Personality and Addictions: Countertransferance in Primary Care

1. Personality and Addictions: Countertransferance in Primary Care Dr. Sharon Cirone MD CCFP(EM) ASAM(Cert.) Focused Practice Addictions Medicine

2. Emily • Your having a busy day at your Family practice, you are seeing Emily, who is now 22 years old, but you have not seen her since she was 12 years. You remember many visits form her mother with concerns about her daughter’s oppositional behavior. • Emily is here for a physical exam, she has come to you because she is now living with her 3 year old son at her parents and she feels her primary care should be with her childhood Family MD rather than the street youth clinic she used to go to. • Emily is on a Methadone Maintenance Treatment (MMT) program. She has a history of street involvement, IV heroin use, and intermittent homelessness between the ages 14- 19. She went onto MMT when she was pregnant. She had a relapse 1 year ago after leaving MMT, but has now returned to care. • She requests if you will be the Family doc for her son too.

3. Julianna • For one year, you have been providing primary care support, through your Family practice, to the local detox in your small town • Today you are seeing Julianna who is 28 years old, she needs a check for STDs, because during intake at the detox she revealed that she had unprotected sex • Julianna is a petite woman, who appears guarded, but speaks forthrightly, immediately stating her distrust of “doctors and their drugs” • The detox told you this is the first time this patient has sought their services for her polysubstance abuse and they would like to engage her in addictions treatment

4. Bill • Bill is a 44 year old long standing patient to you.He requests appointments almost monthly, when you see him, you usually find that he has minor or vague symptom complaints. • You have discussed anxiety symptoms with Bill before, and you have started him on an SSRI, which he reports is somewhat helpful. Although he accepted the pharmacotherapy, he has always avoided answering any questions about his worries or sources of anxiety. He states that his difficulties with people and worrying is why he does not work, has few friends, lives with his mother. • His mother, also your patient, has booked an appointment, for him, with you, for an AHEx. She wants you to talk to him about the health effects of sitting at the computer all day long. • On your systemic review for his AHEx, Bill revealed he drinks alcohol nightly for sleep and to deal with his day. Upon further enquiry using the CAGE Questionnaire, you realize he may have a problematic use of alcohol.

5. Meredith • Meredith is a 44 year old relatively new patient to you. You have done an intake history and noted her cycles of depression. She was told you do some GP Psychotherapy and you agreed, to her request, and the hallway referral from your older colleague, for regular counseling. • You usually book Thursday afternoons for 20 minute therapy sessions. You provide counseling for patients from your own and your colleagues’ practices for mood disorders and situational emotional stressors. • Within your first two sessions with Meredith, you learn that she has had multiple suicide attempts and visits to the Emergency Department when she was younger. She has attended many individual counseling and group therapy programs. She willingly admits that she uses cannabis to self medicate her symptoms of stress and insomnia. As she is relaying this history, your mind wanders from her narrative and you notice her arms have multiple old and healed cuts across the volar surface.

6. Personality and Addictions: The Hijacked Brain • Inherited predispositions • Prenatal exposure to stressors & substances • Early childhood experiences • Mental health stressors, disorders, and treatment • Exposure to exogenous substances: changes to the brain reward circuitry • Neuro-psychologic, physiologic, endocrine, genetic, and structural adaptations

7. Borderline Personality Disorder: A Neurobiologic Perspective • A pervasive disorder of the emotion dysregulation system • Best thought of in terms of tempermental dimensions rather than as a categorical disorder • Emotional dysregulation: anger, passivity, invalidating • Interpersonal dysregulation: unstable relationships • Behavioral dysregulation: impulsivity • Cognitive dysregulation: rigid, dichotomous thinking • Dual brain pathology, affecting the prefronal and limbic circuits

8. Addiction: A Developmental and Neurobiologic Perspective • Initiation of use> dopamine and reward system activation > homeostasis • Chronic use> glutamate activation accompanied by increased salience of drug versus non-drug motivational stimuli and > drug seeking behavior • End-stage addiction> genetic and less reversible adaptations > ongoing use to avoid withdrawal • Pre-existing vulnerabilities for transition from use to addiction: family history & genetic predisposition, prenatal exposure, perinatal hypoxia, learning disorders and ADHD, family environment & stressors, age of first alcohol and drug use, adolescent brain, concurrent disorders & self-medication • Dysregulation of the brain reward system and hypothalamic-pituitary system

9. BPD and Addictions: Similar Dimensions of Behavior • Affective instability • Self-invalidation • Mood issues • Hopelessness • Anger & aggression • “Amorphous suffering” • Damaged interpersonal relatedness • Limited or rigid coping skills • Impulsivity • Para-suicidal & suicidal behavior

