Evidence Based Practices: An Overview

Evidence Based Practices: An Overview
Desiree MacPhail-Crevecoeur, Ph.D. Integrated Substance Abuse Programs University of California, Los Angeles

Overview Part One: Addiction as a Chronic Disease
The Addicted Brain A chronic, relapsing disease Part Two: What are Evidence Based Practices? Part Three: Cognitive Behavioral Therapy Part Four: Motivational Interviewing Part Five: Medically Assisted Treatments

Addiction as a Chronic Brain Disease
Part One: Addiction as a Chronic Brain Disease

Addiction = Brain Disease
Addiction is a brain disease that is chronic and relapsing in nature. Instructions Indicate that you will explain the basic workings of the brain and how and where drugs such as methamphetamine work in the brain. Tell participants that you will discuss the "reward pathway“ of the brain and the effects of addictive drugs on that pathway. Explain that the brain is the most complex organ in the body. The brain is made up of a complex network of billions of nerve cells called neurons, as well as other kinds of cells, all protected by the bones of the skull. The typical brain weighs only about 3 pounds, but it is the source of most qualities that make you who you are. Neurons in the brain and spinal cord are part of the nervous system and act as a body’s “Command Central.” Explain that the brain is constantly active, even when we are asleep. As a matter of fact, asleep or awake, the brain requires 20% of the heart’s output of fresh blood and 20% of the blood’s oxygen and glucose to keep functioning properly. Glucose is a type of sugar that is our brain’s primary fuel. Explain that the brain produces enough electrical energy to power a 40-watt light bulb for 24 hours. That’s a lot of energy for a human organ a little bigger than a softball. (Source: NIDA) 4 4

Instructions Explain that certain parts of the brain govern specific functions. Point to areas such as the sensory (blue), motor (orange), and visual cortex (yellow) areas of the brain to highlight their specific functions. Point to the cerebellum (pink), for coordination, and to the hippocampus (green), for memory. Indicate that nerve cells or neurons connect one area to another via pathways to send and integrate information. Explain that the distances that neurons extend can be short or long. Point to the reward pathway (orange). Explain that this pathway is activated when a person receives positive reinforcement for certain behaviours ("rewards"). Indicate that you will explain how this happens when a person takes an addictive drug. As another example, point to the thalamus (magenta). This structure receives information about pain coming from the body (magenta line within the spinal cord), and passes the information up to the cortex. (Source: NIDA) 5 5

How a neuron works Instructions
Describe neurons using the schematic in this slide. The cell body, which contains the nucleus, is the center of activity. Dendrites receive chemical information from other neurons that is converted to electrical signals that travel towards the cell body. When the cell body receives enough electrical signals to excite it, a large electrical impulse is generated and it travels down the axon towards the terminal. In the terminal area, chemicals called neurotransmitters are released from the neuron in response to the arrival of an electrical signal. Indicate that the different regions of the brain are connected by nerve cells or neurons via pathways. These pathways of neurons send and integrate information (electrical and chemical). Tell participants that you will explain this in more detail, using the neurochemical serotonin as an example. (Source: NIDA) 6 6

Instructions Remind participants that the different regions of the brain are connected by nerve cells or neurons via pathways. These pathways of neurons send and integrate information (electrical and chemical). Indicate that these pathways are made up of neurons. Point to the paths connecting the two neurons. Explain that this image contains real neurons from the thalamus. They have been filled with a fluorescent dye and viewed through a microscope. Remind your audience about the anatomy of a neuron; point to the cell body (soma), dendrites and axon (marked with text). At the end of the axon is the terminal, which makes a connection with another neuron. [Note: the axon has been drawn in for clarity, but actually, the axons of these neurons travel to the cerebral cortex] Explain the normal direction of the flow of information (electrical and chemical) or impulse flow. An electrical impulse (the action potential) travels down the axon toward the terminal. Point to the terminal. The terminal makes a connection with the dendrite of a neighboring neuron, where it passes on chemical information. The area of connection is called the synapse. While the synapse between a terminal and a dendrite (shown here) is quite typical, other types of synapses exist as well--for example a synapse can occur between a terminal and a soma or axon. Source: NIDA ( 7 7

The Reward System Natural rewards Food Water Sex Nurturing
Instructions Introduce the concept of reward by explaining that humans, as well as other organisms, engage in behaviours that are rewarding. Pleasurable feelings provide positive reinforcement so that the behaviour is repeated. There are natural rewards as well as artificial rewards, such as drugs. Read the list of natural rewards to the audience. 8 8

