Treatment Approaches for Drug Abuse and Addiction

1. Treatment Approaches for Drug Abuse and Addiction Lisa K. Ray, M.S., L.A.D.A.C., C.C.S. Project Coordinator – Addictions Studies Program Department of Health Sciences University of Central Arkansas

2. Objectives • Define evidence based practices and describe the principles of effective treatment. • Apply the Stages of Change model to drug abuse treatment. • Identify and describe the key components of motivational interviewing and cognitive behavioral therapy.

3. What Are Evidence-Based Practices? Interventions that show consistent scientific evidence of being related to preferred client outcomes.

4. How Are Evidence-Based Practices Documented? Gold Standard • Multiple randomized clinical trials Second Tier • Consensus reviews of available science Third Tier • Expert opinion based on clinical observation (Drake, et al. 2001. Implementing evidence based practices in routine mental health service settings. Psychiatric Services, 52, 179 – 182)

5. Principles of Effective Treatment 1. No single treatment is appropriate for all 2. Treatment needs to be readily available 3. Effective treatment attends to the multiple needs of the individual 4. Treatment plans must be assessed and modified continually to meet changing needs 5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness

6. Principles of Effective Treatment 6. Counseling and other behavioral therapies are critical components of effective treatment 7. Medications are an important element of treatment for many patients 8. Co-existing disorders should be treated in an integrated way 9. Medical detox is only the first stage of treatment 10. Treatment does not need to be voluntary to be effective

7. Principles of Effective Treatment 11. Possible drug use during treatment must be monitored continuously 12. Treatment programs should assess for HIV/AIDS, Hepatitis B & C, Tuberculosis and other infectious diseases and help clients modify at-risk behaviors 13. Recovery can be a long-term process and frequently requires multiple episodes of treatment - NIDA (1999) Principles of Drug Addiction Treatment

8. Scientifically-Based Approaches to Addiction Treatment • Cognitive–behavioral interventions • Community reinforcement • Motivational enhancement therapy • 12-step facilitation • Contingency management • Pharmacological therapies • Systems treatment Principles of Drug Addiction Treatment: A research-based guide (1999). National Institute on Drug Abuse

9. Group/Individual Counseling Urine Monitoring Core Treatment Abstinence Based Case Management Intake Assessment Pharmaco-therapy Continuing Care Treatment Plans Self-Help (AA/NA) Core Components of Comprehensive Services Medical Financial Mental Health Housing & Transportation Vocational Child Care Educational Family Legal AIDS / HIV Risks http://www.ibr.tcu.edu/index.htm

10. More on Motivational Interviewing

11. A Usual Question: Why should we attend to the patient’s perceived needs and wants when WE best know what will make their lives better?Answer:People are more likely to change when they decide they are ready to change and when they are able to choose their own path

12. According to Research: • Care and Concern More Effectively Facilitates Change than does Confrontation and Consequences

13. The Common Factors Associated with Change In Therapy (Lambert, 1992) • Extra-therapeutic Factors • 40% • Motivation • Environment • Strengths • Needs • Abilities • Preferences Therapeutic Relationship 30% Therapist Techniques 15% Patient Expectations 15%

14. “Person Discount” Approaches: “You are too sick to make your own decisions” “You have to leave because your illness is getting in the way of efforts to treat you” “You don’t know what you want and I don’t care if you say you do” “I know better than you do and this is what you should do because this is what I say you need”

15. Person Centered Values Underlying Best Practice for the Treatment of Persons with Substance Use Disorders

16. Best Practice Value #1First Things First

17. Best Practice Value # 2The 3 Purposes of Therapeutic Intervention: Provide Relief, Offer Comfort, and Facilitate Recovery. All are Important and Serve to Promote Health and Well Being.“The Sheer Act of Love Transcends it’s Outcome.”- Mother Teresa

