Providing Substance Abuse Treatment in Private Practice

1. Providing Substance Abuse Treatment in Private Practice Joan E. Zweben, Ph.D. Executive Director: East Bay Community Recovery Project Clinical Professor of Psychiatry; UC San Francisco IN COLLABORATION WITH Arnold Washton, Ph.D. Recovery Options New York, NY & Princeton, NJ

2. Today’s Topics • Addiction Treatment versus Psychotherapy • Recovery-Oriented Therapy: Integrative Model • Psychodynamics of Addiction & Recovery • Motivational Interviewing & Stages of Change • Assessment Techniques • Stage-Specific Treatment Interventions

3. Addiction Treatment & Psychotherapy

4. Rift between psychotherapy and mainstream addiction treatment • Different beliefs about the fundamental nature of addiction • Many addiction treatment programs subscribe to a biopsychosocial model; some are rigidly disease model • Prevailing view among psychotherapists is either a learning/behavioral model or a psychodynamic model • Many believe that if the behavior is learned, it can be unlearned, changed, or controlled or that insight will produce change

5. Rift between psychotherapy and mainstream addiction treatment • Psychodynamic therapists tend to view addiction as merely a symptom of underlying psychological problems or unresolved conflicts • Therapists who search for the “root causes” of an active addiction can be compared to a paramedic rushing to the scene of an accident with injured victims lying bleeding on the ground and taking time out before attending to the victims to ask what caused this accident to happen.

6. Rift between psychotherapy and mainstream addiction treatment • Seeing addiction as a symptom fosters the unrealistic belief that once the underlying problems are resolved the person can return to using alcohol or drugs moderately. • Psychodynamic therapy can be very helpful during latter stages of recovery when abstinence is reasonably secure, but in the early stages it can serve as a form of enabling and also stimulate further alcohol/drug use when highly charged emotional issues are uncovered too early in the recovery process.

7. Rift between psychotherapists and mainstream addiction treatment field • In the early abstinence stage, the emergence of highly charged issues (e.g., childhood traumas) threatens to overwhelm the addict’s shaky sense of self and fragile commitment to abstinence. Feelings that have been medicated and numbed for years by alcohol/drugs often emerge once the chemical blanket is removed. • Mainstream addiction treatment has traditionally downplayed the psychological aspects of addiction and devalued the role of psychotherapy in fostering long-term recovery. Some believe that AA alone is enough.

8. Recovery-Oriented Psychotherapy An Integrative Approach

9. Stages of Recovery-Oriented Therapy 1. Assessment with motivational feedback 2. Engaging the client who is actively using 3. Negotiating an abstinence contract 4. Helping the client to stop using (early abstinence) 5. Consolidating abstinence, changing lifestyles, developing adaptive coping skills (relapse prevention) 6. Addressing developmental/interpersonal issues (psychotherapy)

10. Recovery-Oriented Psychotherapy • Framework that integrates disease model addiction treatment with abstinence-based psychotherapy • Individual, group, & couples therapy • Supports, facilitates , and encourages but does not mandate involvement in AA • Therapist’s tasks shift according to the patient’s stage of recovery • Collaborative stance toward the patient

11. Therapist’s Role • Facilitate change • Mobilize motivation • Non-judgmental coach, advisor, and guide • Educator • Voice of reason and reality • Safety net and backstop • Steady, reliable resource • Supply ego functions that the patient lacks

12. Stance of the Therapist • Primacy of the therapeutic alliance • Respect for patient’s autonomy while providing forthright feedback • Respect for change as a process • Respect for individual differences • Awareness of transference & countertransference dynamics

13. Countertransference • Abrupt or unilateral changes in the treatment plan • Rejecting, controlling, stereotyping behaviors • Disengaged or over-involved • Rescue fantasies • Preoccupation, dreams, anxiety • Emotionally depleted- “burnt out” • Hoping that the patient cancels or no shows • Excessive self-disclosure • Need to be idealized

14. What NOT to do • Warn of dire consequences • Impose negative consequences • Take an authoritarian stance • Reject and/or abruptly terminate the patient • Ally with others against the patient • Change treatment plan out of anger or frustration • Act out savior & control fantasies • Act out other countertransference dynamics

