MOTIVATION AND THERAPEUTIC ALLIANCE AS ESSENTIAL ASPECTS OF INTEGRATIVE TREATMENT FOR CO-

OCCURRING TRAUMA AND SUBSTANCE USE DIAGNOSES

JUSTIN WATTS, M. ED, NCC

LAURA ANNE COPLEY, M. A., LPC

Department of Educational Psychology, Counseling, and Special EducationThe Pennsylvania State University

OBJECTIVES

Upon completion of this session participants will:

Understand the biological, psychological, and social implications of trauma and substance abuse through a review of empirical research

Understand Motivational Interviewing, and become familiar with how to use this approach within a trauma and substance abuse context

Utilize basic knowledge of Motivational Interviewing in small-group experiential activity

CO-OCCURRING TRAUMA AND SUBSTANCE USE

Lifetime prevalence rates for PTSD among individuals who are seeking treatment for substance use disorders range from 43% to 52%

Studies have established that 80-95% of individuals who seek treatment for substance use issues report trauma histories though they may not meet the criteria for PTSD

Most (80%) who do not meet the full criteria exhibit at least one cluster of PTSD symptoms

Individuals with COTSUD are much more likely to have an additional psychiatric diagnoses

Ouimette, Read, Wade, & Tirone (2010); Ouimette, Wade, & Brown (2006); Clark, Masson, Delucchi, Hall, & Sees (2001); Norman et al. (2007

TREATMENT ADHERENCE: A CENTRAL ISSUE

High rate of treatment dropout amongst multiple trials (Najavits, Weiss, Shaw, & Muenz, 1998; Brady et al., 2001; Najavits et al., 2006; McGovern et al., 2009; Hien et al., 2009) suggests that a considerable quantity of individuals who could benefit from treatment are not having

their needs met.

In some samples (Najavits et al., 2006), only 27% of participants received a full course of integrative treatment, in others (Hien et al., 2009; McGovern et al., 2009) participants attended approximately half of the sessions on average.

When testing the efficacy of the SS model, researchers (Najavits et al., 2006; Torchalla et al., 2012) demonstrated that participants only attended on average 11.78 of 25 sessions, only 1.33 of which were dedicated to trauma related material.

Brady et al. (2001) considered the efficacy of exposure therapy for individuals with COTSUD, also reported that 75% of participants dropped out before exposure therapy was initiated.

MOTIVATION FOR TREATMENT

Clients with COTSUD frequently demonstrate low treatment motivation and lack of commitment to change; they are also more likely to drop out of treatment

Individuals with COTSUD may be motivated to avoid activities that bring about increased arousal Individuals with PTSD exhibit high levels of anxiety sensitivity which may prompt them to avoid

traumatic cues, but also arousal inducing experiences Clients who drop out of treatment report more severe traumatic symptomology and re-experiencing

when compared to individuals who complete treatment Motivation to change measured by substance use treatment completion is moderated by trauma

load and severity of trauma history Lack of motivation and loss of hope are central themes for individuals who leave treatment

early within this population Also show higher levels of negative urgency meaning that they have difficulty tolerating extreme

emotional states without immediate action Individuals with substance use disorder have further difficulty engaging in treatment as they often

demonstrate distress intolerance which is likely to influence treatment dropoutWeiss, Tull, Anestis, and Gratz (2013); Najavits, (2006); Daughters et al. (2006); Torchalla et al., (2012); (DiClemente et al.,

(2008); Odenwald et al. (2013)

MOTIVATIONAL INTERVIEWING (MI)

People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the mind of others

- Blaise Pascal

Clients may be at very different stages of change, how do we balance readiness to change (aka resistance) in one area of growth verses another?

MI incorporates a collaborative conversation style for strengthening a person’s motivation and commitment for change

MI is frequently used to develop specific treatment goals for individuals and to establish a therapeutic relationship which is essential for assisting clients in processing traumatic material, building motivation to change dysfunctional behaviors, and challenging clients who lack motivation to change.

Practitioners who utilize MI build and strengthen motivation through creating a collaborative environment which focuses on the client’s specific treatment needs

MI can be used to encourage individuals to move toward behavior change, while providing an atmosphere of rapport, support and trust as individuals surrender dysfunctional coping mechanisms and engage in healing traumatic experiences.

Miller & Rollnick, (2013); SAMHSA, (2013)

MI PROCESS

Miller & Rollnick (2013)

Engaging Process of establishing a helpful connection and working relationship

Focusing Process by which you develop and maintain a specific direction in the conversation about change

Evoking Eliciting the clients own motivations for change and lies at the heart of MI

Planning Developing commitment to change and formulating a concrete plan of action

AMBIVALENCE AND RESISTANCE IN MI

Ambivalence is often at the heart of our struggles to embark upon change.

MI can help in resolving ambivalence by promoting behavior change and eliciting their own arguments to change on their own direction.

• MI Tool: Ask the client to report their readiness to change or ability to change on a scale of 1-10.

• Ask the client why they did not report a LOWER number ex. why 7 instead of 5: Result = Change Talk

INCORPORATING TRAUMA

Avoidance, a common defensive strategy for coping with shame and trauma, can be highly adaptive in the short term (Van Vliet, 2010)

When change is hard for someone who has experience trauma, it is normally NOT because of lack of information, laziness, or oppositional personality, or intentional resistance.