18. Best Practice Value # 3If The Treatment Plan Doesn’t Work, Get Rid of the Plan, Not the Patient“I haven’t failed, I’ve found 10,000 ways that don’t work” - Thomas Edison

19. Best Practice Value #4We Should Offer a Welcoming Therapeutic Environment and Utilize Natural Helpers as Much as Possible

20. Best Practice Value #5Identify Patient Strengths and Promote Self Efficacy and Remember that Any Progress is Progress

21. Best Practice Value #6Honor Patient Choices and Respect their Right To Choose To Give in is not to Give Up.

22. Best Practice Value #7 Commit to Doing All You Can to Sustaining a Belief in the Possibility of Change It is Our Job to be Purveyors of Hope and Expectancy

23. Best Practice Value #8Just Showing Up and BEING with the Patient Makes a Difference“The silence often of pure innocence persuades when speaking fails.” - Shakespeare, The Winter’s Tale

24. Best Practice Value #9Never, Never, Never Give Up “Only Infinite Patience Produces Immediate Results” - Course in Miracles

25. Why Do We Need A Strategy for Motivating Substance Abusers?

26. Drug Abusers Straddle the FenceSource: Maxine Stizer Continued Use Abstinence

27. Methods are needed to: Drug Abstinence Continued Drug Use • counteract ambivalence- increase motivation for change • Source: Maxine Stizer

28. Why Motivationally Challenged Substance Abusers are Motivationally Challenged • Addicted brain is not open for business • Drug use satisfies desires & needs • Limited experience of success • Lack education and employment skills • Live in unstable & unsafe environments • Lack transportation • Special therapeutic & medical needs for which there are limited resources

29. Prochaska and DeClemente’s Model of Change • Pre-contemplation • Contemplation • Preparation • Action • Maintenance stage • The five stages can occur in any order, taking into account individual differences.

30. Stages of Change precontemplation relapse contemplation maintenance preparation action

31. Stage 1: Precontemplation • No intent to change • Under-awareness • Pros outweigh cons • No self-efficacy; demoralized by past failed attempts • Coercion • Denial • Resistance

32. Stage 2: Contemplation • Thinking about making a change • Information seeking • Evaluating pros and cons • No concrete change effort enlisted

33. Stage 3: Preparation • Developing concrete strategies and solutions • Time line for change is within one month • Tentative actions may be taken • Aware of lessons in past failed attempts • Links Contemplation to Action via determination

34. Stage 4: Action • Actively engaged in behavior change (~6mos.) • Skills acquisition • Employing strategies to control behavior and behavioral contexts • Transtheoretical

35. Maintenance • Sustaining gains • Avoiding/preventing relapse • Termination when confident and secure in maintaining change • Multiple cycles may be necessary to achieve this goal

36. Pre-contemplation Raise doubt Contemplation Tip the balance Preparation Help determine the best course of action Action Help take steps toward change Maintenance Help to identify and use strategies to prevent relapse. Relapse Help to renew the process without becoming stuck or demoralized because of relapse. Therapist’s Motivational Tasks

37. Five Strategies of MET & MI 1.Express Empathy 2. Develop Discrepancy 3. Avoid Argumentation 4. Roll with Resistance 5. Support Self-Efficacy

38. Emotions and Cognition • The center of our EMOTION is in the limbic system. The limbic system lacks language. • We EXPRESS that emotion through our cortical functions, language and behavior.

39. Behavioral Approaches Donald Meichenbaum’s Ten Central Tenets of Cognitive Behavioral Therapy • Behavior is reciprocal between a client’s thoughts, feelings, psychological processes and resultant consequences. • Cognitions do not cause emotional difficulty. • Counselors help clients understand how they construct and construe reality. • CBT therapists dissuade from the rationalist or objectivist position. • There is an emphasis on collaboration with the client.

