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Non-Pharmacological Treatment Approaches for Substance Abuse

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?

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Non-Pharmacological Treatment Approaches for Substance Abuse

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  1. Non-Pharmacological Treatment Approaches for Substance Abuse Dr. Jim Peck NPIH Staff Psychologist ISAP Co-Investigator/Clinical Research Manager

  2. 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

  3. 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)

  4. Stages of Change Model(Prochaska & DiClemente, 1992)

  5. Stages of Change • Why consider stage of change? • Presumably matching treatment approach to stage would yield better outcomes

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. Motivation • How we conceptualize motivation will determine how we approach treatment • What are your beliefs about motivation?

  12. 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

  13. 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”

  14. 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

  15. MotivationPieces 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

  16. MotivationSearch 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)

  17. MotivationPieces of the Puzzle • 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.

  18. MotivationPieces of the Puzzle • 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

  19. MotivationPutting thePieces 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.

  20. MotivationPutting thePieces 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.

  21. MotivationQuantifying/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

  22. MotivationQuantifying/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.

  23. MotivationEnhancing 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?

  24. MotivationEnhancing 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.

  25. MotivationEnhancing Motivation-FRAMES • 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.

  26. MotivationEnhancing Motivation-FRAMES • 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.

  27. MotivationEnhancing Motivation-FRAMES • 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.

  28. MotivationEnhancing Motivation-FRAMES • 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.

  29. MotivationEnhancing Motivation-FRAMES • 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.

  30. MotivationEnhancing Motivation-FRAMES • 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.

  31. MotivationEnhancing Motivation-FRAMES • 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.

  32. MotivationEnhancing Motivation-FRAMES • 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.

  33. MotivationEnhancing Motivation-FRAMES • 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.

  34. MotivationEnhancing Motivation-FRAMES • 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.

  35. MotivationEnhancing Motivation-FRAMES • 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).

  36. MotivationMotivational 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 .

  37. MotivationMotivational 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.

  38. MotivationMotivational Interviewing 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.

  39. MotivationMotivational Interviewing 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.

  40. MotivationMotivational Interviewing 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.

  41. MotivationMotivational Interviewing 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.

  42. MotivationMotivational Interviewing 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.

  43. 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.

  44. 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.

  45. 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”.

  46. 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”

  47. 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

  48. 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.

  49. 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

  50. 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

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