non-pharmacological treatment approaches for substance abuse dr. jim peck npih staff psychologist...

Non-Pharmacological Treatment Approaches for Substance Abuse

Dr. Jim Peck

NPIH Staff Psychologist

ISAP Co-Investigator/Clinical Research Manager

Overview of 2 weeks

• Week 1– Why attempt to develop integrated psychotherapeutic

and pharmacotherapeutic treatment approaches for addictions?

– Stages of Change, Motivation/Motivational Interviewing, and Minnesota Model

• Week 2– Behavioral and Cognitive-Behavioral Treatment

Approaches

Goals of Psychotherapeutic Approaches

• Develop/enhance motivation; work toward resolving ambivalence

• Teach coping skills (drug use is overgeneralized)• Change reinforcement contingencies• Develop means of addressing painful affect• Improve interpersonal functioning/social support• Foster compliance with pharmacotherapy

(Carroll, 1997)

Stages of Change Model(Prochaska & DiClemente, 1992)

Precontemplation No intent to change

More pros than cons to using

Contemplation Thinking about changing

Seeking information

Preparation Ready to change (attitude and behavior)

May begin self-regulation

Action Actively modifying problem behaviors; learning skills to prevent relapse

Maintenance Long-term strategies for maintaining the changes that have been accomplished

Stages of Change

• Why consider stage of change? – Presumably matching treatment approach to

stage would yield better outcomes

Precontemplation

• Defensive• No awareness of problem• Resistant to suggestions of problems associated with

alcohol/drug use• Uncommitted to treatment• Consciously or unconsciously avoiding steps to

change behavior• May seek treatment because of others’ pressure• May feel coerced by significant others• May appear in tx because they are mandated

Contemplation

• Seeking to evaluate and understand their behavior

• May experience some level of distress• May be thinking about making changes• Have not taken action and are not prepared

to do so• May have made previous attempts to

change

Preparation

• Have intention to change behavior

• Exhibit readiness to change both in attitude and behavior

• Engaged in the change process and are on the verge of taking action

• Decision to change has been made and they are ready to commit to the actions involved

Action

• Firm decision to initiate change; this has been verbalized or somehow committed to.

• Taking action to change behavior and environment

• Ct exhibits motivation

• Willing to follow suggested strategies and activities

Maintenance

• Working to sustain changes

• Attention focused on avoiding relapses

• May express fear/anxiety about facing high-risk situations

• Less frequent but still intense cravings to use substance, particularly in response to various stressors

Motivation

• How we conceptualize motivation will determine how we approach treatment

• What are your beliefs about motivation?

Motivation

• Motivation– Is a stable trait, consistent across situations, not

modifiable because it lies within the patient– Clinician’s behavior is irrelevant to patient’s

motivation– Denial is standard defense mechanism for

people with addictions– Resistance is the patient’s problem

Motivation

• Motivation– Is a process that happens between a patient and

a clinician– Is a fluid state that changes across situations, in

different environments, and is at least partially determined by interpersonal interactions

– Resistance is a “therapist skill challenge”

Motivation

• People with substance use disorders often– Terminate treatment early– Continue to use during treatment– Are noncompliant with treatment

• Traditional wisdom holds that:– These patients are resistant, in denial, and

unmotivated– They will have to “hit bottom” before they can

succeed in treatment

Motivation Pieces of the Puzzle

• Consistently, controlled trials of brief interventions with problem drinkers show significant reductions in drinking compared to control groups

• Some of these interventions are as brief as 1 or 2 sessions, for only 10 or 15 minutes

• Brief intervention (4 session MET) reduced drinking as much as longer (12 weeks of CBT or 12-Step oriented tx) interventions (i.e. Project MATCH, 1993).

• It may be that there are certain critical ingredients that trigger change, that can happen very quickly

Motivation Search for Common Elements

• Miller & Sanchez (1994) – FRAMES– 6 ingredients frequently present in brief

interventions:• Feedback

• Responsibility

• Advice

• Menu

• Empathy

• Self-efficacy• (discussed in detail later)


• patient outcomes differ by therapist (Miller, Taylor, & West; 1980). – Degree of therapist empathy as defined by Carl

Rogers predicted patients’ rates of drinking at 6 (r = .83) and 12 (r = .67) months after treatment. The more empathic the therapist, the more the patient made changes and maintained those changes over time.


• Problem drinkers’ level of resistance related to a single therapist characteristic: confronting. The more the randomly assigned therapist confronted, the more the patient drank, even up to a year later (Miller et al., 1993).– Challenges traditional 12-Step tx approaches

Motivation Putting the Pieces of the Puzzle Together

• Positive change is a natural process that a therapist does not originate or own but can facilitate.

• Enduring change can be triggered by a combination of an awareness that there is a problem and a belief that there is a way out, facilitated by a supportive and empathic therapeutic relationship.

