-efficacy
Evoking Motivation for Change

Ambivalence resolves by tipping the
balance in favor of change.

People tend to become more committed
to what they hear themselves saying.

The importance of speaking one’s
motivation aloud in the presence of
another person.
Change Talk and Sustain Talk vary with
Counselor Approach Glynn and Moyers 2010
80
70
60
50
Change Talk
Sustain Talk
40
30
20
10
0
FA-1
CT-1
FA-2
CT-2
Cognitive Behavioral
 Targets
intrapersonal & interpersonal
triggers
 social pressures, cravings, conflict in
relationships
 Coping
skills training
 drug refusal skills
 Builds
sober healthy activities
Relapse Prevention
 A Cognitive
behavioral approach
addressing the relapse process in
order to prevent relapses and
minimize harm of relapses that do
occur
 Relapse – return to use/drinking following
period of abstinence or period of lower
level of use/drinking
Relapse Prevention
Relapse is not
viewed as an “endstate,” but rather
as a process that
begins before use
of the substance
and continues
afterward.
Relapse Prevention

Patients relapse because they lack
cognitive & behavioral skills to cope with
immediate determinants/ covert
antecedents
 Immediate determinants –
environmental/emotional characteristics of
situations associated with relapse
 Covert antecedents – subtler, often
broader factors that predispose patients to
relapse
Relapse Prevention

Examine previous use/drinking episodes
in order to identify what the immediate
determinants and covert antecedents
have been in the past
 What new information and strategies are
needed in to order address weaknesses in
patients’ cognitive and behavioral skill set?
Immediate Determinants
High Risk
Situation
High Risk
Situation
Lack of coping
skill &
confidence
Coping skill
and selfefficacy
Abstinence
violation effect
& relapse
Decreased
risk of relapse
Covert Antecedents

Increase risk of relapse by increasing
chance of exposure to high risk situations
 Seemingly irrelevant decisions
○ call cousin “to see how he’s doing,” keep alcohol
in the house for guests
 Lifestyle factors
○ imbalance of “wants” vs “shoulds”
○ lack of pleasurable or meaningful activities
 Urges/cravings
○ desire for immediate gratification
Relapse Prevention Strategies
Examine previous episodes for high risk
situations and teach new coping skills
 Positive Expectancies
 Enhance self-efficacy
 Retrain thinking about lapse and relapse to
help combat abstinence violation effect
 Teach lapse management by creating
lapse-response plan

Contingency Management
A behavioral
approach to reinforce
abstinence from
substance use
The goal s to provide
patients with a period
of abstinence
Contingency Management

Based on principles of operant conditioning
 Positive reinforcers increase probability
of behavior
○ Raises/awards, allowances/privileges,
treats/food
 Punishers decrease probably of behavior
○ Poor evals/demotions,
detention/grounding
Contingency Management

Based on principle that behavior will
increase if followed by a reward

Positive reinforcement is more effective
than punishment for lasting behavior
change
 Behavior to increase when reward is immediate,
tangible, consistent, and unique to the target
behavior
 Natural rewards for abstinence are delayed,
intangible, and inconsistent
How Does CM Work?
 Set
specific target behavior
(abstinence from specific
substance)
 Measure
this target behavior
frequently and objectively
(2x/week UDS testing)
How Does CM Work?
 Provide
immediate, tangible,
desirable rewards when the target
behavior occurs (fishbowl draws for
negative UDS results)
 Increase size of reward for consistent
performance of target behavior (increased # of
draws up to 8)
 Withhold the reward when the target behavior
does not occur – based on UDS only
 Reset the size of reward for next occurrence of
target behavior
Contingency Management

The fishbowl contains 500 prize slips:




250 (50%) “Good Job!” = $0
209 (41.8%) “Small” = $1
40 (8%) “Large”= $20
1 (0.2%) “Jumbo” = $100
Earn 1 draw for the first negative sample
and increase up to 8 draws with consistent
abstinence
 When abstinence is not verified, no draws
are earned, and draws reset to 1 for the
next negative sample

Contingency Management






12 week protocol - excused and unexcused
absences
Patients earn an average of about $240
over the 12 weeks
Can be utilized with other target behaviors
(e.g., attendance)
Can be implemented by LIPs and non-LIPs
Few contraindications – can be used in
conjunction with other treatments
Fun treatment for providers and patients
12-Step Facilitation (TSF)
 Based
on the principles of Alcoholics
Anonymous (AA) and the “Disease
Model” of addiction
 Assumes
that substance use
disorders are chronic diseases that
require lifelong commitment to
abstinence
12-Step Facilitation
 Manualized
approach designed to
enhance ongoing involvement in 12
step meetings
 Can
be used as a stand-alone
treatment or used in conjunction with
another model
12-Step Facilitation

Introduces patients to the principles of
the 12-step model, learn about options
for meetings in their area, and begin to
set goals for getting involved in NA/ AA.

