Assessment and Treatment of Addictive Behaviors

1. Assessment and Treatment of Addictive Behaviors Lecture 6 Change and Functional Analysis

2. Transtheoretical Model of Change • Founders • James Prochaska • Carlo DiClemente • Origin • 1979 • Systems of Psychotherapy: A Transtheoretical Analysis published in 1979

3. Factors leading to its development • Called trans-theoretical model because it brings together over 18 different forms of psychotherapy • Eclectic in nature • Instead of finding separate change processes in each of the 18 leading systems of therapy, only 10 processes of change(the mechanisms people use) were identified • Process were at both the level of the individual and the environment

4. 10 Processes (1-2) • Consciousness Raising  • Efforts by the individual to seek new information and to gain understanding and feed-back about the problem behavior / observations, confrontations, interpretations, bibliotherapy. • I recall information people had given me on how to stop smoking • Self-Reevaluation • Emotional/cognitive reappraisal of values with respect to the problem behavior/value clarification, imagery, corrective emotional experience. • Binging to maintain my weight makes me feel disappointed in myself

5. 10 Processes (3-4) • Environmental Reevaluation • Consideration and assessment of how the problem behavior affects the physical and social environment / empathy training, documentaries • I consider the view that smoking can be harmful to the environment • Dramatic Relief • Experiencing and expressing feelings about the problem behavior and potential solutions / psychodrama, grieving losses, role playing • I react emotionally to warnings about drugs

6. 10 Processes (5-6) • Social Liberation • Awareness, availability, and acceptance by the individual of alternative, problem-free lifestyles in society / empowering, policy interventions • I find society changing in ways that make it easier for the nonsmoker • Self Liberation  • Choice and commitment to change the problem behavior, including belief in the ability to change, New Year's resolutions, logotherapy techniques, commitment enhancing techniques • I will make it my New Year’s resolution to quit X

7. 10 Processes (7-8) • Counterconditioning • Substitution of alternatives for the problem behavior / relaxation, desensitization, assertion, positive self-statements • Doing other things with my hands is a good substitute for smoking • Stimulus Control • Control of situations and other causes which trigger the problem behavior / adding stimuli that encourage alternative behaviors, restructuring the environment, avoiding high risk cues, fading • I remove things from my home that remind me of gambling

8. 10 Processes (9-10) • Reinforcement Management • Rewarding oneself or being rewarded by others for making changes / contingency contracts, overt and covert reinforcement, self-reward • I reward myself when I don’t binge drink • Helping Relationships  • Trusting, accepting, and utilizing the support of caring others during attempts to change the problem behavior • I have someone who will shoot me a disapproving look whenever I chant “Vegas Baby, Vegas”

9. Decision Balance • Decision making was conceptualized by Janis and Mann (1977) as a decisional "balance sheet" of comparative potential gains and losses • Two decisional balance measures, the pros and the cons, have become critical constructs in the Transtheoretical model • The pros and cons combine to form a decisional "balance sheet" of comparative potential gains and losses • The balance between the pros and cons varies depending on which stage of change the individual is in

10. Self-Efficacy / Situational Temptations (Bandura, 1977) • Conceptualizes a person's perceived ability to perform on a task as a mediator of performance on future tasks • A change in the level of self-efficacy can predict a lasting change in behavior if there are adequate incentives and skills • The Transtheoretical model employs an overall confidence score to assess an individual's self-efficacy • Situational temptations assess how tempted people are to engage in a problem behavior in a certain situation.

11. Stages of Change • Precontemplation is the stage at which there is no intention to change behavior in the foreseeable future. Many individuals in this stage are unaware or underaware of their problems • Contemplation is the stage in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action • Preparation is a stage that combines intention and behavioral criteria. Individuals in this stage are intending to take action in the next month and have unsuccessfully taken action in the past year • Action is the stage in which individuals modify their behavior, experiences, or environment in order to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy • Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action. For addictive behaviors this stage extends from six months to an indeterminate period past the initial action

12. Alcohol: Stages of Change (Short Form) • In the last month have you had 5* or more drinks in a row? • 1:Yes, and I do not intend to stop drinking 5 or more drinks in a row • 2:Yes, but I intend to stop drinking 5 or more drinks in a row during the next 6 months • 3:Yes, but I intend to stop drinking 5 or more drinks in a row during in the next 30 days • 4:No, but I have had 5 or more drinks in a row in the past 6 months. • 5:No, and I have not had 5 or more drinks in a row in the past 6 months • 6:No, I have not had 5 or more drinks in a row • Scoring • 1 = Precontemplation • 2 = Contemplation • 3 = Preparation • 4 = Action • 5 = Maintenance • 6 = N/A