How the Reward System Works
Instructions Explain that natural rewards such as food, water, sex, and nurturing allow the organism to feel pleasure when eating, drinking, procreating, and being nurtured. Such pleasurable feelings reinforce the behavior so that it will be repeated. Each of these behaviors is required for the survival of the species. Remind your audience about the pathway in the brain that is responsible for rewarding behaviors as illustrated in more detail in the next slide. 9 9

Instructions Tell participants that this is a view of the brain cut down the middle. An important part of the reward pathway is shown and the major structures are highlighted. Point to the ventral tegmental area (VTA), the nucleus accumbens, and the prefrontal cortex. Explain that the VTA is connected to both the nucleus accumbens and the prefrontal cortex via this pathway and it sends information to these structures via its neurons. The neurons of the VTA contain the neurotransmitter dopamine, which is released in the nucleus accumbens and in the prefrontal cortex (point to each of these structures). Reiterate that this pathway is activated by a rewarding stimulus. Notes The pathway shown here is not the only pathway activated by rewards. Other structures are involved, too, but only this part of the pathway is shown for the sake of simplicity. (Source: NIDA) 10 10

Activating the System with Drugs
Instructions Explain that the discovery of the reward pathway was achieved with the help of animals such as rats. Rats were trained to press a lever for a tiny electrical jolt to certain parts of the brain. Point out that when an electrode is placed in the nucleus accumbens, the rat keeps pressing the lever to receive the small electrical stimulus because it feels pleasurable. This rewarding feeling is also called positive reinforcement. Explain that drugs have the same positive reinforcement effect by activating the reward system artificially (not natural rewards). (Source: NIDA.) 11 11

The Brain After Drug Use (1)
Instructions Explain to your audience that this slide has two brain images of the “reward centres of the brain”: one from a control subject and the other from a methamphetamine-using subject, who is one month abstinent from methamphetamine. Point to the difference in dopamine transporters (this is essentially a measure of dopamine activity) in the images (red means higher amounts, green and blue, lower amounts). Explain that decreased dopamine activity in methamphetamine users is probably why users in early recovery have depressed feelings (anhedonia) and have difficulty concentrating. It is important for recovering users and for clinicians to understand that during the first months of recovery, the brain has not fully recovered and this affects how people think and feel. (Source: NIDA InfoFacts) Control Methamphetamine 12 (Source: McCann et al. (1998). Journal of Neuroscience, 18, ) 12

After Protracted Abstinence
Partial Recovery of Brain Dopamine Transporters in Methamphetamine Abuser After Protracted Abstinence 3 Instructions Explain to your audience that this slide has three brain images of the brain reward system (the yellow-red area): a normal control subject, a methamphetamine user 1 month after detoxification, and a methamphetamine user 24 months after detoxification. Point to the difference in dopamine transporters between the first two brain images (normal control and 1-month post-detoxification; red means higher amounts, green and blue mean lower amounts). Point to the difference in dopamine transporters. Point to the difference in dopamine transporters between the second and third brain images (1-month post-detoxification and 24-months post-detoxification). Explain that decreased dopamine transporters binding in methamphetamine users recovers after months of abstinence. Point at the first and third brain images to show that the normal control brain and the 24-months post-detoxification brain are alike in dopamine transporters in comparison to the 1-month post-detoxification brain. This recovery in dopamine activity is essentially the brain healing from the damage done by methamphetamine. (Source: Volkow, N.D., et al., Journal of Neuroscience, 2001, Vol. 21, pp ) ml/gm Normal Control METH Abuser (1 month detox) METH Abuser (24 months detox) 13

The Brain After Drug Use (2)
Instructions Explain to your audience that this slide has three sets of brain images: the top one from a control subject, the middle one from a cocaine user after 10 days of abstinence, and the bottom one from a cocaine user after 100 days of abstinence. Point to the difference in dopamine transporters between the first two sets of brain images (normal control and cocaine user after 10 days of abstinence; red means higher amounts, green and blue mean lower amounts). Point to the difference in dopamine transporters. Point to the difference in dopamine transporters between the second and third sets of brain images (cocaine user after 10 days of abstinence and cocaine user after 100 days of abstinence). Explain that decreased dopamine transporters binding in cocaine users show some recovery after 3 months of abstinence. Point at the first and third sets of brain images to show that the normal control brain and the brain of a cocaine user who has been abstinent for 100 days are more alike in dopamine transporters in comparison to the cocaine user after 10 days of abstinence, but the 100-day abstinent brain has not yet reached functionality comparable to a non-user. Additional Information for Trainers This PET scan shows us that once addicted to a drug like cocaine, the brain is affected for a long time. In other words, once addicted, the brain is literally changed. Let’s see how... In this slide, the level of brain function is indicated in yellow. The top row shows a normal-functioning brain without drugs. You can see a lot of brain activity. In other words, there is a lot of yellow color. The middle row shows the brain of a person addicted to cocaine after 10 days without any cocaine use at all. What is happening here? [Pause for response.] Less yellow means less normal activity occurring in the brain—even after the cocaine abuser has abstained from the drug for 10 days. The third row shows the same brain after 100 days without any cocaine. We can see a little more yellow, so there is some improvement—more brain activity—at this point. But the brain is still not back to a normal level of functioning more than 3 months later. Scientists are concerned that there may be areas in the brain that never fully recover from drug abuse and addiction. (Photo courtesy of Nora Volkow, Ph.D. Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11: , 1992; Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14: , 1993.) 14 DA = Days Abstinent 14

