Transcript Selling an Idea or a Product - East Bay Community Recovery

Providing Substance Abuse
Treatment in Private Practice
Joan E. Zweben, Ph.D.
Executive Director: East Bay Community Recovery Project
Clinical Professor of Psychiatry; UC San Francisco
IN COLLABORATION WITH
Arnold Washton, Ph.D.
Recovery Options
New York, NY & Princeton, NJ
Today’s Topics
 Addiction
Treatment versus Psychotherapy
 Recovery-Oriented Therapy: Integrative
Model
 Psychodynamics of Addiction & Recovery
 Motivational Interviewing & Stages of Change
 Assessment Techniques
 Stage-Specific Treatment Interventions
Addiction Treatment
& Psychotherapy
Rift between psychotherapy and
mainstream addiction treatment
Different beliefs about the fundamental nature of
addiction
 Many addiction treatment programs subscribe to a
biopsychosocial model; some are rigidly disease model
 Prevailing view among psychotherapists is either a
learning/behavioral model or a psychodynamic model
 Many believe that if the behavior is learned, it can be
unlearned, changed, or controlled or that insight will
produce change
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Rift between psychotherapy and
mainstream addiction treatment
Psychodynamic therapists tend to view addiction as
merely a symptom of underlying psychological
problems or unresolved conflicts
 Therapists who search for the “root causes” of an
active addiction can be compared to a paramedic
rushing to the scene of an accident with injured
victims lying bleeding on the ground and taking time
out before attending to the victims to ask what caused
this accident to happen.
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Rift between psychotherapy and
mainstream addiction treatment
Seeing addiction as a symptom fosters the unrealistic
belief that once the underlying problems are resolved
the person can return to using alcohol or drugs
moderately.
 Psychodynamic therapy can be very helpful during
latter stages of recovery when abstinence is reasonably
secure, but in the early stages it can serve as a form of
enabling and also stimulate further alcohol/drug use
when highly charged emotional issues are uncovered
too early in the recovery process.
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Rift between psychotherapists and
mainstream addiction treatment field
In the early abstinence stage, the emergence of highly
charged issues (e.g., childhood traumas) threatens to
overwhelm the addict’s shaky sense of self and fragile
commitment to abstinence. Feelings that have been
medicated and numbed for years by alcohol/drugs
often emerge once the chemical blanket is removed.
 Mainstream addiction treatment has traditionally
downplayed the psychological aspects of addiction and
devalued the role of psychotherapy in fostering longterm recovery. Some believe that AA alone is enough.
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Recovery-Oriented
Psychotherapy
An Integrative Approach
Stages of Recovery-Oriented Therapy
1. Assessment with motivational feedback
2. Engaging the client who is actively using
3. Negotiating an abstinence contract
4. Helping the client to stop using (early abstinence)
5. Consolidating abstinence, changing lifestyles,
developing adaptive coping skills (relapse prevention)
6. Addressing developmental/interpersonal issues
(psychotherapy)
Recovery-Oriented Psychotherapy
Framework that integrates disease model addiction
treatment with abstinence-based psychotherapy
 Individual, group, & couples therapy
 Supports, facilitates , and encourages but does not
mandate involvement in AA
 Therapist’s tasks shift according to the patient’s stage
of recovery
 Collaborative stance toward the patient
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Therapist’s Role
Facilitate change
 Mobilize motivation
 Non-judgmental coach, advisor, and guide
 Educator
 Voice of reason and reality
 Safety net and backstop
 Steady, reliable resource
 Supply ego functions that the patient lacks
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Stance of the Therapist
 Primacy
of the therapeutic alliance
 Respect for patient’s autonomy while
providing forthright feedback
 Respect for change as a process
 Respect for individual differences
 Awareness of transference &
countertransference dynamics
Countertransference
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Abrupt or unilateral changes in the treatment plan
Rejecting, controlling, stereotyping behaviors
Disengaged or over-involved
Rescue fantasies
Preoccupation, dreams, anxiety
Emotionally depleted- “burnt out”
Hoping that the patient cancels or no shows
Excessive self-disclosure
Need to be idealized