After a traumatic experience, people find it difficult to motivate themselves in everyday life activities. Post Traumatic Stress Disorder (PTSD) interferes with motivation.

As anxiety increases, resulting in both physiological and psychological impact, the tendency is to avoid rather than to engage in our lives. Biologically, as the body is in heightened

states of arousal, memory integration and accessibility is interrupted. The tendency is to separate the body from the mind.

Psychologically, avoidance to decrease intrusive thoughts, anxiety, and other emotions.

Socially

AVOIDANCE

Avoidance eventually becomes a maladaptive coping mechanism, as the individual puts forth mental, emotional, and behavioral efforts to escape a triggering stressor to protect oneself from further psychological damage (Friedman, 2006).

Symptomology of PTSD are the precursor to avoidance coping. What maladaptive coping behaviors have you seen with your clients suffering from traumatic

stress?

The co-occurring condition of trauma and substance abuse lead to withdrawal and self-sabatoging behaviors, often manifesting in the personality as indecision and lack of confidence (Kantor, 2010)

INTAKE: CASE ILLUSTRATION

Diana, a 32 year old biracial female, entered your counseling office due to severe depression and anxiety. She experiences these symptoms every day, and can sometimes get so severe that she has anxiety attacks and suicide ideality. She is married with one child, noting that her marriage is falling apart due to her “always feeling stuck and unhappy” and she cannot take care of her child the way she wants to. She reports that sometimes her depression gets so severe that she will isolate herself in her room for days, and self-medicate with prescribed Xanax and alcohol. She drinks 5-8 glasses of wine on top of her Xanax several times a week, mostly at night “when things are the worst.” Diana reported, “the mixture of the Xanax and wine help me feel numb. I sleep a lot, which helps me not think about my past.” When questioned about her past, Diana responds: “It was just some bad stuff. Bad relationships, bad childhood… I can’t do this right now.” Diana struggled focusing on sharing her relevant history during the intake session

How can we incorporate MI into an Intake?

SESSION 3: CASE ILLUSTRATION

You have been seeing Diana for a few weeks now, and just completed your third session with her. During this session, Diana became very emotional, reporting that she feels “stuck” and does “not know what to do anymore.” Diana realized that she was not able to function during her daily life while she was overly medicated and drinking. It was impacting her attendance at work, her presence as a mother and wife, and her overall health. At the same time, she shared that she does not want to stop out of fear of remembering her traumatic past. Diana disclosed that she grew up in an extremely abusive home with domestic violence, and also had a physically and sexually abusive boyfriend during her freshmen year of college. Self-medicated and consuming large quantities of alcohol became her “escape” from these thoughts. Diana reported: “I am just as scared now, even though I am an adult and safe from these individuals, as I was when I was witnessing it as a part of my daily life. I cannot handle this fear, but I can’t go on living like this either. I need help.”

How can use you MI throughout this session in order to help Diana?

SELECTED REFERENCES

Bernstein, J., Bernstein, D., Tassipoulos, K., Heeren, T., Levenson, S., & Hingson, R. (2005). Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug and Alcohol Dependence, 77, 49-59.

Burke, P., Chapman, C., Hohman, M., Manthey, T., & Slack, K. (2010). Guiding as practice: Motivational interviewing and trauma informed work with survivors of intimate partner violence. Partner Abuse, 1, 93-104

Burke, P. A., & Carruth, B. (2012). Addiction and psychological trauma: Implications for counseling strategies. In L. L. Levers, L. L. Editor. (Ed.) Trauma counseling theories and interventions (pp. 214-229). Danvers, MA: Springer

Carroll, K., Ball, S., Nich, C., Martino, S., Frankforter, T., Farentinos, C… & Woody, G. (2006). Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: A multisite effectiveness study. Drug and Alcohol Dependence, 81, 301-312.

Martino, S., Carroll, K., Kostas, D., Perkins, J., & Rousanville, B. (2002). Dual diagnosis motivational interviewing: A modification of motivational interviewing for substance-abusing patients with psychotic disorders. Journal of Substance Abuse Treatment, 23, 297-308.

Read, J. P., Brown, P. J., Kahler, C. W. (2004). Substance use and posttraumatic stress disorders: Symptom interplay and effects on outcome. Addictive Behaviors, 29, 1665-1672.

Substance Abuse and Mental Health Services Administration (2013). About co-occurring. Retrieved from http://www.samhsa.gov/co-occurring/.

Weiss, N. H., Tull, M. T., Anestis, M. D., & Gratz, K. L. (2013). The relative and unique contributions of emotion dysregulation and impulsivity to postratumatic stress disorder among substance dependent patients. Drug and Alcohol Dependence, 128, 45-51

USING MI WITH CO-OCCURRING TRAUMA AND SUBSTANCE USE DISORDERS

• Partnership and Collaboration

• Evocation• Compassion and support

• Acceptance and Autonomy

• Change-Talk• Open-ended questions, affirmations, reflections, and summaries

• Express empathy• Support self-

efficacy• Roll with

resistance• Develop

discrepancies

• Ask evocative questions

• Explore decisional balance

• Ask for elaborations/examples

• Go back, go forward• Explore goals and values

• Challenge extremes

Strategies of MI

Principles of MI

Spirit of MI

Skills of MI