Psychosocial interventions for ATS use

1. RegionalSeminar on ATS Treatment and Care 18-21 April 2011 Kunming, China Psychosocial interventions for ATS use Dr Nicole Lee Director, LeeJenn Health Consultants & Associate Professor, National Centre for Education and Training on Addiction

2. Psychological features of ATS use • Physical effects are acute and usually resolve quickly with detoxification • High rates of mental health problems associated with ATS use • Significant cravings • High relapse rates • Impulsivity • Low levels of motivation Interventions that specifically address the salient symptoms of ATS use are key

3. Neurological changes • ATS disrupts the dopamine system causing depletion of dopamine stores and transporters (Barr et al., 2006) • Dopamine depletion leads to • Problems with concentration and memory • Difficulty making decisions • Irritability, mood swings, loss of interest in pleasurable activities • Insomnia • Lack of motivation

4. Neurological changes • Neurotransmitters replenished with abstinence but changes may remain for weeks, months or sometimes years • Practitioners understanding that users may need more support to make changes because of these brain changes is important • Helping users understand why they continue to experience these symptoms because of long term brain changes after they stop using is also important

5. Early intervention is important • Transition to dependent use occurs relatively quickly • Transition from regular use to dependence about 2 years (Lee et al, 2008) • 3-4 times a week is likely to be dependent use • Rapid development of tolerance can drive transition to stronger formulations (crystal meth) and alternative routes of administration (injecting or smoking) (Jenner, 2011) • Time to treatment is long – at least 5 years from regular use • Average age of first use is 22yo, average age in treatment is in 30’s • Emphasis on early recognition of adverse effects could prompt users to self-regulate or seek treatment earlier than might otherwise be expected (Looby & Earleywine, 2007)

6. Range of use patterns • Experimental users and occasional users • The majority do not go on to use regularly or become dependent • Regular users • Most of these also do not go on to become dependent but many do • High risk users • Can be using a lot or a little but in a risky way (eg injecting, sharing needles) • Dependent users • Have developed tolerance • Mostly likely require detoxification

7. ATS use and users - summary • Largely using occasionally • But a group of risky, regular or dependent users • High rates of mental health problems • Even at relatively low doses • A potentially quick transition to high risk routes of administration and/or dependent use • But a long time lag to treatment • A lot of psychological symptoms during withdrawal and after but relatively few physical symptoms

8. What is ‘psychosocial’ treatment • Psychosocial treatment addresses both psychological and social factors of drug use • Drug use • Relationships with others and the drug • Lifestyle factors that maintain drug use • The gold standard response to ATS use is outpatient psychosocial treatment • Inpatient treatment is recommended when presentation is complicated by • Polysubstance dependence • Severe mental health or medical complications • Living conditions are not conducive (eg no social support) • Outpatient treatment has failed repeatedly

9. Which psychosocial treatments are effective? • ATS users are very responsive to treatment • Control groups in many studies also do well • A review of the literature shows effective treatments included (Lee & Rawson, 2008; Baker & Lee, 2003): • Cognitive behaviour therapy (CBT) • Contingency management (CM) • Motivational interviewing (MI) • They have in common: • Collaborative • Empowering for the patient • Brief • Focus on the here and now • Focus on highlighting automatic processes

10. Why psychosocial treatment? • Have proven effectiveness and efficacy in ATS • Research shows that psychological treatments added to medication are often better than medication alone • Straightforward to implement and tailor to patient’s needs • Can address the drug use AND mental health issues associated with ATS together • Can address the motivational issues associated with ATS use • There is no robust pharmacotherapy for ATS dependence or withdrawal • Symptomatic relief only

11. Brief intervention is possible • At least initially brief interventions are effective, and sometimes preferable • 2 sessions of motivational interviewing and cognitive behaviour therapy effective in increasing abstinence (Baker et al, 2005) • Even for those who are not very motivated to change • Even for those with significant mental health comorbidities • Interventions of up to 10 or more sessions are available for more motivated patients

12. Range of use patterns ATS users use many different ways

13. Readiness to change ATS users come to treatment at different levels of readiness to address their issues Contingency management Motivational interviewing Brief CBT Intensive CBT

14. Tailoring psychosocial treatments • Intervention needs to be mindful about readiness to engage • Think about readiness to change • Readiness to engage in therapy • Relapse is common, intervention may not be successful the first time • Ongoing attempts at treatment can be successful over time • Importance of a good treatment experience so they are motivated to return • A stepped care approach can help • Offering low level interventions for everyone • Increasing the intensity for those who do not respond or who have special needs

15. What is Motivational Interviewing? ‘Client centered, semi-directive’ Philosophy is strengths base Draw out and harness patients own resources for change MI is based on 4 principles: Express empathy Develop discrepancy Roll with resistance Support self-efficacy Miller and Rollnick

16. What is Motivational Interviewing? Goals of MI Establish rapport Move towards commitment to change Characterised by Open ended questions Reflective listening Therapist de-investment in the outcome No skills training Miller and Rollnick