Motivation Putting the Pieces of the Puzzle Together

• This can occur even in a single session, which is good news because length of substance abuse treatment tends to be short.

• Change is usually facilitated not by therapist confronting, directing, or pushing, but by listening reflectively to the patient and evoking the patient’s own motivation for change and healing.

Motivation Quantifying/measuring Motivation

• Instruments that assess stage of readiness to change such as URICA (University of Rhode Island Change Assessment) can indicate level of patient motivation

Motivation Quantifying/measuring Motivation

• SOCRATES (Stages of Change Readiness and Treatment Eagerness Scale) also assesses stage of change, but appears to actually measure 3 underlying factors:– Recognition of problem– Ambivalence– Taking steps toward change.

Motivation Enhancing Motivation

• patients further along on readiness for change may benefit from action-oriented approaches focused on skill development and strategies for behavior change.

• Taking this approach with patients less ready to change is likely to be ineffective.

• What to do with these folks?

Motivation Enhancing Motivation-FRAMES

• Back to FRAMES acronym– Feedback – refers to personalized feedback or

health-relevant information based on careful assessment (not educational material about harmful effects of alcohol/drugs)

• Personal feedback may include: results of lab tests, calendar recording days of use, measures of motivation, etc.


• Feedback (cont’d)– Is patient ready to hear feedback?– How feedback is presented affects patient’s

ability to hear it. Can be helpful to ask permission to give feedback.

– Helpful to listen reflectively to patient’s response to feedback.

– Feedback can trigger patient self-reflection, which may increase motivation.


• Feedback (cont’d)– Initial evaluation/assessment can provide

source of feedback, as can systematic follow-up over time.

– In healthcare systems, patient knowing that clinician will check back with them in a few months seems to enhance outcome.


• Responsibility – Conveying individual responsibility with tone

of trust and respect is common element in effective brief interventions.

– Respectfully remind patient that they are ultimately in charge of what happens, including whether or not to change, and if so, how.

– Reinforce whatever responsibility patient has already taken.


• Responsibility– Informed consent process, in either treatment or

research, helps remind patient that they are the one responsible for making choices about their life.

– Informed consent can be important part of rapport-building.

– Clarifying ground rules and limits to confidentiality helps structure the interaction and empowers the patient to decide how much to disclose.


• Advice– Have to be careful with this one-it can be a

roadblock to listening and developing rapport.– Clear and respectful advice appears to be

important component in enhancing motivation to change harmful lifestyles.


• Menu of Options– Advice about changing more likely to be

carried out if patient has a variety of options to choose from.

– Menu also increases patients’ perception of personal choice and control, which promotes intrinsic motivation and can foster optimism.

– Can be helpful to offer menu of change goals, as well as change methods.


• Empathy– May be the most crucial of the FRAMES

elements.– Creates environment conducive to change,

instills sense of safety, of being understood and accepted, and reduces defensiveness.

– Sets the tone within which the entire communication occurs. Without it, other components may sound like mechanical techniques.


• Empathy– Nature of clinician-patient relationship, even in

a single session, predicts treatment retention and outcome (Luborsky et al., 1985).

– Rogers (1959) – skillful reflective listening that clarifies and amplifies the patient’s own experience and meaning, without imposing the clinician’s material.


• Empathy– Empathy represents conceptual opposite of

confrontational strategies. – Establishing empathy builds trust and rapport

and provides a doorway through which to introduce more difficult addiction issues.

– Asking about positive aspects of substance use can be a good starting point and help put patient at ease.


• Self-efficacy– Can be conceptualized as a specific form of

optimism, a “can-do” belief in one’s ability to accomplish a particular task or change.

– Crucial to help patient experience their own ability to make positive changes.

– Part of this is the clinician believing in the patient’s ability to change.


• Self-efficacy– When patients asked about characteristics of

good counselors, they stated that their counselor believed in them and that helped them to believe in themselves (Nelson-Zlupko et al., 1996).

Motivation Motivational Interviewing (Miller, 1983)

• Developed in early 80’s; originally designed to be a prelude to treatment and increase patient compliance with help.

• Good evidence to show that treatment outcomes are enhanced by adding initial motivational interview (Bien et al., 1993; Brown & Miller, 1993; Saunders et al., 1995).

• Unexpected finding was that motivational interviewing was associated with behavior change when used as a stand-alone intervention .

Motivation Motivational Interviewing

• MI is not so much a set of techniques as a style or way of being with patients, helping them resolve ambivalence and find resources within themselves.

• Basic principles overlap somewhat with components of FRAMES.


1. Express empathy– It is a paradox but true nevertheless that

acceptance facilitates change.– Approaches that emphasize that where the

patient is now is unacceptable have poor track record in facilitating change.


