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Psychosocial interventions for ATS use Dr Nicole Lee

Director, LeeJenn Health Consultants &Associate Professor, National Centre for Education and Training on

Addiction

Regional Seminar on ATS Treatment and Care

18-21 April 2011Kunming, China

+Psychological features of ATS use Physical effects are acute and usually resolve quickly

with detoxification

High rates of mental health problems associated with ATS use

Significant cravings

High relapse rates

Impulsivity

Low levels of motivationInterventions that specifically address the

salient symptoms of ATS use are key

+Neurological changes

ATS disrupts the dopamine system causing depletion of dopamine stores and transporters (Barr et al., 2006)

Dopamine depletion leads to Problems with concentration and memory Difficulty making decisions Irritability, mood swings, loss of interest in pleasurable

activities Insomnia Lack of motivation

+Neurological changes

Neurotransmitters replenished with abstinence but changes may remain for weeks, months or sometimes years

Practitioners understanding that users may need more support to make changes because of these brain changes is important

Helping users understand why they continue to experience these symptoms because of long term brain changes after they stop using is also important

+Early intervention is important

Transition to dependent use occurs relatively quickly Transition from regular use to dependence about 2 years (Lee et

al, 2008) 3-4 times a week is likely to be dependent use

Rapid development of tolerance can drive transition to stronger formulations (crystal meth) and alternative routes of administration (injecting or smoking) (Jenner, 2011)

Time to treatment is long – at least 5 years from regular use Average age of first use is 22yo, average age in treatment is in

30’s Emphasis on early recognition of adverse effects could prompt

users to self-regulate or seek treatment earlier than might otherwise be expected (Looby & Earleywine, 2007)

+Range of use patterns

Experimental users and occasional users The majority do not go on to use regularly or become dependent

Regular users Most of these also do not go on to become dependent but many

do

High risk users Can be using a lot or a little but in a risky way (eg injecting,

sharing needles)

Dependent users Have developed tolerance Mostly likely require detoxification

+ATS use and users - summary

Largely using occasionally But a group of risky, regular or dependent users

High rates of mental health problems Even at relatively low doses

A potentially quick transition to high risk routes of administration and/or dependent use But a long time lag to treatment

A lot of psychological symptoms during withdrawal and after but relatively few physical symptoms

+What is ‘psychosocial’ treatment Psychosocial treatment addresses both psychological

and social factors of drug use Drug use Relationships with others and the drug Lifestyle factors that maintain drug use

The gold standard response to ATS use is outpatient psychosocial treatment Inpatient treatment is recommended when presentation is

complicated by Polysubstance dependence Severe mental health or medical complications Living conditions are not conducive (eg no social support) Outpatient treatment has failed repeatedly

+Which psychosocial treatments are effective? ATS users are very responsive to treatment

Control groups in many studies also do well

A review of the literature shows effective treatments included (Lee & Rawson, 2008; Baker & Lee, 2003): Cognitive behaviour therapy (CBT) Contingency management (CM) Motivational interviewing (MI)

They have in common: Collaborative Empowering for the patient Brief Focus on the here and now Focus on highlighting automatic processes

+Why psychosocial treatment?

Have proven effectiveness and efficacy in ATS

Research shows that psychological treatments added to medication are often better than medication alone

Straightforward to implement and tailor to patient’s needs

Can address the drug use AND mental health issues associated with ATS together

Can address the motivational issues associated with ATS use

There is no robust pharmacotherapy for ATS dependence or withdrawal Symptomatic relief only

+Brief intervention is possible

At least initially brief interventions are effective, and sometimes preferable

2 sessions of motivational interviewing and cognitive behaviour therapy effective in increasing abstinence (Baker et al, 2005) Even for those who are not very motivated to change Even for those with significant mental health comorbidities

Interventions of up to 10 or more sessions are available for more motivated patients

+Range of use patternsATS users use many different ways

+Readiness to changeATS users come to treatment at different levels of readiness to address their issues

Motivational interviewingBrief CBT

Intensive CBT

Contingency management

+Tailoring psychosocial treatments Intervention needs to be mindful about readiness to

engage Think about readiness to change Readiness to engage in therapy

Relapse is common, intervention may not be successful the first time Ongoing attempts at treatment can be successful over time Importance of a good treatment experience so they are

motivated to return

A stepped care approach can help Offering low level interventions for everyone Increasing the intensity for those who do not respond or who

have special needs

+What is Motivational Interviewing?

‘Client centered, semi-directive’

Philosophy is strengths base Draw out and harness patients own resources for change

MI is based on 4 principles: Express empathy Develop discrepancy Roll with resistance Support self-efficacy

Miller and Rollnick

+What is Motivational Interviewing?