10. BPD: Physician Responses • Emotional Responses: manipulated, criticized/mistreated/on guard, frustrated/overwhelmed/disorganized,disengaged/distant, helplessness/inadequacy, hopelessness/sadness, parental/overprotective • Cluster B personality traits associated with negative, distanced feelings toward the patient, Cluster C associated with positive, helpful feelings • Behavioral Responses: take control, invalidation, abandonment, over involvement • Therapeutic Responses: regular appointments with clear boundaries, acceptance and validation, reliable medical care, supportive counseling, referral and follow-up

11. Alcohol and Substance Use Disorders: Physician Responses • Fear and confidence: “black box” • Frustration and time limitations: “Pandora’s box” • Manipulation, anger, fear: drug seeking • Helplessness: compliance and effectiveness • Fear, anger, sadness, and helplessness: family of origin issues • Embarrassment: patient privacy, lack of knowledge, self disclosure

12. Countertransferance in Addicitons: Physician Beliefs • GP and FP negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review. Addiction 2005 • Most did not have negative beliefs and attitudes • Too time consuming • Ineffective • Reported lacking confidence to discuss the issue • Intrusion on patients privacy

13. Addictions: Physician Attitudes and Satisfaction • Satisfaction when caring for substance abusing patients lower than for other illnesses • Professional satisfaction experienced when caring for substance-abusing patients. J. of Gen Int Med 2007 • Perception that providing care to patients with SUD is repetitive and detracts from the care of others • Satisfaction achieved in caring for alcohol and substance abusing patients diminished over the years of training Physician-in-training attitudes toward caring for and working with alcohol and drug abuse diagnoses. Southern Medical Journal 2006 • 20% of GPs said no alcohol misusing patients in their practice, 62% reported not seeing drug misusing patients • Although GPs surveyed had strong negative perceptions and attitudes about alcohol and drug misusing patients, 61% felt the primary care setting was an appropriate place to treat alcohol problems, and only 6% felt the same for drug using patients

14. Overcoming Pessimism About Treatment of Addiction • Negative attitudes of physicians toward the diagnosis and treatment of addiction create barriers to early identification and treatment • “Volitional disability”: initiation of use is a choice, transition to addiction is less about choice and more about neurobiology • Physicians are trained to treat the acute medical conditions resulting from drug dependence, but lack the training to recognize and manage it as a chronic illness • Even brief interventions are effective in decreasing alcohol intake among problem drinkers • Rates of compliance and efficacy of addiction treatment are similar to rates found in other chronic illness such as diabetes, HTN, and asthma

15. Countertransferance: A Pathway for Change • Mindfulness about our attitudes, perceptions, and responses can serve as tools for effective patient care • Countertrasferance: reciprocal cycles of interaction and emotional responses between the patient and the physician • The doctor-patient relationship informs and transforms to become the medicine • Through awareness of our countertransferance, we seek the ability to tolerate and contain our own and the patient’s affective experience to move towards emotional stability, goal directed behaviors of recovery, and neurobiologic rewiring and repair

16. “DBT Lite”: Using Countertransferance in Primary Care • A focus on acceptance and validation of personality disordered traits and behavior combined with the challenge to change behavior • A blended approach of a matter-of-fact, somewhat irreverent attitude and one of warmth, flexibility, and responsiveness • We seek to teach the patient to trust and validate her own emotions and to modulate extreme emotionality and mood-dependent behaviors • Teaching a common sense approach to self-care and self- soothing • Address the behaviors that undermine the doctor-patient relationship

17. Addictions:Therapeutic Responses • Screening and identification • Empathic attunement: authentic and responsive • Therapeutic alliance: the relationship is the healer • Motivational Enhancement: a relational approach to challenge and help the patient to change • Environmental adaptations: a team approach • Tools and resources: feeling prepared • Self awareness and self care • Collegial support: MMAP

18. Alcohol and Substance Use Disorders: Screening • Addressing alcohol and substance use issues in the primary care setting: intake interviews, annual health exams, child developmental visits, every visit • Screening tools: CAGE and CRAFFT questionnaires • Low Risk Drinking Guidelines

19. Motivational Interviewing: Using Countertransferance in Primary Care What is Motivation? • Motivation is a state of readiness to change, not a personality problem • The will power myth • Motivation and change occur along a continuum

20. What is Motivational Interviewing? • “ a directive, client-centered counseling style for eliciting behavior change by helping people to explore and resolve ambivalence” • Working with ambivalence is working with the heart of the problem • Intervention is matched to the readiness to change