What NOT to do
Warn of dire consequences
 Impose negative consequences
 Take an authoritarian stance
 Reject and/or abruptly terminate the patient
 Ally with others against the patient
 Change treatment plan out of anger or frustration
 Act out savior & control fantasies
 Act out other countertransference dynamics
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Integrative Approach
 Stages
of change
 Motivational interviewing
 Cognitive-behavioral techniques
 Disease model & AA
 Adaptive “self medication” model
 Psychodynamic, insight-oriented techniques
Using Different Strategies at
Different Stages
1. Initially, focus on motivational issues and treatment
engagement
2. Once the client becomes willing to change, utilize
cognitive-behavioral strategies to facilitate transition
from active use to stable abstinence
3. As recovery proceeds, incorporate insight-oriented
techniques to address broader issues, but always
keeping addiction issues in focus
Integrative Approach
Treatment must address more than the
substance abuse itself:
Developmental arrest
 Interpersonal problems
 Managing feelings
 Self-esteem issues
 Co-existing Axis I & II disorders
 Other addictive/compulsive behaviors
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Key Points
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There is no single best pathway to recovery
for everyone
Accept that you are powerless to control
another’s drug use; let go of your control
fantasies
Maintain an empathic connection; the single
most important aspect of treatment is the
therapeutic alliance
Key Points
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Re-conceptualize resistance as
ambivalence
Start where the patient is- NOT where you
want him/her to be
Listen to your clients. They will tell you
what they are ready or not ready to do.
Psychodynamic Issues
at Different Stages
Psychodynamic Issues in the Early Phase
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Therapeutic alliance
Warmth, empathy, positive regard
Trust, respect, concern
Unconditional acceptance
Consistency & availability
Counteract internalized self-loathing, shame, guilt
Support self-efficacy, autonomy, reduce dependency fears
Environment of safety: accountability, limits, realistic
feedback, boundaries
Psychodynamic Issues in the Middle Phase
 Ongoing
ambivalence about giving up
alcohol/drugs
 “I’ve stopped using, but I’m still unhappy”
 Affect management: “self-medication”
 Defining interpersonal, self-esteem, and
boundary issues
 Shame and guilt issues
Psychodynamic issues in later stages
 Intimacy
with autonomy*
 Separation-individuation*
 Affect
management: “self-medication”
 Grief and loss
 Early traumas
 Residual narcissistic & controlling behaviors
Couples Issues
Choosing a mate while actively addicted
 Power dynamics: control and dominance
 Equality: no longer willing to be discounted
 Out of synch: personal responsibility for
behavior/problems, having an “observing ego”
 Lingering resentments: especially infidelities !!
 Jealousy: support system, therapist, group
 Will he/she still want me?
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Will the relationship survive recovery?
Good Prognostic Signs
 Joined
prior to onset of the addiction
 Willing to learn about addiction/recovery and
use opportunity to enhance his/her own life
 Willing to enter couples or individual therapy
and Al-Anon to address his/her own unresolved
issues
Will the relationship survive recovery?
Poor Prognostic Signs
Joined while addiction was active
 Unrelenting anger, hostility, resentment
 Refuses to take any responsibility whatsoever for
contributing to the mess
 Unable to see the need for personal change: it’s all
his/her fault, not mine !
 Unwilling to go for therapy or to Al-Anon
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Relapse Dreams
Can occur at any stage
 Wake up not sure whether they have actually used
 Worst fear is that the dream is prophetic
 In early stage often due to ambivalence and self-doubt
 In middle stage often due to fears about relapse- “Is
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there something moving me toward relapse??”
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In latter stages often stimulated by unresolved issues
and/or being overwhelmed with feelings
Relapse Dreams
What feelings were stimulated by the dream?
 Why did this dream occur at this particular point in
time?
 What could the dream be telling you about where you
need to strengthen your recovery plan?
 What issues/problems may have given rise to the
dream?
 Does the dream signal unresolved or renewed
ambivalence about giving up alcohol/drugs?