The long term goal of TSF may be
abstinence, but the short-term objective
is to encourage commitment to and
participation in 12-step groups.
Two Primary TSF Goals
Acceptance
Willpower alone is not
enough
Chronic & progressive
disease
Life has become
unmanageable
Only alternative is
complete abstinence
Surrender
Reach out beyond
oneself and follow the
12- steps
Acknowledge hope for
recovery
Faith that a high
power can help when
willpower cannot
Organization & Structure TSF
 Includes
a core program, an elective
program, and a conjoint or family
program
 12
to 15 individual sessions, plus 2 to
3 conjoint sessions if needed
Organization & Structure TSF
 Core Program
 4 Core Topics
○ Assessment, Acceptance, Surrender,
and Getting active in AA or NA
Organization & Structure TSF
 Elective
6

Program
Elective Topics
Genograms, Enabling, People-placesroutines, Emotions, Moral inventories,
and Relationships
Organization & Structure TSF
 The conjoint program
 Purpose is to educate the patient’s
partner about addiction and to introduce
them to the 12-step model
○ introduce to the concept of enabling and
encouraged to make a commitment to attend
six Al-Anon or Nar-Anon meetings.
Review (10 minutes)
Review of Journal
Note what AA/NA meetings the patient attended since the last session
Discuss patients reactions to those meetings
Review of slips
What if anything did the patient do to try to stay abstinent after the
slip?
What NA/NA resources could the patient use in the event of a future
slip?
Review of urges to drink or use
Review of sober days
New Material (30 minutes)
Introduction of new concepts for discussion
Questions and reactions to material discussed
Recovery Tasks (10 minutes)
Which meetings will the patient attend between now and the next
session?
What should the patient read before the next session?
Summary (5 minutes)
What was the overview of today’s discussion?
Does the patient understand the recovery tasks that have been
suggested?
Are slogans just bumper sticker
Psychology?
There is practical
wisdom captured
in these slogans
and they are
valuable to those
who participate in
the model.
Community Reinforcement
Approach (CRA)
“A behavioral treatment based on the
tenants of operant conditioning and
helping patients rearrange their lifestyles
so that healthy drug free living becomes
rewarding and then competes with the
positive effects of drug and alcohol use.”
Development of CRA
 Punishment
is an ineffective way to
modify human behavior (Skinner
1974)
 SUD
treatments based on
confrontation were largely ineffective
at reducing use of alcohol or drugs
(Miller and Wilbourne 2002)
CRA Procedures

Functional analysis is used to identify
internal and external triggers and to
explore the consequences of substance
use
External Triggers
Who are you usually with when you use?
 My 2 buddies from work
Where do you usually use?
 We drink in the pub across from work; if we smoke its in my friend’s truck.
When do you usually use?
 Quitting time – 5 pm
Internal Triggers
What are you usually thinking about right before you use?
 I can’t wait to get out of this crummy place and have some fun
What are you usually feeling physically right before you use?
 Don’t know; maybe all tensed up
What are you usually feeling emotionally right before you use?
 Stressed, frustrated, angry; but happy when I think about getting together
with my friends.
Using Behavior
What do you usually use?
 Alcohol (Beer and Whiskey), but sometimes marijuana too
How much do you usually use?
 6-pack of beer, 3 – 4 shots of Whiskey if pot – a few hits
Functional Analysis for Using Behaviors Meyers, R.J. & Sam, J.E. 1995
Short-Term Positive Consequences
What do you like about using with (your buddies)?
 They’re fun to joke with about our boss; they like to have a good time
What do you like about using at (the pub)?
 I can be goofy and nobody cares; nobody judges me.
What do you like about using (right after work)?
 It helps me unwind; puts a good ending on a rough day.
What are the pleasant thoughts you have while using?
 I guess I make believe I’m the boss, or that we have a different one.
What are the pleasant emotions you have while using?
 Happy, content
Long-Term Negative Consequences
What are the negative results of your using in each of these areas?
 Interpersonal My girlfriend is getting fed up
 Physical Headache in the morning
 Emotional Don’t know
Functional Analysis for Using Behaviors Meyers, R.J. & Sam, J.E. 1995
CRA Procedures

