It Takes a Village to Resolve an Addiction…And Certain Kinds of Villagers

1. It Takes a Village to Resolve an Addiction…And Certain Kinds of Villagers Barbara S. McCrady Center on Alcoholism, Substance Abuse, and Addictions University of New Mexico Presented at the Addiction Summit “A Climate for Change” Melbourne, Australia 10 July 2008

2. Individuals Live in Complex Social Environments Family of Origin Work Sex Age Race Ethnicity Religion Sexual orientation Family History Genetics Temperament Personality Psychopathology Community Organizations: >Religious >Social >Service Friends Nuclear Family >Spouse >Children

3. Individuals Live in Complex Social Environments Family of Origin Work Sex Age Race Ethnicity Religion Sexual orientation Family History Genetics Temperament Personality Psychopathology Community Organizations: >Religious >Social >Service Friends Nuclear Family >Spouse >Children

4. Purpose of Talk • To briefly review what we know about social support and alcohol/drug use disorders • To discuss selected findings from outside our field that might help us think more broadly about how social support works • To pose some questions • To present some modest propositions

5. Positive Social Support “It takes a village to hold a world.” Photograph courtesy of Diane Walker

6. Harry Harlow’s Monkeys Wire Milk Mother Cloth Mother

7. Social Support and Health “Social bonding and soothing behaviors mitigate the destructive effects of negative environmental events and promote enhanced health and well-being (Berscheid, 2003). Indeed, social isolation is now considered a major health risk (House, Landis, & Umberson, 1988). Moreover, married people tend on average to be happier and healthier than unmarried people (Wood, Rhodes, & Whelan, 1989), and among married individuals, higher marital quality is associated with decreased risk of infection, faster recovery from injury, and a lower rate of mortality following a diagnosis of life-threatening illness.” Coan et al., 2006

8. Alcohol/Drug Use and Positive Social Support

9. Monkeys and Drinking Ethanol consumption (g/kg) Davenport, Maxey, Daunals, & Friedman, 2008

10. Social Support and the Resolution of SUDs • Having more social support is associated with better drinking outcomes • Support from the most important person • Number of supportive persons • Having more nondrinking friends is associated with better outcomes • Both alcohol specific and general support are important

11. Quality of Relationships is Associated with SUD Outcomes • Family adjustment • Family cohesion • Active, recreational orientation • Low conflict • Quality of marriage • Specific marital support

12. When Social Support Goes Awry

13. The Four Horsemen of the Apocalypse • Criticism • Defensiveness • Stonewalling • Contempt

14. When Social Support Goes Awry for Alcohol and Drug Users

15. Negative Family Functioning Proportion Abstinent 100 200 300 Days Since Entering Behavioral Couples Therapy O'Farrell et al. (1998)

16. Negative Social Environmental Predictors of Outcome • Support for drinking predicts negative outcomes • Having more drinking friends is associated with poorer outcomes • Certain partner behaviors predict a negative response to treatment • withdrawing from the drinker • avoiding dealing with drinking • tolerating drinking

17. Social Support and Treatment

18. Social Support and Treatment • Involving a concerned significant other in treatment improves outcomes • For persons who have not sought treatment themselves • For men and women with alcohol or drug use disorders • For teens

19. 70 60 50 40 % engaged in treatment 30 20 10 0 Al-Anon facilitation Unilateral (CRAFT) Johnson Intervention Influencing Problem Recognition and Help-Seeking Unilateral Family Therapies Miller et al., 1999

20. Engaging Families in Treatment - Alcohol Behavioral Couples Therapy • Focus on primary intimate relationship • Based on cognitive-behavioral approaches to: • Alcohol use disorders • Distressed relationships • Three major treatment elements • Teach abstinence skills • Teach partner behaviors to cope with drinking and support change • Improve intimate relationship

21. Treatment Follow-up Percent Days Abstinent * * * * * * * * * * * * Months Alcohol Behavioral Couples Therapy and Abstinence 100 90 80 70 60 ABIT 50 ABCT 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 McCrady, Epstein, Cook, Jensen, & Hildebrandt, 2008

22. 40 35 30 25 ABIT 20 ABCT 15 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Alcohol Behavioral Couples Therapy and Heavy Drinking Percent Days Heavy Drinking Treatment Follow-up * * * * * * * * * * Months McCrady, Epstein, Cook, Jensen, & Hildebrandt, 2008

23. Social Support in Detoxification • A simple meeting with the person in a detoxification program and a concerned other to recommend continuing care resulted in: • 92% entering continuing care vs • 62% who received treatment as usual O’Farrell, Murphy, Alter, & Fals-Stewart, 2008

24. A Pause

25. The first half of the talk: • We have a fundamental drive to connect and be connected • Positive social support plays a powerful role in change in addictions • Social influences also play a powerful role in perturbing the process of change • Treatments that involve significant others lead to better outcomes

26. What’s to come: • Three questions to contemplate: • How does social support actually change a person’s behavior? • How do people elicit or repel social support? • How do people effectively provide social support?