2. Develop Discrepancy– Help patient to become more aware of the discrepancy

between their addictive behaviors and their more deeply-held values and goals.

– Part of this is helping patient to recognize and articulate negative consequences of use. More effective if the patient does this, not the clinician.

– Explore values and life goals and then ask patient to reflect on how their addictive behavior fits into them.


3. Avoid Argumentation– In general, it is unhelpful to argue with patients.

Confrontation elicits defensiveness, which predicts a lack of change.

– Particularly countertherapeutic for clinician to argue that there is a problem while patient argues that there is not.

– No evidence that patient needs to accept diagnostic label (e.g. “addict” or “alcoholic”) for change to occur.


4. Roll with Resistance– Seemingly resistant responses from patients are met not

with opposition but with acceptance and an invitation to try new perspectives.

– The ambivalence about treatment, about change, that is usually interpreted as “resistance” is probably a normative response to giving up accepting ways of being and choosing new ones.


5. Support Self-efficacy– Clinician must support the patient’s belief that they can

change.

– A realistically optimistic belief in the possibility of change can be a powerful instigator and motivator of change.

– Ultimately, patient is responsible, but the sense of hope that the clinician can generate is very important.

Disease Model

• Disease: “dysregulation of homeostasis resulting in a predictable constellation of disabling symptoms”

• Heart of disease model of addiction: addiction is a physical illness, not a matter of willpower nor the result of a deeply ingrained habit of recurrent excessive consumption.

Disease Model

• Model has evolved over time; current iteration of disease model incorporates psychological, social, and cultural factors that interact with a genetic component to produce addiction.

• Exact biological etiology for most chronic diseases such as alcoholism are still unknown.

Disease Model

• Silkworth (1939: Alcohol dependence is an “illness characterized by an atypical physiological reaction to alcohol that triggers a mental obsession”. – Describes “mental anguish of the alcoholic

faced with an inability to reduce or stop drinking”

– “Only a pervasive personality change would alleviate the emotional turmoil and spiritual bankruptcy of the alcoholic”.

Disease Model

• This “personality change” was described by William James in Alcoholics Anonymous (1955) as involving a gradual yet significant change in consciousness, or a “spiritual awakening”.

• This spiritual aspect of AA is what some clients refer to as the program being “religious”

Disease Model• Alan Leshner (former Director of National

Institute on Drug Abuse):– “Addiction is a brain disease and it matters” (1997)

– At some point during drug use, a molecular “switch” in the brain marks a change from use or abuse to addiction (dependence). Brain becomes fundamentally altered, producing drug effects and behaviors that are different from “pre-disease” state. May mark the point at which the change in neural pathways described last week takes place.

– Important to remove stigma and moral overtones from conceptualization of addiction

Disease Model

• Brain changes lead to “loss of control”, hallmark symptom of disease model.

• Because it is a disease, no blame placed on individual, but it is made clear in treatment that the patient has a responsibility for participating fully in recovery-that their “illness” can’t simply be “cured” with a medication.

Disease ModelMaintenance

• In addition to reinforcing properties of substance itself, disease is maintained by emergence of elaborate defense system that denies severity of drinking or using behavior and its consequences.

• Minimization• Rationalization• Blame others• Intimidation, angry defensiveness, manipulation

often seen

Disease ModelTreatment

• From the disease model evolved the Minnesota Model of treatment.

• Also known as the Hazelden model.• Holistic approach that uses multidisciplinary team

for assessment and treatment• Incorporates some of major tenets of Alcoholics

Anonymous • Originally developed for use in residential tx

settings

Disease ModelComponents of Minnesota Model

Mental health care– Psychotherapy and non-addictive

psychotropic meds used

Spiritual care– People struggling with addictions have often

abandoned values and beliefs they once held important. Finding meaning and strength beyond personal willpower helps people learn new ways of living w/out substances.

Disease ModelComponents of Minnesota Model

• Chemical dependency counseling– Individual and group counseling– Counselor coaches, mentors, and teaches by

taking active role as agent of change– Similar to an AA sponsor

Disease ModelMinnesota Model - Treatment

• Builds on methodology of 12 Steps of AA:– Education-information– Therapy-focus on psychological issues

producing “negative” affect– Fellowship – “interpersonal value of self-help

that builds a group motivation to modify self-defeating behavior, gain support for ongoing change, and establish resources for continuous learning.”


• Treatment approach is designed to promote access to and participation in 12-step groups after residential treatment.

• Since there is no biological cure, consistent, lifelong maintenance of behavioral change is required to prevent relapse.


• Initial tx goals focus on recognition and acceptance of the problem.– Promote self-discovery rather than denial– Recognize need to accept help from other

people– Step 1 – “We admitted we were powerless over

alcohol-that our lives had become unmanageable.”