21. How Does Change Occur? Precontemplation Contemplation Relapse Preparation Maintenance Action J. Prochaska,C. DiClemente: Six Stages of Change

22. Precontemplation • No intention to change behavior in the foreseeable future • Unaware or underaware of their problem • Families, friends , and coworkers are often aware that the precontemplation has problems • May even demonstrate change, but only as long as the pressure is on • They may wish to change, but not planning to change

23. Contemplation • Ambivalent about change • Both considers change and rejects it • Can stay stuck here for long periods • Open to information and decisional balance considerations

24. Preparation • Prepare to make a specific change • Taking small, tentative steps in getting ready to make change • Intend to take action “soon”

25. Action • Engaging in particular actions intended to bring about change • Making the change

26. Maintenance, Relapse, Recycling • Incorporating the new behavior “over the long haul” • Sustaining the change • Many recycle several times before the change becomes truly established • Slips and relapses are normal

27. Spiral of Change MAINTENANCE relapse action relapse action relapse action precontemplation contemplation preparation

28. Precontemplation Contemplation Preparation Action Maintenance Relapse Raise doubt- increase the patient’s perception of the risks and problems with current behavior Tip the balance- evoke reasons to change, risks of not changing; strengthen the patient’s self efficacy to change Help the patient to determine the best course of action to take in seeking change Help the patient to take steps toward change Help the patient to identify and use strategies to prevent relapse Support the patient through renewal Matching the Task to the Stage of Change

29. Five General Principles • Express Empathy • Develop Discrepancy • Avoid Argumentation • Roll with Resistance • Support Self-Efficacy

30. Brief Motivational Interviewing

31. Ingredients of Brief Counseling • FRAMES • Feedback • Responsibility • Advice • Menu • Empathy • Self Efficacy

32. Motivation as an Interpersonal Interaction • “Motivation for change does not simply reside within the skin of the client, but involves an interpersonal context.” • “Lack of motivation” is a challenge to our skills, not a fault for which to blame our clients

33. The Opening • Raising the issue of Substance Abuse • Avoid labeling, confrontation, and giving advice • Proceed at the client’s own speed • Establish rapport • Use open-ended questions • Find a “way in” • “Tell me, where does your use of cocaine fit into all of this?”

34. Opening Strategies • Ask Open-Ended Questions • Listen Reflectively • Affirm • Summarize • Elicit Self-Motivational Statements

35. Getting Going • Exploring Concerns and Options for Change • Ask about substance use in more detail • Ask about a typical day of use • Ask about lifestyle and stresses • Ask about health, then substance use • Ask about good things, then less good things • Ask about substance use in the past and now

36. Exploring Concerns and Options for Change • Provide information and ask, “What do you think?” • Ask about concerns directly • open-ended questions: “What concerns do you have about your___________?” • Ask about the next step • “It sounds like you have concerns about your use of ________. I wonder what’s the next step?”

37. PRECONTEMPLATION Goal; patient will begin thinking about change “What would have to happen for you to know that this is a problem?” “What warning signs would let you know that this is a problem?” “Have you tried to change in the past?” CONTEMPLATION Goal: patient will examine benefits and barriers to change “Why do you want to change at this time?” “What are your reasons for not changing?” “What would keep you from changing at this time?” “What might help you with that aspect?” “What things have helped in the past to change?” Questions to Evoke Self Motivation

38. READINESS TO CHANGE • On a scale of 1 to 10 where 1 is where you are only willing to hope and pray that things improve and 10 is where you are willing to do anything to change, how ready are you to make changes? • “What would help to move you from a 6 to an 8?” • “What would have to happen to make you more ready?”

39. CONFIDENCE TO CHANGE • Ability to change depends on one’s confidence in one’s ability= “self efficacy” • On a scale of 1 to 10 how confident are you that you will be able to make these changes? • 1=not all confident 10= fully confident • “What would help you to move from a 3 to a 6?”

40. Summarize • Key Questions • ”What would be some of the good things about making a change?” • “What do you think has to change?” • “What are your options?” • “It sounds like things can’t stay the way that they are now, what are you going to do?” • “How would you like for things to turn out for you, ideally?”

41. Ending the Session • A decision to change does not have to be the goal • Any time expressing concerns is time well spent • Summarize the progress of the discussion • Emphasize freedom of choice • Offer willingness to provide further support • Provide information and referrals if appropriate

42. Relapse from Changed Behavior • Support • Encouragement • Focus on the successful parts of the plan • “Relapse is not a failure, it’s an opportunity to learn” • Respect for relapse

43. Addiction Education and Treatment Resources • www.camh.net • www.nida.org • www.Erowid.com • www.dart.on.ca • 12 Step groups (AA,CA,NA) on line