40. Behavioral Approaches Donald Meichenbaum’s Ten Central Tenets of Cognitive Behavioral Therapy (continued) • Relapse prevention is central to cognitive behavioral therapy. • The client/therapist relationship is critical for change to occur. • Emotions play a critical role in cognitive-behavioral therapy. • CBT is used with couples and families. • CBT can be used in a variety of setting with a variety of issues.

41. Behavioral Approaches Applied Behavioral Analysis: Central Constructs • Client-counselor relationship is imperative and counselors exhibit high levels of empathy, self-congruence and interpersonal contact. The relationship is collaborative and relationship variables differ according to client and culture. • Operationalization of Behavior: Focuses on the concreteness and specifics of behavior. Vagueness is transformed into objective, observable actions. • Functional Analysis: The ABC’s of behavior. An individual's behavior is directly related to events and stimuli in the environment.

42. Cognitive Behavior Therapy Strategies for Helping Clients • Cognitive Modeling: Identification of what maladaptive or bad thoughts or emotions the client wishes to be rid of and then the therapist models with self-talk that the client will incorporate. • Covert Modeling: A client imagines engaging in the desired behaviors he or she wants to learn or adopt. • Thought Stopping: Interruption of unwanted thoughts when they occur by shouting “stop” whenever the unwanted thought pops into consciousness.

43. Cognitive Behavior Therapy Strategies for Helping Clients • Cognitive Restructuring: Replacement of negative, maladaptive thoughts with positive, adaptive ones. • Reframing: To modify or restructure a person’s view or perception regarding a problem or behavior. • Stress Inoculation: A process of teaching clients both cognitive and physical skills for autonomously coping with future stressful and distressing situations.

44. Cognitive Behavior Therapy Strategies for Helping Clients • Meditation and Relaxation: Helps the client concentrate on some internal or external stimulus that serves to focus the client’s attention away from aversive stimuli. • Biofeedback: Uses technology to communicate to a client what his or her own body is doing and then allows that person to use mental processes to control bodily functions. • Neurolinguistic programming: Using the client’s sensory language to fully experience the client’s inner world (e.g. I see that (visual); I feel that (kinesthetic) ; I hear that auditory).

45. Cognitive Behavior Therapy Advantages of Cognitive Behavior Therapy • It has established human thought processes as data or events that can be studied. • It validated a number of relaxation techniques. • It has enhanced the rational therapies such as Rational Emotive Behavior Therapy. • Uses the systematic scientist-practitioner model.

46. Behavioral Approaches Albert Ellis/Rational-Emotive Behavior Therapy (REBT) Theoretical Constructs and Techniques • Focuses on dysfunctional, irrational, unrealistic and distorted thoughts. • Feelings and behavior are also addressed. • Unconditional acceptance is important. • Ellis also believed in authenticity. • Clients are encouraged to think rationally.

47. Behavioral Approaches Albert Ellis/Rational-Emotive Behavior Therapy (REBT) Philosophy and Beliefs • Understanding belief systems is important. • Belief systems are organized ways of thinking about reality. • Belief systems affect one’s self-view. • The language a client uses, will speak to their philosophy and belief system.

48. Behavioral Approaches Albert Ellis/Rational-Emotive Behavior Therapy (REBT) Philosophy and Beliefs (continued) • Clients can create their own emotional disturbances by believing in absolute and irrational beliefs. • Clients can choose their belief system. • Counselors can help clients by identifying irrational beliefs and helping the client find meaning in their lives. Beliefs

49. Behavioral Approaches Albert Ellis/Rational-Emotive Behavior Therapy (REBT) Identifying Irrational Thinking • Helpless thinking is the result of irrational thinking. • It usually includes “all or nothing” statements. • It usually includes the words should, ought, never and must.

50. Behavioral Approaches William Glasser/Reality Therapy/Choice Theory The Basics • Instead of seeking to change behavior, Reality Therapy works on changing awareness of responsibility. • Once responsibility is acknowledged by the client, it is then possible to work on behavior change. • The locus of the decision is placed on the client.