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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 Back, S. E., Foa, E. B., Killeen, T.K., Mills, K.L, Teeson, M., Cotton, B.D., Carroll, K. M., & Brady, K. T. (2015). Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE). Therapist Guide. Oxford University Press. Back, S. E., Foa, E. B., Killeen, T.K., Mills, K.L, Teeson, M., Cotton, B.D., Carroll, K. M., & Brady, K. T. (2015). Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE). Patient Workbook. Oxford University Press. Hien et al. (2010). Do treatment improvements in PTSD severity affect substance use outcomes? A secondary analysis from a randomized clinical trial in NIDA’s clinical trials network. Am J Psychiatry 167:95-101. Carroll, K.M. (1998). A Cognitive Behavioral Approach: Treating Cocaine Addiction. Therapy Manuals for Drug Abuse. National Institute on Drug Abuse. Drake, R. E., Essock, S. M., Shaner, A., Carey, K. B., Minkoff, K., Kola, L., et al. (2001). Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services, 52(4), 469 -476. 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 Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. September 2015. O’Farrel, T.J. & Fals-Stewart, W. (2006). Behavioral couples therapy for alcoholism and drug abuse. New York: Guilford Press. Miller, W.R. & Meyers, M.S.; The community reinforcement approach. Alcohol Research & Health 23(2): 116-120, 1999. Meyers, R.J., Roozen, H.G. & Smith, J.E.; The community reinforcement approach: An update of the evidence. Alcohol Research & Health 33(4),2014. Nathan, P.E. & Gorman, J.M. (2015). A Guide to Treatments that Work 4th ed. Oxford. Miller, W.R., Rollnick, S. (2013). Motivational Interviewing. Helping people change. 3rd Edition. New York. Guilford Press. Arkowitz, H., Westra, H. A., Miller W.R., & Rollnick, S. (2008). Motivational Interviewing in the treatment of psychological problems. New York: Guilford Press.