DRUGS CHANGE THE BRAIN! Drugs Change the Brain
After repeated drug use, “deciding” to use drugs is no longer voluntary because DRUGS CHANGE THE BRAIN! Instructions 1. Read the slide to your audience. 2. Explain that when you first think about trying drugs, it is usually a voluntary decision. “Maybe I should see what it’s like…just this once,” you might think. Or a friend dares you. Or you just want to feel good or forget your troubles. Most drugs of abuse—including nicotine, alcohol, marijuana, cocaine, and heroin—activate a part of the brain called the reward system, and that makes you feel good. But just for a little while. Drug abuse has serious consequences. The most serious consequence is that prolonged drug use changes the brain in fundamental and long-lasting ways. Eventually, it becomes difficult to experience other pleasures. 3. Explain that after repeated drug use, you reach a point when deciding to use drugs is no longer voluntary. Scientists have proof now that drugs literally change your brain. It’s as if a “switch” goes off in the brain. At that point, the drug abuser becomes a person addicted to drugs. 4. Explain that addiction is actually a different state of being—a brain disease. Addiction is a chronic relapsing disease characterized by compulsive, often uncontrollable drug seeking and drug use in the face of negative consequences. 5. Explain that most people addicted to drugs need professional help and treatment to help them cope with these changes and possibly change the brain back to normal. (Source: Adapted from NIDA, 1999.) 15 15

IOM Quality Chasm Recommendations
“Substance use disorder treatment should move toward building its standards of care, performance measurement and quality, information and cost measures upon a chronic illness model rather than the current, acute illness-based, fragmented and deficient system of health care.”

Acute Care Treatment Model
Substance Abusing Patient Treatment Non- Substance Abusing Patient 17

Traditional Service Approach Discontinuous treatment
Severe Symptoms Acute symptoms, Discontinuous treatment Crisis management Remission Time 18 Resource: Tom Kirk, Ph.D. 18 18

NQF Recommendations “Patients treated for Substance Use Disorders (SUD) should be engaged in long-term, ongoing management of their care. Primary medical care providers should support and monitor ongoing recovery in collaboration with the specialty provider who is managing their SUD.”

A Recovery-Oriented Approach
Severe Symptoms Continuous Treatment Response Remission Time 20 Resource: Tom Kirk, Ph.D 20 20

A Continuing Care Model
Substance Abusing Patient Detox Duration Determined by Performance Criteria Rehabilitation Here is a reasonable model of contemporary treatment with three stages. I have made it a point to separate these stages out for several reasons but in particular – because each stage is designed to do something quite different and because, what you as legislators care about – treatment that leads to sustained positive outcomes - is contingent upon effective performance in the earlier stages of care. It is very much like a school model in two ways. First, education is a continuing process and so is treatment. Second, you can’t do well in high school if you have not learned what you need to know and developed the skills you need in elementary and junior high school. This is also true in addiction treatment. Also – please notice that the duration of these stages should NOT be determined by time constraints but rather by performance milestones – meeting the objectives of the early stages of care should qualify you for the next stages. Finally, different parts of the education system focus on different skills and developmental issues – again, this is true in addiction treatment. Let’s discuss these three stages. Duration Determined by Performance Criteria Continuing Care Recovering Patient

Lessons from Chronic Illness
Medications relieve symptoms but…. behavioral change is necessary for sustained benefit Treatment effects usually don’t last very long after treatment stops.

Lessons from Chronic Illness
Patients who are not in some form of treatment or monitoring are at elevated risk for relapse. In addiction this could include monitoring or AA

Summary Drugs affect the brain in ways that are long term but reversible. These brain changes profoundly influence cognition, emotions and behavior. There are multiple forms of treatment that can be effective in treating addicted individuals. Addiction and many psychiatric illnesses are chronic illnesses, and, like other chronic disorders, require continuous ongoing (not episodic) treatment and support.