• Goals of Step 1 treatment:– Self-awareness of extent and severity of

drinking/using behavior– Cost-benefit analysis of continued addictive

behavior compared to making changes necessary for recovery

– Recognition of addiction as a disease, beyond control of normal willpower

– Reduction of shame and self-blame


• Step 2: “Came to believe that a Power greater than ourselves could restore us to sanity.”

• Higher Power conceptualized as self-defined, highly personalized experience not the same as a particular religious belief system

• For some, represents God/supernatural source, for others it is nature, a particular counselor or sponsor, or AA itself.


• Goals of Step 2:– Development of spiritual understanding that

helps shape and give meaning to life and promotes hope

– Development of realistic optimism about capacity to recover by utilizing available resources

– Less cynicism– Foundation for self-efficacy and stronger sense

of self– Start to connect more with other people


• Step 3: “Made a decision to turn our will and our lives over to the care of God as we understood Him.”

• Steps 2 and 3 together are about surrendering• Connotes a willingness to trust an evolving sense

of spirituality to the extent of being willing to relinquish dysfunctional behaviors in favor of suggested new behaviors.


• This stage stresses introspection and self-responsibility

• Slogans like “Easy does it” are taught to promote self-regulation of reactivity to environmental cues

• Serenity Prayer does same thing-provides a spiritually-oriented cognition that promotes realistic appraisal of potentially problematic situations.


• Step 3 treatment approaches are action-oriented and can include cognitive restructuring, assertiveness training, relaxation training, psychoeducational assignments, pastoral counseling, family conferences


• Step 3 goals:– Accept and act upon feedback from trusted

sources– Assess personal needs and assert them

realistically without resorting to manipulation or aggressiveness

– Willingness to ask for help– Seeking input from others before acting

impulsively


• Step 4: “Made a searching and fearless moral inventory of ourselves.”

• Comprehensive self-appraisal used to evaluate major life dimensions

• Inventory is confidential, allows for recognition of past mistakes and problems while considering personal strengths and resources


• Step 4 often difficult and patients may begin to become aware of painful affect

• Some people continue to blame others

• Others become too triggered by anxiety/emotional pain and come close to relapse, must then take a break from this step and return to a previous step


• If successfully negotiated, step 4 tx approaches can lead to the beginning of resolution of shame and self-reproach; growing willingness to consider one’s shortcomings that may be risk factors for relapse; develop more effective coping mechanisms or work on changing maladaptive personality traits.


• Step 5: “Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.”

• Provides opportunity for catharsis of long-repressed emotions

• Important to provide accepting, non-judgmental environment for people to do this work

• The act of disclosure to another person is thought to be the therapeutic mechanism here


• Goals of Step 5 tx approaches:– Greater willingness to identify risk factors for

relapse– Greater acceptance of responsibility for one’s

actions– Greater awareness of disease’s impact on

character development– Relief of shame, guilt, and self-reproach


• Steps 1-5 are conceptualized as the initial phase of recovery

• Taken together, they provide the opportunity for a “spiritual awakening”, where the person metaphorically “wakes up” to their situation and accepts guidance and counsel of others to acquire the skills for sober living.


• These new attitudes and behaviors are then renewed and reinforced by Steps 6-12, which are referred to as relapse prevention steps.

Steps 6-12

• Step 6: “Were entirely ready to have God remove all these defects of character.”

• Step 7: “Humbly asked Him to remove our shortcomings.”

• Step 8: “Made a list of all persons we had harmed, and became willing to make amends to them all.”

• Step 9: “Made direct amends to such people wherever possible, except when to do so would injure them or others.”

Steps 6-12

• Step 10: “Continued to take personal inventory and when we were wrong promptly admitted it.”

• Step 11: “Sought through prayer and meditation to improve our conscious contact with God as we understood him, praying only for knowledge of His will for us and the power to carry that out.”

• Step 12: “Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.”


• Key treatment modality is the mentoring relationship between a primary therapist and individual client.

• Role of counselor is that of mentor and coach, similar to AA “sponsor”

• Preference in these tx settings for counselors who are either in recovery themselves or have experience with 12-Step groups such as Al-Anon.


• This is one of the most widely-used forms of treatment, although outpatient programs are being promoted more than residential programs in the era of managed care

• Not much research on efficacy, perhaps because of its development outside of academic settings


Strengths of the model:1. Clients benefit not only from counselors but

peers as well2. Other people further ahead in the recovery

process serve as natural role models for newer clients

3. Clients become part of a support group of recovering people that exists around the world; become part of something larger than themselves


Limitations of the model:1. Since it relies on a multidisciplinary team,

services can be time-consuming and expensive

2. If interpreted and implemented too dogmatically, can be presented in a confrontive, religious, or generic manner that leads to client resistance

non-pharmacological treatment approaches for substance abuse dr. jim peck npih staff psychologist...

Documents

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matching treatment approach

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skills drug use

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