Sobriety Sampling is based on belief that is
not always helpful for a therapist to tell their
patient that he or she can never drink again for
the rest of their life

Behavioral Skills Training to learn skills such
as problem solving, communication, and drink
refusal skills

Job Skills Training which simply involves basis
steps for getting and keeping a job
CRA Procedures

Social and Recreational Counseling
aimed at new sources of pleasurable
activities

Relapse Prevention to identify high risk
situation for using and how to anticipate
and cope with these situations.
Behavioral Couples and Family
Therapy
involvement of the patient’s
spouse or partner
 Active
 12
to 20 couples sessions over 3 to 6
months.
What makes a good candidate?
 Married
or living with a partner
 Willing to accept at least temporary
abstinence
 Both people are willing to work on the
issues
 No high risk for violence
 Generally treatment recommended
following detox, residential or IOP
Objectives
Engage the couple
 Support abstinence with recovery
contracts (daily rituals that support
abstinence)
 Improving relationship by building
positive activities and improving
communication
 Continuation of care and relapse
prevention

BCT Recovery Contract
 Rebuild
trust
 Reduce conflict about substance
use
 Reward abstinence
BCT Recovery Contract
 Daily Trust Discussion
 Patient states intention to stay abstinent
that day
 Spouse thanks patient for efforts to stay
abstinent
BCT Recovery Contract





Daily Trust
Discussion
Focus on present,
& future, not past
Self-help
involvement
Weekly UDS
Calendar to record
progress
Increasing Positive Activities &
Communication
Catch your partner doing something nice
 Shared rewarding activities
 Caring day assignment
 Listening skills
 Expressing feelings directly
 Communication sessions
 Negotiating for requests

Relapse Prevention
 Continuing
Recovery Plan
 Actions to maintain abstinence and
relationship gains after weekly couples
treatment ends
 Relapse
Prevention Plan
 High risk situations and warning signs
 Make plan to prevent or minimize relapse
Psychosocial Treatments with
Promise
 The Matrix Model
 IOP that combines relapse prevention, skills
training, facilitation of involvement in 12step, and family education
 Non-confrontational approach based on
motivational interviewing & includes
individual & group therapy
 Educational session designed to facilitate
medication assisted treatment and also uses
routine drug screens
Psychosocial Treatments with
Promise
 Mindfulness
Based Interventions
 Mindfulness based stress reduction and
acceptance and commitment therapy, and
behavioral interventions to help them
become aware of their triggers
○ Mindfulness Based Sobriety
Integrated Treatment of Cooccurring Disorders
Co-Occurring Disorders
 Those
that involve one or more
non-nicotine substance use
disorder and one or more mental
disorder.
Co-Occurring Disorders
Atkins, 2014
Mental disorder
rates in people
seeking SUD
treatment = 50 to
75%
SUD is found in
50% of patients
seeking mental
health treatment
Patients with COD
have worse
outcomes, & >
physical problems
Patients with COD
are more likely to
require
hospitalization
Patients with COD
have > rates of
suicide thoughts,
plans & attempts
Historical perspective

Three basic and consistent findings
 1. co-occurrence of mental disorders and
substance use disorders is quite common
 2. co-occurring disorders is associated with
more negative outcomes including higher rates
of relapse, hospitalizations, incarceration,
homelessness, and violence
 3. The history of parallel and separate services
for patients with mental disorders and SUD often
delivered fragmented and less effective care
Integrated treatment for cooccurring disorders

The same clinician or team of providers working in one
setting, provide mental health and substance use disorder
interventions in a coordinated fashion

The services are seamless with a consistent approach,
philosophy and set of recommendations

Includes combining appropriate treatments and modifying
traditional interventions

“Recovery means that the individual with a co-occurring
disorder learns to manage both illnesses so that he or she
can pursue meaningful life goals.” (Mead et al 2000)
Treatment Improvement Protocol
(tip 42, Csat/samhsa)

Motivational Interviewing (MI)

Contingency Management (CM)

Cognitive Behavioral Therapy (CBT)

Relapse Prevention (RP)
Mechanisms of Change
Moving beyond
asking “Which
treatments
work?” to asking
“Why do certain
SUD treatments
work?”
Mechanisms of Change
 Motivational Interviewing
 Change Talk
 Discrepancy
○ Both have positive impact on SUD
outcomes
▪
Apodaca & Longabough, 2009
Mechanisms of Change
 Cognitive
Behavioral
Interventions
 Quality verses quantity of coping
skills
 Self-efficacy
Kiluk, 2010
Mechanisms of Change

Contingency Management & Community
Reinforcement Approach
 Improved treatment attendance,
 Medication compliance
 Increased self-efficacy
○ CRA study - higher rates of abstinence after 2
years was mediated by more AA attendance,
and increased self-efficacy
Mechanisms of Change
 12-Step




approaches
Increased self-efficacy
More coping skills
Improved motivation
Being a part of healthy social network
Kelly et al. (2009)
Common Factors

Common factors may explain why the
limited evidence for specific mediators of
the effects of treatment approaches.

