week 7: Psychosocial forms of treatment for addiction Flashcards
Understand the components of motivational interviewing and its practical application for the treatment of addiction
According to Miller and Rollnick (2013), MI is based on the principles of:
Expressing empathy
Developing discrepancy between current behaviour and personal goals or values
Rolling with resistance and avoiding argument
Supporting self-efficacy for change
Motivational interviewing (MI) is a patient-centred directive approach based on the premise that lack of motivation is not inherent to an individual but is open to change (Britt et al., 2004). The main focus of MI, then, is to facilitate behaviour change by assisting individuals to explore and resolve ambivalence about behaviour change (Britt et al., 2004; Ruiz & Strain, 2014). MI is one of the most influential and widely used BI (Miller & Rollnick, 2013) but is also used as part of assessment and evaluation sessions or in pre-treatment, and applied across a range of health settings (Ruiz & Strain, 2014).
basic skills
- open ended questions
- make affirmations
- Use reflections
- Use summarizing
Precontemplation
People in this stage are not thinking seriously about changing and tend to defend their current AOD use patterns. May not see their use as a problem. The positives or benefits, of the behaviour outweigh any costs or adverse consequences so they are happy to continue using.
Contemplation
People in this stage are able to consider the possibility of quitting or reducing AOD use but feel ambivalent about taking the next step. On the one hand AOD use is enjoyable, exciting and a pleasurable activity. On the other hand, they are starting to experience some adverse consequences (which may include personal, psychological, physical, legal, social or family problems).
Preparation
Have usually made a recent attempt to change using behaviour in the last year. Sees the ‘cons’ of continuing as outweighing the ‘pros’ and they are less ambivalent about taking the next step. They are usually taking some small steps towards changing behaviour. They believe that change is necessary and that the time for change is imminent. Equally, some people at this stage decide not to do anything about their behaviour.
Action
Actively involved in taking steps to change their using behaviour and making great steps towards significant change. Ambivalence is still very likely at this stage. May try several different techniques and are also at greatest risk of relapse.
Maintenance
Able to successfully avoid any temptations to return to using behaviour. Have learned to anticipate and handle temptations to use and are able to employ new ways of coping. Can have a temporary slip, but don’t tend to see this as failure.
Describe Cognitive Behavioural Therapy (CBT) and the skills involved in practice
CBT aims to assist individuals to recognise the situations in which they are most likely to use drugs or alcohol [or gamble], avoid those situations when possible or appropriate, and learn to cope more effectively with a range of problems and problematic behaviours associated with substance use [and gambling behaviour]
Cognitive strategies
Identifying and challenging dysfunctional thoughts
Recognising decisions that lead to relapse
Behavioural strategies
Coping with cravings Cue exposure Promoting non-drug/gambling related activities Contingency management Relaxation training Emotional regulation training Preparing for emergencies Coping with relapses Other strategies
Social skills training
Problem solving skills
Specifically, a large body of evidence exists for the use of CBT to effectively treat problematic alcohol, cannabis, amphetamines, cocaine, heroin, and injecting drug use (NSW Dept Health, 2008). CBT is often considered the most effective substance use treatment and has been found to be as effective as pharmacotherapy.
Few studies have examined the long-term efficacy of CBT for treatment of problem gambling.
Functional analysis
Clinician and client identify thoughts, feelings, and circumstances before and after substance use
Skills training
Initial focus is on basic skills mastery in relation to the control of the addiction.
Training is then broadened to address other problems the client may be facing, e.g., unemployment, relationship difficulties, anger
Training addresses both the intrapersonal (e.g., coping with craving) and interpersonal (e.g., refusing offers of the addictive substance or invitations to gamble)
Training includes teaching specific here-and-now strategies and general strategies that can be applied to variety of other problems
Relapse Prevention (RP) is a cognitive-behavioural approach that involves identifying high risk situations which threaten an individual’s positive behaviour changes and teaching coping skills to assist individuals to manage such situations without reverting to substance use or other addictive behaviours (Ruiz & Strain, 2014) (see Figure 1 below).
Individuals with an addiction are vulnerable to the abstinence violation effect: an overwhelming feeling that a lapse will lead to an uncontrollable return to a relapse, regular drug use or addictive behaviour. RP is focused on developing strategies in skills training, cognitive restructuring and lifestyle balancing necessary to avoid a relapse (Larimer et al., 1999). RP training is delivered in a range of ways, including individual and group treatment, through workbooks, experiential learning (e.g., role plays), and daily diaries/inventories.
Define and describe Brief Intervention tools, including Motivational Enhancement Therapy (MET) and its assessment effects
Brief interventions (BI) are appropriate for non-treatment seeking populations and are delivered on an opportunistic basis. Typically they last 5-30 minutes and can be conducted across a number of sessions. The common elements of BI can be conceptualised by the acronym FRAMES:
Feedback – provision of personal feedback regarding risks of current substance use/behaviour
Responsibility – emphasis is on individual responsibility and choice to change
Advice – provision of clear advice on the importance of change
Menu – a menu of change options are provided to individuals, for example setting limits, coping with stress, pacing one’s drinking/gambling, etc.