15. Integrative Approach • Stages of change • Motivational interviewing • Cognitive-behavioral techniques • Disease model & AA • Adaptive “self medication” model • Psychodynamic, insight-oriented techniques

16. Using Different Strategies at Different Stages 1. Initially, focus on motivational issues and treatment engagement 2. Once the client becomes willing to change, utilize cognitive-behavioral strategies to facilitate transition from active use to stable abstinence 3. As recovery proceeds, incorporate insight-oriented techniques to address broader issues, but always keeping addiction issues in focus

17. Integrative Approach Treatment must address more than the substance abuse itself: • Developmental arrest • Interpersonal problems • Managing feelings • Self-esteem issues • Co-existing Axis I & II disorders • Other addictive/compulsive behaviors

18. Key Points • There is no single best pathway to recovery for everyone • Accept that you are powerless to control another’s drug use; let go of your control fantasies • Maintain an empathic connection; the single most important aspect of treatment is the therapeutic alliance

19. Key Points • Re-conceptualize resistance as ambivalence • Start where the patient is- NOT where you want him/her to be • Listen to your clients. They will tell you what they are ready or not ready to do.

20. Psychodynamic Issues at Different Stages

21. Psychodynamic Issues in the Early Phase • Therapeutic alliance • Warmth, empathy, positive regard • Trust, respect, concern • Unconditional acceptance • Consistency & availability • Counteract internalized self-loathing, shame, guilt • Support self-efficacy, autonomy, reduce dependency fears • Environment of safety: accountability, limits, realistic feedback, boundaries

22. Psychodynamic Issues in the Middle Phase • Ongoing ambivalence about giving up alcohol/drugs • “I’ve stopped using, but I’m still unhappy” • Affect management: “self-medication” • Defining interpersonal, self-esteem, and boundary issues • Shame and guilt issues

23. Psychodynamic issues in later stages • Intimacy with autonomy* • Separation-individuation* • Affect management: “self-medication” • Grief and loss • Early traumas • Residual narcissistic & controlling behaviors

24. Couples Issues • Choosing a mate while actively addicted • Power dynamics: control and dominance • Equality: no longer willing to be discounted • Out of synch: personal responsibility for behavior/problems, having an “observing ego” • Lingering resentments: especially infidelities !! • Jealousy: support system, therapist, group • Will he/she still want me?

25. Will the relationship survive recovery? Good Prognostic Signs • Joined prior to onset of the addiction • Willing to learn about addiction/recovery and use opportunity to enhance his/her own life • Willing to enter couples or individual therapy and Al-Anon to address his/her own unresolved issues

26. Will the relationship survive recovery? Poor Prognostic Signs • Joined while addiction was active • Unrelenting anger, hostility, resentment • Refuses to take any responsibility whatsoever for contributing to the mess • Unable to see the need for personal change: it’s all his/her fault, not mine ! • Unwilling to go for therapy or to Al-Anon

27. Relapse Dreams • Can occur at any stage • Wake up not sure whether they have actually used • Worst fear is that the dream is prophetic • In early stage often due to ambivalence and self-doubt • In middle stage often due to fears about relapse- “Is there something moving me toward relapse??” • In latter stages often stimulated by unresolved issues and/or being overwhelmed with feelings

28. Relapse Dreams • What feelings were stimulated by the dream? • Why did this dream occur at this particular point in time? • What could the dream be telling you about where you need to strengthen your recovery plan? • What issues/problems may have given rise to the dream? • Does the dream signal unresolved or renewed ambivalence about giving up alcohol/drugs?