27. How Does Social Support Change a Person?

28. Social Support Affects Brain Function • Responses measured in fMRI when • Husband hand-holding • Research assistant hand-holding • No hand-holding Coan, Schaefer, & Davidson, 2006

29. Social Support Affects Brain Function • The unpleasantness of the threat was lower when anyone held the woman’s hand • Neural activation to the threat was lower when her husband held her hand than when no one held her hand in: • Right dorsolateral prefrontal cortex, left caudate–nucleus accumbens, and superior colliculus • Neural activation to threat was lower when anyone held her hand in: • Ventral anterior cingulate cortex, posterior cingulate, right postcentral gyrus, and left supramarginal gyrus

30. fMRI Results Coan et al., 2006

31. How Does Social Support Change a Person with an Alcohol/Drug Problem? • Does it impact psychological functioning? • Motivation? • Self-efficacy? • Outcome expectancies? • Coping skills? • Affect regulation? • Does it damp down craving responses to alcohol cues? • Does it impact neural function?

32. Social Support Affects Motivation • Unpublished research from McCrady graduate student, Dorian Hunter-Reel: • Used structural equation modeling to test the impact of pretreatment social support on 3-month motivation • Then tested the impact of 3-month motivation on 9-month drinking outcomes in a sample of women with alcohol use disorders • Pretreatment support for drinking was a negative predictor of 3-month motivation • Motivation partially mediated the relationship between support for drinking and 9-month drinking outcomes

33. Social Support Affects Self-Efficacy Abstinence Self- Efficacy .33 (SD = .11) * .21 (SD = .08) * AA Exposure Positive Outcome .30 (SD = .05) Reduced to = .21 (SD = .06) Forcehimes & Tonigan, in press

34. Does Social Support Affect Neurocognitive Function? • A study in progress: • Exposure to alcohol cues for persons with alcohol use disorders in an fMRI • Present these alcohol cues with and without intimate other present and holding the drinker’s hand • Examine changes in brain function in regions associated with reward Ladd, McCrady, Hutchison, & Tonigan, in progress

35. How do People Elicit or Repel Social Support?

36. What does a Person do to Have Good Social Supports? • How does a drinker/drug user find social networks that will support nonproblem alcohol or drug use? • How does a drinker/drug user engage others to provide support? • We don’t have answers to these questions

37. What Does a Person Do that Makes it Hard to Obtain Social Support? • Can a drinker or drug user drive others away through alienating behaviors (other than those associated with the substance use)?

38. Alienating Interpersonal Behaviors • Variable B SE B Beta Adjusted R2 • Change • Step 1: Baseline 0.39 0.08 0.43 0.13** • Percent Drinking Days • Step 2: Tx Condition 5.77 4.76 0.11 0.01 • Step 3: Baseline 1.06 0.36 0.03 0.07** • Alienating Interpersonal • Behaviors • ** p < .01 Hunter Reel, McCrady, & Epstein, 2007

39. What Do Other Persons do to Provide Effective Social Support?

40. Providing Effective Social Support • Having a sponsor is one of the strongest predictors of success in AA • But, we know nothing about effective and ineffective sponsoring • We know that having a supportive family enhances outcomes, but we have not isolated effective family behaviors

41. Implications for Change

42. Some Modest Propositions • We should consider the universality of the need for bonding, attachment, and love in thinking about the change process • Treatment should create an environment of bonding and attachment • Treatment should help individuals learn to elicit support from others • We should help individuals in the social support system learn to delicate balance between “enabling” and effecting change • We should find more ways to bring treatment to people in their existing social environments

43. Some Research Needs • Study the psychological interface between the social environment and the individual – what happens at a psychological level? • Study the brain functions that underpin positive social support to learn to enhance the impact and understand more about how it goes awry • Study people who are particularly effective at eliciting positive social support • Study people who are particularly effective at providing positive social support, even in the face of negative behavior

44. It Takes a Village to Resolve an Addiction…And Certain Kinds of Villagers