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Motivational Interviewing
and the Stages of Change
Facilitating Change
 Motivational
Interviewing offers a way to
conceptualize and deal more effectively with
problems of patient resistance and poor
motivation
 Stages
of Change Model provides a
framework for determining the readiness of
patients to change their behavior and for
matching treatment interventions accordingly
Stages of Change
Precontemplation- Not seeing the behavior as a
problem or feeling a need to change (“in denial”)
 Contemplation- Ambivalent, unsure, wavering
about necessity and desirability of change
 Preparation- Considering options for change
 Action- Taking specific steps to change behavior
 Maintenance- Relapse prevention
 Relapse- Returning to use or earlier stage of change
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Stages of Change
Stages of Change Model
Facilitates empathy- patients seen as “stuck” in a
particular stage of the process rather than “resistant”
 Defines ambivalence as normal not pathological
 Leads to better patient-treatment matching by
defining the types of clinical interventions that work
best with patients in each stage of change
 Provides “roadmap” and sets the tone for more
positive interaction with “resistant” patients
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Motivational Approach
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Start where the patient is
Roll with resistance
Avoid arguments, power struggles
Back off in the face of resistance
Be persuasive not confrontive
Reframe resistance as ambivalence
Offer choices to increase patient acceptance and investment
Negotiate, don’t pontificate
Acknowledge positive drug effects
Adjust interventions to stage of readiness for change
Diagnosis
Substance USE
 Absence
of problems/consequences
 No apparent or significant risk
 No obsession or preoccupation
 Under volitional control
Substance ABUSE
 Use
is associated with significant risks or
consequences
 Exceeds medical/cultural norms
 No obsession or preoccupation
 Under volitional control
Substance DEPENDENCE
 Continued
use despite adverse
consequences
 Impaired control
 Preoccupation/obsession
 Exaggerated importance/priority
 Tolerance/withdrawal (optional)
NIAAA “Low Risk” Drinking
MEN
No more than 14 drinks per week (2 per day) and no
more than 4 drinks per occasion
WOMEN
No more than 7 drinks per week (1 per day) and no
more than 3 drinks per occasion
SENIORS- OVER AGE 65
No more than one drink per day
One “Standard” Drink
One
12 oz. bottle of beer
One 5 oz. glass of wine
1.5 oz of distilled spirits
“Low Risk” Qualifiers
PRESUMES ABSENCE OF:
 Pregnancy
 Medical or psychiatric conditions likely to be
exacerbated by ETOH use
 Medication that interacts adversely with ETOH
 Prior personal or family history of substance abuse
 Hypersensitivity to alcohol
“At Risk” Drinking
 Frequently
exceeds recommended limits
 No evidence yet of adverse consequences
 Drinking exposes the individual to
significant risk
 Prime target for preventive efforts
“Problem Drinking” ALCOHOL ABUSE
Evidence of recurrent medical, psychiatric,
interpersonal, social, or legal consequences related to
alcohol use; OR
 Being under the influence of alcohol when it is clearly
hazardous to do so (e.g., operating a vehicle or other
machinery, delivering health care services)
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 No
evidence of physiological dependence
 No prior history of alcohol dependence
“Alcoholism” ALCOHOL DEPENDENCE
BEHAVIORAL syndrome characterized by:
 Compulsion to drink
 Preoccupation or obsession
 Impaired control (amount, frequency, stop/reduce)
 Alcohol-related medical, psychosocial, or legal
consequences
 Evidence of withdrawal- not required
 Evidence of tolerance- not required
Assessment Techniques
Assessment Goals
 Assess
nature and extent of substance use
 Assess nature and extent of substance-related
problems and consequences
 Assess patient’s stage of readiness for change
 Formulate an initial diagnosis
 Provide motivation-enhancing feedback based
on assessment results
Assessment Domains
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Typology of use
Positive benefits
Negative consequences
Need for medical detoxification
Other addictive behaviors
Prior attempts to stop or cut down
Prior treatment and self-help experience
Diagnostic signs of substance dependence disorder
Family history of alcohol/drug problems
Stage of readiness for change
Typology of Use
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Types of substances
Amount/frequency
Administration route (oral, intranasal, pulmonary, i.v., i.m.)
Temporal pattern (continuous, episodic, binge)
Environmental precursors (external “triggers”)
Emotional precursors (internal “triggers”)
Settings and circumstances linked with use (people, places..)