29. Motivational Interviewingand the Stages of Change

30. Facilitating Change • Motivational Interviewingoffers a way to conceptualize and deal more effectively with problems of patient resistance and poor motivation • Stages of Change Modelprovides a framework for determining the readiness of patients to change their behavior and for matching treatment interventions accordingly

31. Stages of Change • Precontemplation- Not seeing the behavior as a problem or feeling a need to change (“in denial”) • Contemplation- Ambivalent, unsure, wavering about necessity and desirability of change • Preparation- Considering options for change • Action- Taking specific steps to change behavior • Maintenance- Relapse prevention • Relapse- Returning to use or earlier stage of change

32. Stages of Change

33. Stages of Change Model • Facilitates empathy- patients seen as “stuck” in a particular stage of the process rather than “resistant” • Defines ambivalence as normal not pathological • Leads to better patient-treatment matching by defining the types of clinical interventions that work best with patients in each stage of change • Provides “roadmap” and sets the tone for more positive interaction with “resistant” patients

34. Motivational Approach • Start where the patient is • Roll with resistance • Avoid arguments, power struggles • Back off in the face of resistance • Be persuasive not confrontive • Reframe resistance as ambivalence • Offer choices to increase patient acceptance and investment • Negotiate, don’t pontificate • Acknowledge positive drug effects • Adjust interventions to stage of readiness for change

35. Diagnosis

36. Substance USE • Absence of problems/consequences • No apparent or significant risk • No obsession or preoccupation • Under volitional control

37. Substance ABUSE • Use is associated with significant risks or consequences • Exceeds medical/cultural norms • No obsession or preoccupation • Under volitional control

38. SubstanceDEPENDENCE • Continued use despite adverse consequences • Impaired control • Preoccupation/obsession • Exaggerated importance/priority • Tolerance/withdrawal (optional)

39. NIAAA “Low Risk” Drinking MEN No more than 14 drinks per week (2 per day) and no more than 4 drinks per occasion WOMEN No more than 7 drinks per week (1 per day) and no more than 3 drinks per occasion SENIORS- OVER AGE 65 No more than one drink per day

40. One “Standard” Drink • One 12 oz. bottle of beer • One 5 oz. glass of wine • 1.5 oz of distilled spirits

41. “Low Risk” Qualifiers PRESUMES ABSENCE OF: • Pregnancy • Medical or psychiatric conditions likely to be exacerbated by ETOH use • Medication that interacts adversely with ETOH • Prior personal or family history of substance abuse • Hypersensitivity to alcohol

42. “At Risk” Drinking • Frequently exceeds recommended limits • No evidence yet of adverse consequences • Drinking exposes the individual to significant risk • Prime target for preventive efforts

43. “Problem Drinking” ALCOHOL ABUSE • Evidence of recurrent medical, psychiatric, interpersonal, social, or legal consequences related to alcohol use; OR • Being under the influence of alcohol when it is clearly hazardous to do so (e.g., operating a vehicle or other machinery, delivering health care services) • No evidence of physiological dependence • No prior history of alcohol dependence

44. “Alcoholism” ALCOHOL DEPENDENCE BEHAVIORAL syndrome characterized by: • Compulsion to drink • Preoccupation or obsession • Impaired control (amount, frequency, stop/reduce) • Alcohol-related medical, psychosocial, or legal consequences • Evidence of withdrawal- not required • Evidence of tolerance- not required

45. Assessment Techniques

46. Assessment Goals • Assess nature and extent of substance use • Assess nature and extent of substance-related problems and consequences • Assess patient’s stage of readiness for change • Formulate an initial diagnosis • Provide motivation-enhancing feedback based on assessment results

47. Assessment Domains • Typology of use • Positive benefits • Negative consequences • Need for medical detoxification • Other addictive behaviors • Prior attempts to stop or cut down • Prior treatment and self-help experience • Diagnostic signs of substance dependence disorder • Family history of alcohol/drug problems • Stage of readiness for change

48. Typology of Use • Types of substances • Amount/frequency • Administration route (oral, intranasal, pulmonary, i.v., i.m.) • Temporal pattern (continuous, episodic, binge) • Environmental precursors (external “triggers”) • Emotional precursors (internal “triggers”) • Settings and circumstances linked with use (people, places..) • Linkage with use of other substances (e.g., cocaine-alcohol) • Linkage with other compulsive behaviors (sex, gambling, spending, eating, etc)

49. Positive Benefits of Use • What first attracted you to this drug? • How has it helped you? • Does it still work as well? • What would be the potential downside of not using it?

50. Negative Consequences • Medical • Job, Financial • Relationships • Legal • Psychological • Sexual