13. Self-change • Most individuals change on their own • b/n 3:1 and 13:1 • Many avoid treatment due to stigma • Some data contrary to major life event as necessary recovery cause (Sobell, 1992) • Cognitive appraisal may be key • Evaluate pros vs. cons • Alcohol success: positive social support • Drug success: avoid negative cues

14. Cognitive Appraisal:Key Features • Make salient costs of addiction • Lessen perceived rewards of use • Make apparent benefits of changing • Identify obstacles (costs of change)

15. Research Findings • Problems aren’t always progressive • Less extensive treatment may work better for less severe problems? • Let clients select own goals • Behavioral components may be key in relapse prevention

16. Functional Analysis Treatment

17. Trigger  Thoughts  Feelings Behavior Consequences • Functional analysis (triggers and consequences) • Thoughts/Feelings/Emotions • Assertiveness and Drink/Drug Refusal • Life Enhancement Strategies and Relapse Prevention

18. Group #1Functional Analysis: Triggersand Consequences

19. Functional Analysis: Triggers and Consequences • Functional Analysis • What does this mean? • Break down Function (why, purpose) • Break down Analysis (look at) • Trigger  Thoughts  Feelings Behavior Consequences

20. Functional Analysis: Triggers and Consequences • Trigger  Thoughts  Feelings Behavior Consequences • What is a trigger? • 3 types of triggers • Person • Place • Thing/Time • 3 strategies for dealing with triggers • Avoid • Alter • Substitute

21. Functional Analysis: Triggers and Consequences Trigger  Thoughts  Feelings Behavior Consequences Consequences Positives Negatives List both How do they differ --- Magnitude + --- Duration + + Immediacy --- + Certainty ---

22. Functional Analysis: Triggers and Consequences Trigger  Thoughts  Feelings Behavior Consequences Consequences Alternatives We can’t give you a list of alternatives What can you take from the previous comparison

23. Group #2ThoughtsFeelings and Emotions

24. Thoughts • Trigger  Thoughts  Feelings Behavior Consequences • What is irrational thinking • Not based in reality • Lead to self-harm • Based on neg beliefs / attitudes (self, others, future, etc) • How do irrational thoughts cause problems? • Person A = wants to be here • Person B = doesn’t want to be here • Which thoughts and feelings go with each type of person? • Who is more likely to get and stay sober

25. Thoughts • Types of irrational thinking • Negative self-statement • Ex - I am… • Unrealistic expectations • Ex - I’ll just have a couple drinks • Assuming the worst • Ex - No matter what, no one will ever trust me again • Catastrophizing • Ex – Overreacting & blowing things out of proportion • Mind-reading • Filling in blanks with negatives

26. Thoughts • Put up behavior chain and list thoughts • Guidelines • Stop • Become aware • Dispute irrational thought (where is evidence) • Develop more rational thought • Replace with new thought • Take action

27. Feelings / Emotions • Difference between feelings and emotions • Feelings inside • Emotions are what is expressed • Only emotions can be directly controlled • Use steam cooker analogy • What can be done to express emotions • Put up behavior chain and list Feelings

28. Group #3Assertiveness &Drink/Drug Refusal

29. Assertiveness and Drink/Drug Refusal • Trigger  Thoughts  Feelings Behavior Consequences • Focus on behavior • Assertiveness • Focus on behavior • Skills require training, practice, and time • Classification • Passive---------------------------Assertive-------------------------------Aggressive • - + + - • Kiss ass Calm accomplished abusive • Low self esteem easy going achieving obnoxious • Low confidence well liked focused high conflict

30. Assertiveness (1) • Focus on behavior • Skills require training, practice, and time • Classification (where does everyone place themselves) Passive---------------------------Assertive-------------------------------Aggressive - + + - kiss assCalm accomplishedabusive low self esteemeasy going achievingobnoxious low confidencewell liked focusedhigh conflict taken advantage ofless conflict leader high stress needs not metundercontrol independentlow control unexpressed feelingsless stress in control poor relationships difficulty w/ conflictmore focused needs are metviolent misunderstoodout of trouble problem solverpushy

31. Assertiveness (2) Summary • Get needs met and attend to needs of others • Best of both personality types • Peope who abuse substances generally not assertive • Closer to middle may reduce need to use and improve self-esteem

32. Drink/drug Refusal Trigger  Thoughts  Feelings Behavior Consequences FOCUS ON BEHAVIOR • “Just” Say No campaign • Doesn’t work – why? • Calculate “yes” time and “no” duration • Skills require training, practice, and time • Saying “Yes” vs Saying “No” • What’s hard about it • What are you good at saying no to (why – goto consequences part of FA)

33. Drink/drug Refusal Guidelines • Make no first word • Offer a one line explanation (is it ok to lie) • Request an alternative • Confront – broken record • Leave (have you put yourself in a position to do this) Do these guidelines change over time?