Linkage with use of other substances (e.g., cocaine-alcohol)
Linkage with other compulsive behaviors (sex, gambling,
spending, eating, etc)
Positive Benefits of Use
 What
first attracted you to this drug?
 How has it helped you?
 Does it still work as well?
 What would be the potential downside of not
using it?
Negative Consequences
 Medical
 Job,
Financial
 Relationships
 Legal
 Psychological
 Sexual
Medical “Red Flags- ALCOHOL
 Hypertension
 Blackouts
 Injuries
 Chronic
abdominal pain
 Liver problems
 Sexual dysfunction
 Sleep problems
 Depression/anxiety
Medical “Red Flags” COCAINE
 Chronic
nasal/sinus problems (snorting)
 Chronic respiratory problems (smoking crack)
 Sexual dysfunction
 Labile moods, paranoia, suicidal ideation
 Sleep problems
 Seizures
 Abuse of alcohol and sedatives
Medical “Red Flags”OPIOIDS
 For
Rx opioids: requests for increased doses,
frequent refills, multiple prescribers, “lost”
prescriptions
 Sexual dysfunction
 Amenorrhea
 Sleep problems
 Constipation
 Liver problems
Biochemical Indicators
of Alcohol Abuse
 Most
markers are late stage and not very
reliable indicators of alcohol problems
 Best used in combination to confirm diagnosis
& establish baseline for follow up
GGT gamma-glutamyltransferase
 MCV mean corpuscular volume
 AST aspartate aminotransferase
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Urine Toxicology- Drugs
 Detects
only recent use (past few days)
 No information about amount, frequency, or
chronicity of use
 No information about problem severity
 Best used as a clinical tool to monitor
treatment progress
Psychosocial Consequences
Vocational: Work life adversely affected?
 Relationships: Family/marital relationships or home
life been adversely affected?
 Legal: Any legal trouble? (e.g., DWI)
 Psychological: Mood or mental functioning been
adversely affected? Suicidal thoughts or actions?
 Sexual: Sex drive or performance been adversely
affected? Cocaine or amphetamine-related
hypersexuality and acting out behavior?
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Need for Medical Detoxification
 Benzodiazepines,
alcohol, opioids
 Abrupt withdrawal from alcohol/benzos can be
life threatening and must be managed
medically
 Opioid withdrawal is uncomfortable, but not
life threatening, except when another medical
condition could be exacerbated (e.g., heart
problems)
Negotiating Goals and
Strategies for Change
If patient seems willing to consider change
Suggest “experiment” with total or partial abstinence
 Suggest reduction of at least 50%
 Suggest alcohol reduction to below “at risk” levels
 Suggest gradual tapering toward abstinence
(“warm turkey”)
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Value of “Experiment” with Abstinence
Provides useful clinical data
 Role of substance use in patient’s life
 Reliance on “self medication” to cope
 Experience things through a “different set of eyes”
 Impact of abstinence on mood, affect, coping ability
 Identify internal and external triggers of use
 Indication of how easy/difficult it is to stop using
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Stage-Appropriate Goals
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Precontemplation- Increase awareness, raise doubt
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Contemplation- Tip the balance toward change
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Preparation- Select the best course of action
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Action- Initiate change strategies
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Maintenance- Learn relapse prevention strategies
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Relapse- Get back on track with renewed
commitment to change
If patient is NOT willing to consider change
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Do not react to patient resistance as a challenge to your
judgement or authority
Avoid getting into arguments or debates about how much
drinking or drugging is too much
Avoid using the labels “addict” “alcoholic”
Emphasize to patients that only they can make the decision to
change- you have no desire to pressure them for change
Agree to disagree: restate your concerns about need for change
Your primary goal is to maintain an ongoing dialogue about
their alcohol/drug use and continue to assess
Working with Patients in the
Precontemplation Stage
GOAL: Help patients see that maybe there is a problem
 Don’t expect immediate agreement or action
 Avoid getting into debates or power struggles
 Discuss the pros/cons: the “good things” and “not so
good things” about using alcohol/drugs
 Acknowledge positive benefits of use
 Ask patients to keep daily diary of substance use to
heighten awareness of when/how much they use
Working with Patients in the
Precontemplation Stage
Re-state your concerns about medical and
psychosocial consequences
 Suggest bringing in a family member/significant other
 Ask: What would have to happen for you to decide
that your use has become a problem?