Goals of MI Establish rapport Move towards commitment to change

Characterised by Open ended questions Reflective listening Therapist de-investment in the outcome No skills training

Miller and Rollnick

+Motivational interviewing

Extensive evidence across a range of health behaviours Less research compared to the other two types with ATS Effective with amphetamine, cocaine

Usually researched as part of CBT intervention Often used at the beginning of CBT therapy to increase

engagement in CBT

Similar outcomes, shorter time frame for treatment

+MI techniques

Communicating responsibility for change lies with the user (self efficacy)

Communicating free choice (roll with resistance)

Offering concern (empathy)

Weighing up the good things and less good things (discrepancy)

Address the 4 principals

+Motivational InterviewingVideo demonstration

+Motivational Interviewing

Notice in the video: The therapist acknowledges the good things about using The therapist allows the client to come up with the less

good things The therapist offers concern and makes suggestions but

allows the client to make the decision about what and how the change happens

+Training in MI

MI can be especially difficult for therapists used to a more directive or confrontational

Eight levels of learning MI1. Overall spirit of MI

2. OARS: client centred counselling skills

3. Recognising a change and sustain talk

4. Eliciting and strengthening change talk

5. Rolling with sustain talk and resistance

6. Developing a change plan

7. Consolidating commitment

8. Transition and blending

For all psychological therapies, clinical supervision is important

+What is Contingency Management

Based on behavioural principles

Offers (usually) rewards for meeting treatment goals Gifts or money Prize draws Extra responsibility (eg takeaway doses, reduced

supervision)

Can help reduce impulsivity associated with ATS use

Highly effective Effects are reduced when contingencies (rewards) are

removed

+CM v MI

CM MI

External motivation to change Internal motivation to change

Planned reinforcers Naturally occurring reinforcers

Reinforces actual behaviour Reinforces verbal behaviour

Learning by direct behavioural exposure

Learning by identifying connections between behaviours

Shapes behaviour directly Shapes thoughts about behaviour

Uses secondary reinforcers (eg money) to create change

Uses primary reinforcers (eg values) to create change

Similar aims, different methods

+Training in CM

For contingency management, the most complex piece is applying the principles consistently

Inconsistent application can have the opposite effect to that intended

Requires the whole service to be involved and consistent The use of a strict protocol may be necessary to maintain

integrity of the intervention among clinic or team members

+What is Cognitive Behaviour Therapy?

‘Umbrella’ that encompasses a range of intervention types Cognitive therapy (Beck) Relapse prevention (Marlatt) Coping skills therapy (Monti) Rational emotive behaviour therapy (REBT) (Ellis) Mindfulness approaches (Marlatt, Williams, Hayes)

Focused on changing ‘faulty thinking’ (cognitive) and developing coping skills (behaviour)

‘Self help’ teaching clients to be their own therapist Homework/take home tasks

+What is Cognitive Behaviour Therapy?

Short term ‘Intensive’ CBT is usually 6-12 sessions Brief interventions based on CBT are effective (1-4 sessions) Can be extended such as for borderline personality disorder –

around 1 year intensive treatment

Structured (but not inflexible), collaborative, active and directional

Highly effective and has an extensive research base, including for ATS and adaptations for Asian cultures

A number of programs specifically for ATS use based on CBT Matrix Brief intervention

+Typical CBT for ATS

Psychoeducation About the effects of ATS About withdrawal from ATS About brain changes from using and during withdrawal About the CBT model and how treatment works

Goal setting

Behavioural strategies Self monitoring Coping with craving Activity scheduling Coping with a lapse

+Typical CBT for ATS

Relapse prevention Refusal skills Identifying high risk situations or people and ways to avoid

them Developing a relapse prevention plan

Cognitive strategies Understanding triggers Link between thoughts, feelings and behaviours Recognising and challenging unhelpful thinking Seemingly irrelevant decisions

+General cognitive behavioural model

Trigger/Situation

+General cognitive behavioural model

Breakup of relationship

+Cognitive Behaviour TherapyBrief demonstration

+CBT

In the video He explained the model but the client helped fill in the

detail (collaboration) Instructional style but helps link up the key concepts

+Training in CBT

At a basic level, CBT can be effective even with relatively inexperienced therapists Can be effective delivered as a protocol Is more effective if the protocol is tailored to individual case

conceptualisation

Training but not necessarily experience is related to better outcomes in cognitive therapy Especially if therapists use a treatment manual

Supervision is important

+CBT in Asia

Hodges & Oei (2007) review of compatibility of CBT with Chinese values Chinese culturally value

Conformity, certainty and discipline Persistence and a strong work ethic Authoritarian systems Achievement orientation

High level of stigma around mental health issues Tendency to somatise mental health issues (express mental

health issues as physical symptoms)

+CBT in Asia

CBT may suit cultural contexts needing a directive and structured therapy style CBT can be adapted to a more instructive style CBT can be offered in a more ‘coaching’ style to reduce

stigma of mental health treatment CBT includes adaptations incorporating Buddhist principles

of mindfulness (eg mindfulness relapse prevention) ‘we are what we think’

+CBT manuals are availablewww.meth.org.au

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+Summary

CBT, CM and MI can assist with ATS use by directly addressing key features of use Impulsivity Mental health issues High relapse rates Reasons for use

All have a strong evidence base for effectiveness

CBT in particular is well suited to, and has been adapted for, some Asian populations of ATS users

Implementation depends on Staff training/expertise – supervision is also important Capacity of service to deliver User and cultural barriers