34. Group #4Life Enhancement Strategiesand Relapse Prevention

35. Life Enhancement Strategies Summary • Difference between “quitting” vs. lifestyle change • Dry drunk example (psychological dependence) • Cite FA group and discuss function of SA • Importance of developing alternatives

36. Life Enhancement Strategies What types of alternatives are there? • Long term goals/life areas • Family • Social • Intimate • Education/training • Employment/career • Hobbies/recreation • Volunteer work/charity • Physical/health issues • Spirituality • Psychological/emotional issues

37. Problems with these goals? • Better understand goals (category mistake) • Consider immediacy and certainty • Return to “extremes” graph

38. Focus on activities w/ immediate & certain small rewards • Over time these activities lead to completion of larger goals • Generate examples of short term activities • Don’t get frustrated, this is new to you • If alternatives were obvious, you’d be doing them • Ask others who live a sober happy life what they do

39. Relapse Prevention • What are your thoughts about these data? • why do we show you this? • Its not easy

40. Relapse Prevention • Pro-lapse vs. Re-lapse • Pro-lapse = getting back on track • Re-lapse = return to previous behavior • Thoughts and feelings at each stage • What would you say to a friend who relpased pro lapse re

41. Relapse Prevention • Warning Signs • Stop taking antibuse • Around high risk people • Cravings • Romanticizing Previous substance use • Uncomfortable emotions • Withdrawing / isolating from others • Temper outbursts • Plan • Call people who don’t use (e.g. sponsor) • Be real & truthful about inner thoughts and emotions • Stop and think about negative consequences

42. Life Enhancement Treatment for Substance Use: LET’S ACT! • Modified BAT-D for chronic substance using population currently receiving residential substance use treatment • 6 sessions over two-weeks + 2 weekly maintenance sessions • Small group format (3-5 patients) • First three sessions ~ 1 hour; Last three sessions ~ 30 minutes • Vocabulary simplified • Complex concepts and forms eliminated, replaced, or modified • Earlier sessions focus on modifying behavior in treatment, while later sessions gradually moved toward post-discharge planning and goals.

43. Session 1 • Introduction and Life Values and Goals • Introduce treatment rationale • Discuss individual life values and goals • Begin self monitoring of current activities and daily mood ratings • Progressive Muscle Relaxation

44. Treatment Model Negative Feelings: Sadness, Anger, Loneliness, Frustration Substance Use Behavioral Activation: Productive, Enjoyable, And Rewarding Behavior Positive Feelings Happiness, Fulfillment, Sense of Accomplishment Decreased substance use, Reduction in depressive symptoms

45. Planned Relaxation • Rationale and Techniques • Stress and tension can be overwhelming and lead to a desire to use substances • Review and Practice in Session • Behavioral relaxation postures • Deep breathing exercises • Homework: Practice relaxation at least 5 minutes per day

46. Session 2 • Identifying Activities • Review self monitoring and daily mood ratings • Identify activities in corresponding life areas • Introduce behavioral contracts • Progressive Muscle Relaxation

47. Identifying Activities • Instruct patient to select activities that will help them towards their goals in each life area • List them on the Selected Activities Form • Refer to Activity Checklist for ideas • Example #1 • Goal: re-establish relationship with my daughter • Activity: Call my daughter 3x a week at 7pm to see how she is doing • Example #2 • Goal: Improve my physical health • Activity: Walk 30 minutes 4x a week

48. Sample Contract Fellow resident / friend / family member: Bob In this contract, I agree to remain sober. Below, I list supportive behaviors from you that will help me achieve this goal. Some are things you are already doing and others are things that also would be helpful. Thank you for all your support! • Each time I sit in the back of the treatment group and don’t pay attention, Bob will tap me on the shoulder and suggest that I move up front. • If I get grumpy and don’t talk to anyone then Bob will ask me to sit with him at meals and I will tell him what is on my mind. Signed: ____________________ ___________________________ You Fellow resident / friend / family member

49. Session 3 • Daily and Weekly Goals • Review self monitoring and daily mood ratings • Review behavioral contracts • Introduce daily and weekly Goals • Progressive Muscle Relaxation

50. Daily Goals Form Instructions: For the day listed, list the life areas you wish to work on and the activities that will help you move toward improving that Life Area and the amount of time you want to do each. At the end of this day, circle whether or not the goal was met for each activity. Circle the day & insert the date M T w Th F Sa Su: _______________