Module 3: Cognitive behavioural treatment of substance abuse Flashcards
Describe the components of cognitive-behavioral treatment of substance abuse [paraphrasing] and indicate how these work and how these could be a applied in the context of a case study [analyzing] Be able to distinguish between the different self-control measures (to prevent use) and emergency measures (to interrupt use), as well as ways to deal with craving! Formulate a functional analysis based on a case study [independent thinking] Name SMART criteria that treatment goals must meet [paraphras
CBT principles
- recognizes problematic situations and triggers or avoiding or learning how to deal with their problematic behaviour
- based on client’s ability to change and appeals to commitment to stop or reduce problematic behaviour through self-perception, improving self-insight and adjusting dysfunctional cognitions and behavioural exercises
How can aversive therapy be used to treat alcohol abuse?
By combining disulfram with alcohol could produce a negative physical reaction
Contingency management
Focusses on positive reinforcement of desired behaviour with direct and small rewards and is based on behavioural contract. Rewards can be withheld if behaviours are not performed. Has been found to be effective but has not been applied systematically.
Motivational interviewing
This can be defined as “a collaborative, goal-oriented conversation style with special attention to change language. It is designed to enhance personal motivation and commitment to a particular goal by eliciting and exploring a person’s reasons for change in an atmosphere of acceptance and compassion”. Individuals are asked about the discrepancy between now and the desired situation and improve competence by identifying main obstacles. So change is being guided here. Change talk and sustain talk is used, and the helper achieves this through asking open questions. After this, the therapist can create a plan of change.
Detoxification
The patient stops using drugs. When medication is used to reduce withdrawal symptoms, prevent seizures and delirium. Opiates can be replaced with methadone or buprenorphine/naloxone and then this can be reduced.
Anti-craving medication
Naltrexone leads to obstruction of the mu-opioid receptor which is indirectly involved with regulating dopamine and reduces the rewarding effect of alcohol. But ineffective for chronic alcoholics, but can be useful in treating gambling. Acamprosate has an inhibitory effect on the glutamatergic system and can reduce craving for alcohol. Nalmefene is fast acting and can be taken preventatively to reduce risk of relapse.
Preservation treatment
Prescribing medication with same chemical properties to addicted drug to reduce withdrawal symptoms and craving. Methadone and buprenorphine/naloxone are the most common.
How does motivation manifest for addicted individuals?
They have different, powerful and conflicting sources of reinforcement as can activate the central reward system, social reinforcement and modelling, physiological dependence and withdrawal resulting in negative reinforcement. Also progressive detachment from other natural sources of positive reinforcement. Can involve behaviours which present harm or risk with sense of compromised personal control.
What were the historical methods used to treat substance abuse?
Addictions were said to be related to pathological personality with immature defense mechanisms like denial, so most treatments were confrontational to overcome this denial
Rationale for motivational interviewing in addiction treatment
- some programmes require readiness for change as a prerequisite
- but, readiness to change is malleable and resistance is due to confrontational counselling style
- clients talk themselves into change
- those with more empathic and client-centred counselling led to better outcomes
- can use coercive interventions but is no longer used
What has research found?
MI is effective in addressing substance use problems, no difference in outcomes of MI with other evidence-based methods compared to MI with less sessions. MI can enhance retention and adherence in other treatments. There can be variation in location and skills and fidelity in practice
How can clients be more engaged?
By providing motivational interviewing on their first visit which already facilitates change, develops a collaborative alliance and increases likelihood of clients coming back
Focusing
There can be differing goals as the goal of the provider may not be shared by the prospective client. The goals can be different when the substance use is not the primary issue and can be related to medical issues. The level of motivation can differ based on the drugs used-> can use this to start on the changes they are willing to make-> harm reduction. Focussing involves the changes that people are willing to make and develop agreed upon goals.
Evoking
Illustrating the client’s own reasons for change, this is usually neglected as the therapist provides own reasons and expects resistance. Can ask more about it, reflect the change, affirm it and summarize. Another way is to ask client to look ahead for the future, if there is defensiveness and justification then a new approach is needed. Delusional balance can be done which is to explore all pros and cons but found to reduce commitment to change and different from MI
Planning
With enough readiness and engagement, planning is the next step. Most professionals take an expert approach which involves being told what to do and many don’t respond well to this, can show resistance. Another approach is to not have enough planning and do not account for possible obstacles, needs to be specific and state their attention. Has black and white thinking as any diversion of the goal is seen as a relapse. Normally progressive: episodes are shorter, less severe, less frequent and remission becomes longer. Planning should take place over time and motivation for change can change.