17. Motivational interviewing • Extensive evidence across a range of health behaviours • Less research compared to the other two types with ATS • Effective with amphetamine, cocaine • Usually researched as part of CBT intervention • Often used at the beginning of CBT therapy to increase engagement in CBT • Similar outcomes, shorter time frame for treatment

18. MI techniques Communicating responsibility for change lies with the user (self efficacy) Communicating free choice (roll with resistance) Offering concern (empathy) Weighing up the good things and less good things (discrepancy) Address the 4 principals

19. Motivational Interviewing Video demonstration

20. Motivational Interviewing • Notice in the video: • The therapist acknowledges the good things about using • The therapist allows the client to come up with the less good things • The therapist offers concern and makes suggestions but allows the client to make the decision about what and how the change happens

21. Training in MI • MI can be especially difficult for therapists used to a more directive or confrontational • Eight levels of learning MI • Overall spirit of MI • OARS: client centredcounselling skills • Recognising a change and sustain talk • Eliciting and strengthening change talk • Rolling with sustain talk and resistance • Developing a change plan • Consolidating commitment • Transition and blending • For all psychological therapies, clinical supervision is important

22. What is Contingency Management • Based on behavioural principles • Offers (usually) rewards for meeting treatment goals • Gifts or money • Prize draws • Extra responsibility (eg takeaway doses, reduced supervision) • Can help reduce impulsivity associated with ATS use • Highly effective • Effects are reduced when contingencies (rewards) are removed

23. CM v MI Similar aims, different methods

24. Training in CM • For contingency management, the most complex piece is applying the principles consistently • Inconsistent application can have the opposite effect to that intended • Requires the whole service to be involved and consistent • The use of a strict protocol may be necessary to maintain integrity of the intervention among clinic or team members

25. What is Cognitive Behaviour Therapy? • ‘Umbrella’ that encompasses a range of intervention types • Cognitive therapy (Beck) • Relapse prevention (Marlatt) • Coping skills therapy (Monti) • Rational emotive behaviour therapy (REBT) (Ellis) • Mindfulness approaches (Marlatt, Williams, Hayes) • Focused on changing ‘faulty thinking’ (cognitive) and developing coping skills (behaviour) • ‘Self help’ teaching clients to be their own therapist • Homework/take home tasks

26. What is Cognitive Behaviour Therapy? • Short term • ‘Intensive’ CBT is usually 6-12 sessions • Brief interventions based on CBT are effective (1-4 sessions) • Can be extended such as for borderline personality disorder – around 1 year intensive treatment • Structured (but not inflexible), collaborative, active and directional • Highly effective and has an extensive research base, including for ATS and adaptations for Asian cultures • A number of programs specifically for ATS use based on CBT • Matrix • Brief intervention

27. Typical CBT for ATS • Psychoeducation • About the effects of ATS • About withdrawal from ATS • About brain changes from using and during withdrawal • About the CBT model and how treatment works • Goal setting • Behavioural strategies • Self monitoring • Coping with craving • Activity scheduling • Coping with a lapse

28. Typical CBT for ATS • Relapse prevention • Refusal skills • Identifying high risk situations or people and ways to avoid them • Developing a relapse prevention plan • Cognitive strategies • Understanding triggers • Link between thoughts, feelings and behaviours • Recognising and challenging unhelpful thinking • Seemingly irrelevant decisions

29. General cognitive behavioural model • Trigger/Situation

30. General cognitive behavioural model • Breakup of relationship

31. Cognitive Behaviour Therapy Brief demonstration

32. CBT • In the video • He explained the model but the client helped fill in the detail (collaboration) • Instructional style but helps link up the key concepts

33. Training in CBT • At a basic level, CBT can be effective even with relatively inexperienced therapists • Can be effective delivered as a protocol • Is more effective if the protocol is tailored to individual case conceptualisation • Training but not necessarily experience is related to better outcomes in cognitive therapy • Especially if therapists use a treatment manual • Supervision is important

34. CBT in Asia • Hodges & Oei (2007) review of compatibility of CBT with Chinese values • Chinese culturally value • Conformity, certainty and discipline • Persistence and a strong work ethic • Authoritarian systems • Achievement orientation • High level of stigma around mental health issues • Tendency to somatise mental health issues (express mental health issues as physical symptoms)

35. CBT in Asia • CBT may suit cultural contexts needing a directive and structured therapy style • CBT can be adapted to a more instructive style • CBT can be offered in a more ‘coaching’ style to reduce stigma of mental health treatment • CBT includes adaptations incorporating Buddhist principles of mindfulness (eg mindfulness relapse prevention) • ‘we are what we think’

36. CBT manuals are available www.meth.org.au

40. Summary • CBT, CM and MI can assist with ATS use by directly addressing key features of use • Impulsivity • Mental health issues • High relapse rates • Reasons for use • All have a strong evidence base for effectiveness • CBT in particular is well suited to, and has been adapted for, some Asian populations of ATS users • Implementation depends on • Staff training/expertise – supervision is also important • Capacity of service to deliver • User and cultural barriers