May also explain limited evidence for the
effectiveness of one treatment over the
other.
Common Factors

There may be social processes that
protect against development of a
substance use disorder.
 Support, goals, structure, non-substance
related rewards, abstinence oriented role
models, development of coping skills, and
increased self-efficacy may all be active
ingredients of effective treatments for SUD.
Moos (2007)
Common Factors
 Understanding
change may lie in the
cognitive, affective, and learning
processes of those people who have
been treated.
 Stanger et al (2013) found changes in decision
making to be a key mediator of SUD treatment
outcomes.
 Computer assisted CBT for SUDs.
○ suggested changes in neural systems involved in
cognitive control, impulsivity, and attention that
may account for the effects of behavioral
therapies.
Therapeutic Alliance & Therapist
Characteristics
The collaborative relationship and the
emotional bond between patient and
provider. It is an agreement between the
two about the specific goals for
treatment
Lebow et al. 2006
Therapeutic Alliance & Therapist
Characteristics
A stronger working
alliance was a
significant predictor
of better drinking
outcomes across all
three modalities in
Project MATCH.
Similar findings in a
study of patients with
Opioid Use Disorders
who were in
methadone treatment
Belding et al. 1997
Therapeutic Alliance & Therapist
Characteristics

Early therapeutic alliance predicted less
substance use during treatment but not
of post-treatment outcomes.
 Alliance could be what keeps patients
engaged in treatment. Meyer et al 2005
 The stronger the alliance, the longer the
patients stays in treatment Simpson et al
1997
What Makes a Strong Alliance?
The individual provider has a lot to
do with it.



Therapists’ interpersonal style
Not due to level of professional training, years
of clinical experience, providers own recovery
status, or the characteristics of the patients
being treated (Najavits and Weiss 1994).
Interpersonally skilled, empathic, and less
confrontational
Continuing Care Following SUD
Treatment
“A period of less intensive treatment
following a more Intensive treatment
episode.”
“continuing” care instead of “after”
emphasizes need for ongoing active
participation & intervention
McKay 2005
Continuing Care
Traditional approaches to treatment view
substance use disorders (SUD) as a
condition that can be effectively treated in
a single acute episode of care.
However, research and clinical experience
show that this is not the case (Dennis &
Scott, 2007).
Why is Continuing Care
Important?
SUDs are best conceptualized as chronic
health conditions that require ongoing
maintenance and care, like diabetes and
hypertension (McLellan et al., 2000).
The need for multiple episodes of care is
the rule rather than the exception (Dennis
et al., 2005).
Why is continuing care
important?
Risk for relapse
greatest in the first 90
days
Significant risk remains
during the first year
and through 5 years of
continuous abstinence
(Blodgett et al., 2014).
Why is continuing care
important?

Good outcomes are contingent on
adequate treatment length
 Treatment participation for less than 90 days
is of limited effectiveness, and lasting longer
is recommended for maintaining positive
outcomes
Principles of Drug Addiction Treatment – A Research
Based Guide (NIDA, 2012)
Is Continuing Care Effective?
Better outcomes tend to be seen
for patients who participate in
continuing care compared to those
who do not (Blodgett et al., 2014)
Is Continuing Care Effective?
Continuing care interventions with longer
duration may be associated with better
outcomes (Moos et al., 2001).
 Patients who engaged in continuing care
for at least 12 months demonstrated best
outcomes (McKay, 2009).
 More participation in self-help activities
(e.g., 12-step meetings) may be associated
with better outcomes (Moos et al., 2001;
Bergman et al., 2015).

References
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Back, S. E., Foa, E. B., Killeen, T.K., Mills, K.L, Teeson, M., Cotton, B.D.,
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Back, S. E., Foa, E. B., Killeen, T.K., Mills, K.L, Teeson, M., Cotton, B.D.,
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Key Elements of Treatment Planning for Clients with Co-Occurring
Substance Abuse and Mental Health Disorders (COD) (Treatment
Improvement Protocal, TIP 42: SAMHSA/CSAT)
References
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