Empathy – professional uses a warm reflective communication style
Self-efficacy – instilling optimism that change can be achieved, developing commitment and a plan for change (Bien, Miller & Tonigan, 1993).
BI usually have a basis in motivational interviewing (Haber et al., 2009; Ritter & Cameron, 2006) and generally involve providing feedback, listening to the patient’s responses, providing advice, discussing and setting goals for patients and developing and implementing strategies for behaviour change
Motivational Enhancement Therapy (MET) is an adaptation of motivational interviewing (MI) that includes normative assessment feedback to clients, presented and discussed in a non-confrontational manner. MI is a goal-oriented, client-centred counselling style for facilitating behaviour change by helping clients to resolve ambivalence across a range of problematic behaviours. MET uses an empathic and strategic approach in which the therapist provides feedback that is intended to strengthen and consolidate the client’s commitment to change and promote a sense of self-efficacy.
ET aims to elicit intrinsic motivation to change substance abuse and other behaviours by evoking the client’s own motivation and commitment to change, responding in a way that minimises defensiveness or resistance.
his therapy consists of an initial assessment battery session, followed by two to four individual treatment sessions with a therapist. In the first treatment session, the therapist provides feedback on the initial assessment, stimulating discussion about personal substance use/addictive behaviour and eliciting self-motivational statements. MI principles are used to strengthen motivation and build a plan for change. Coping strategies for high-risk situations are suggested and discussed with the patient. In subsequent sessions, the therapist monitors change, reviews cessation strategies being used, and continues to encourage commitment to change or sustained abstinence. Patients sometimes are encouraged to bring a significant other to sessions.
Define the systems approach to treatment, including family inclusive treatment
systems approach to treatment considers substance use and addiction in the context of the system of relationships, activities and parts that characterises an individual and their addiction. Thus, in treatment, the client and their issues are considered in terms of the pivotal relationships they have. Family members engage in the treatment process and the systemic therapist explores how the different people within the system communicate, what they communicate, and how these relate to the roles and expectations of the various individuals. The length of treatment typically ranges five to 20 sessions (
Behavioural Couples Therapy (BCT) utilises the support of a significant other in the treatment of addiction. This treatment approach assumes that a reciprocal relationship exists between relationship functioning and substance use disorders, whereby substance use can detrimentally impact the relationship, and this relationship distress can subsequently increase substance use. The focus of BCT is on improving a partner’s coping with substance-related situations as well as improving overall relationship functioning (McHugh et al., 2010). Recent meta-analyses have provided support for the use of BCT compared to individually-focused psychological treatment for alcohol use disorders. Compared to other treatment approaches, those in the BCT condition demonstrated reduced frequency of alcohol use, reduced number of negative consequences of alcohol use, and greater relationship satisfaction (McHugh et al., 2010).
The four common group therapy approaches used to treat substance use disorders are recovery-focused, motivation enhancement, relapse prevention and psychodynamic process.
Recovery-focused groups
Recovery-focused groups are based on the disease model of addiction and the 12 step principles of AA. Key aspects of this approach include active involvement in the program and an ongoing commitment to maintain abstinence from all psychoactive substances during and after treatment (Washton, 2014).
Motivation enhancement groups
This approach is based on the stages of change model and aims to engage patients in treatment, enhance motivation and readiness for change and support behaviour change efforts. This approach emphasises working through ambivalence rather than confronting resistance.
Relapse prevention groups
Based on social learning theory, this approach includes a range of cognitive-behavioural, psychoeducational and supportive elements. The focus is on overcoming coping skills deficits, increasing coping abilities, and preventing relapses.
Psychodynamic process groups
The key focus of psychodynamic process groups is to help clients understand how substance use is used to cope with negative affect associated with stressful situations, interrelationship conflict, or intrapersonal issues.
Understand relapse prevention models for addiction.
The twelve steps, as presented by AA are:
We admitted we were powerless over alcohol - that our lives had become unmanageable.
Came to believe that a Power greater than ourselves could restore us to sanity.
Made a decision to turn our will and our lives over to the care of God as we understood Him.
Made a searching and fearless moral inventory of ourselves.
Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
Were entirely ready to have God remove all these defects of character.
Humbly asked Him to remove our shortcomings.
Made a list of all persons we had harmed, and became willing to make amends to them all.
Made direct amends to such people wherever possible, except when to do so would injure them or others.
Continued to take personal inventory and when we were wrong promptly admitted it.
Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.
SMART Recovery Model SMART Recovery (Self-Management and Recovery Training) is a CBT based program for substance use addictions delivered in a self-help group setting. Based on the three principles of self-management, mutual aid, and choice, the SMART Recovery program comprises four components:
Building and maintaining motivation
Coping with urges
Managing thoughts, feelings and behaviours
Living a balanced life.