 Discuss discrepancies between patient’s view versus
others’ view of the substance use
 Agree to disagree, but continue the dialogue
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Working with Patients in the
Precontemplation Stage
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Columbo Technique: “Maybe I’m not entirely correct. I suppose
it’s possible that your substance use is not nearly as serious as it
might appear. I wonder where I may have gone wrong?”
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At all cost, don’t antagonize or alienate the patient
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Don’t give up assuming that you are just wasting your time:
subliminal change still may be occurring!
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Express your interest and curiosity, keep the door open, ask
permission to continue the dialogue, resist your temptation to
pressure for change
Working with Patients in the
Precontemplation Stage
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Avoid prescribing action-oriented strategies
Acknowledge positive benefits of alcohol/drug use
Draw connections between substance use and presenting
complaints
Educate about some of the subtle, insidious effects of
substance use on values, priorities, self-esteem, coping
abilities, mood, personal growth
Ask about the extremes- the worst, the most
Help patients assess the potential and not-so-obvious risks of
continuing to use (play the tape forward, what if...)
Working with Patients in the
Contemplation Stage
GOAL: Reduce ambivalence and facilitate movement
toward change
 Don’t jump ahead: If you push too hard for change,
the patient will retreat and defend the use
 Discuss fears and drawbacks about reducing or
stopping use
 Discuss potential barriers to reducing or stopping use
Working With Patients in the
Contemplation Stage
 Being
of “two minds” about stopping
 Being unsure, undecided, wavering
 Therapist: “Speak to me from the side of you that
still feels positively about your alcohol/drug use and
wants to continue using, despite the problems that it
appears to be causing you.”
Working with Patients
in the Contemplation Stage
Normalize ambivalence
 Acknowledge positive benefits of substance use
 Help the patient tip the balance in favor of change:
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Review the “good” and “not so good” things about use
 Review same for any prior periods of abstinence
 Highlight discrepancies : where you are now versus where
you want to be (values vs. actions)
 Discuss expectations and anticipated difficulties with
changing
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Working with Patients
in the Contemplation Stage
Emphasize personal choice- this is your decision
 Propose a brief “experiment” with abstinence or
moderation
 What are you willing to consider doing at this point?
 Suggest keeping a diary of use
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Working with Patients in the
Contemplation Stage
Ask the “Miracle Question” (Berg & Miller)
“How would your life be different if by
tomorrow morning your substance use had
miraculously disappeared? What would
you notice? What would others notice?”
Working with Patients in
the Preparation Stage
GOAL: Choose a realistic plan of action with goals
that feel achievable to the patient
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Compliment for planning to take action
Acknowledge any positive steps taken thus far
Negotiate specific goals and time frame
Explore what has worked and not worked in past
Discuss menu of treatment options and offer recommendations,
but respect patient’s autonomy to choose
Working with Patients in the
Preparation Stage
 Discuss
the practical “nuts-and-bolts” of how
the patient’s goals will be accomplished
 Discuss potential obstacles and how to
overcome them
Working with Patients in
the Action Stage
Support a realistic view of change through small steps
 Create structure, support, and safety net (e.g.,
frequent visits, drug testing, family involvement,
linkage with AA)
 Acknowledge difficulties in the early stages of change
 Convey optimism and hope while working through
initial setbacks
 Assist the patient in finding new reinforcers of
positive change
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Action Stage Strategies to Help the
Patient Stop Using
External Triggers
 Internal Triggers
 Impulse (Craving) Control
 Onsite Alcohol & Drug Testing
 Short-Term Focus
 Develop Support System
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Clinical Value of
Alcohol/Drug Testing
 Deterrent
to impulsive use
 Disrupts denial
 Objective marker of progress
 Rapid identification of use
 Restores credibility with S.O.’s
 NOT intended to uncover lies; avoid “gotcha”
Action Stage CAUTIONS!
This is NOT the time for uncovering psychotherapy.
It will likely elicit strong affects that the patient is not
prepared to handle without returning to “self
medication” with alcohol/drugs
 Contain and postpone work on highly charged issues
(e.g., trauma, victimization) until stable abstinence
and recovery has been attained of at least 6-12
months. Offer strategies to manage feelings, vs
resolve issues.
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Working with Patients in the
Maintenance Stage
Reinforce a proactive stance toward preventing
relapse; educate that relapse is a process not an event
 Address affect management (“self-medication”) and
other psychological issues (e.g., self-esteem,
boundaries, relationships, traumas)
 Never lose sight of the SU disorder; remain evervigilant for early warning signs of relapse
 Respond therapeutically to slips and relapses
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Working With Patients in the
Maintenance Stage
 Relapse
is a process that begins before the
person returns to alcohol/drug use
 A key to preventing relapse is developing
awareness of early warning signs and taking
appropriate action to short-circuit the relapse
process that has been set in motion
Responding to Slips & Relapses
Express empathy and understanding to counteract
shame and guilt
 “Relapse Debriefing”- ask for recounting of specific
events leading up to use
 Focus on antecedent feelings, moods, and behaviors
 Reframe as acting out of ambivalence- “being
overtaken by the side that still wants to use”
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Case Example: “James”
Demographics: 40 yo investment banker, married for
past 5 years, wife is an attorney who stopped working
last year during difficult pregnancy and now stays
home with 1 yo twins
 Presenting problems: marital discord, depression
 Substance use: 2-3 martinis, 4-5 evenings per week at
local bar before coming home from work. Smokes
marijuana on weekends. Pattern has existed for past
year. No prior or family history of SUDs
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James’ Presenting Complaints
“My problem is that since my wife gave birth to our twins, our marriage
and sex life have gone down the tubes. We are at each other’s throats from
the minute I come home from work until we fall asleep from exhaustion.
The only way I’m able to tolerate this situation is to drink every evening on
my way home from work. But then I wake up the next morning feeling
depressed. Over the past year, my depression has been getting worse and
my wife has become furious about my drinking. I know I should probably
do something about the drinking, but I just can’t deal with the thought of
coming home at night without medicating myself first. The pot is not really
a problem except that it stimulates my appetite and causes me to gain
weight. I came here for help with my marital problems hoping that if I
made some headway I’d be less likely to drink. I don’t think that I’m an
alcoholic and I’m unwilling to even think about going to AA meetings. I
also think that antidepressant medication might help me.”
“James”
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Stage of change?
For alcohol
 For marijuana
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What else would you want to know about his
substance use before formulating an initial diagnosis?
 How would you approach him?
 What types of interventions would you deliberately
want to avoid with James at this point?
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Case example: “Lorraine”
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Demographics: 38 yo, self-employed as freelance editor, never
married, no children, lives alone
Presenting Problems: low self-esteem, intense conflict with
controlling parents, unsuccessful relationships with men, confusion
about sexual orientation (bisexual?)
Substance Use: intranasal cocaine use 1-2 times per month, stays
up all night with female friend embroiled in intense conversation,
drinks beer/wine to come down from cocaine, smokes marijuana
occasionally to relieve work-related stress. Pattern has remained
unchanged for past two years. Diagnosed with depression as
teenager. Adamantly against going to a treatment program or AA.
Lorraine’s Presenting Complaints
“I’m here because I want to feel better about myself. Nothing makes
me happy and I’m confused. I’m tired of chasing after business just to
keep up with paying bills, especially since I stopped taking money from
my parents. I thought my cocaine use was getting a little out of hand,
but I’ve cut down recently. I’ve used it only once in the past two weeks.
I seem better able to control it now. Sometimes I drink too much while
doing cocaine and then feel horrible the next day. Otherwise, alcohol is
not a problem for me. Pot helps me a lot. It’s a great stress reliever and
I don’t want to even consider giving it up. Actually, it works a lot
better for me than any of the medications I’ve been given by
psychiatrists.
“Lorraine”
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Stage of change?
For cocaine
 For alcohol
 For marijuana
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What else would you want to know about her
substance use before formulating an initial diagnosis?
 How would you approach her?
 What types of interventions would you specifically
want to avoid with her at this point?
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