Evidence Based Practices
Part Two: Evidence Based Practices

What are Evidence Based Practices?
Interventions that show consistent scientific evidence of being related to preferred client outcomes. 26 26

Evidence Based Practices
Standards of Care are Changing It is abundantly clear that not all treatment works, some types show evidence of being more effective than others >1000 clinical trials published in Addiction Cities, states and other funding sources are increasingly demanding the use of EBPs Closer integration of behavior health with healthcare will apply same standards 27 What Defines “Evidence Based Practices” and What Does it Mean to Implement EBT? NIDA Blending Meeting,? November 2006 27

Principles of Effective Treatment
1. No single treatment is appropriate for all 2. Treatment needs to be readily available 3. Effective treatment attends to the multiple needs of the individual 4. Treatment plans must be assessed and modified continually to meet changing needs 5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness 28 - NIDA (1999) Principles of Drug Addiction Treatment 28

6. Counseling and other behavioral therapies are critical components of effective treatment 7. Medications are an important element of treatment for many patients 8. Co-existing disorders should be treated in an integrated way 9. Medical detox is only the first stage of treatment 10. Treatment does not need to be voluntary to be effective 29 - NIDA (1999) Principles of Drug Addiction Treatment 29

11. Possible drug use during treatment must be monitored continuously 12. Treatment programs should assess for HIV/AIDS, Hepatitis B & C, Tuberculosis and other infectious diseases and help clients modify at-risk behaviors 13. Recovery can be a long-term process and frequently requires multiple episodes of treatment 30 - NIDA (1999) Principles of Drug Addiction Treatment 30

Examples of Evidence Based Practices
Contingency management Medically Assisted Treatment Brief intervention Cognitive–behavioral interventions Community reinforcement Behavioral contracting Motivational enhancement therapy 12-step facilitation 31 31

Part 3: Cognitive Behavioral Therapy (CBT) & Relapse Prevention Strategies One Example of an Evidence Based Practice 32 32

What is CBT and how is it used in addiction treatment?
CBT is a form of “talk therapy” that is used to teach, encourage, and support individuals to reduce / stop their harmful drug use. CBT provides skills that are valuable in assisting people in gaining initial abstinence from drugs (or in reducing their drug use). CBT also provides skills to help people sustain abstinence (relapse prevention) Instructions Read the slide to your audience. Explain that the cognitive-behavioural paradigm works under the assumption that substance abuse is a learned maladaptative behaviour rather than caused by an underlying pathology. Under this assumption, therapy for substance abuse takes the form of an educational-learning process in which the clinician becomes a coach and the client has an active learning role throughout the process. The goal is for the individual with an addiction is to re-learn alternative behaviours to substance abuse while the clinician teaches, coaches, and reinforces his or her positive behaviour. Explain that CBT attempts to help clients recognise, avoid, and cope. That is, RECOGNISE the situations in which they are most likely to use drugs, AVOID these situations when appropriate, and COPE more effectively with the range of problems and problematic behaviours associated with substance abuse. 33 33

What is relapse prevention (RP)?
RP is a cognitive-behavioral treatment (CBT) with a focus on the maintenance stage of addictive behaviour change that has two main goals: To prevent the occurrence of initial lapses after a commitment to change has been made and To prevent any lapse that does occur from escalating into a full-blow relapse Because of the common elements of RP and CBT, we will refer to all of the material in this training module as CBT Instructions Read the slide to your audience. Explain that relapse prevention is a cognitive-behavioural treatment that includes a large educational component (Marlatt & Donovan, 2005). Relapse prevention aims to increase the client’s awareness of high-risk situations and increase coping skills, self-efficacy, and control of internal and external variables that may make them more vulnerable to relapse. Relapse prevention (RP) combines cognitive and behavioural techniques such as thought-stopping, coping skills, alternative activities, etc. Additional Information Relapse prevention is a generic term that refers to a wide range of therapeutic techniques to prevent lapses and relapse of addictive behaviours. The term “relapse” was initially employed in the medical context to refer to those people who re-experience a disease stage. Currently, this term is being used for a variety of behaviours including returning to regular substance abuse (Marlatt & Donovan; 2005). People who make behavioural changes (e.g., smoking cessation, increasing regular exercise, etc.) tend to relapse to previous behavioural repertoires over time (Polivy & Herman, 2002). Similarly, it has been demonstrated that few individuals are able to completely succeed in substance abuse abstinence for the long-term on the first attempt (Addy & Ritter, 2000). Sobriety and relapse are both part of an interactive, complex process in the treatment context. Relapse prevention skills can be improved over time in a lapse/relapse learning curve in which increasing practise of coping skills will decrease the probability of relapse. The main goal of RP is maintaining sobriety over time and preventing the occurrence of lapses and their escalation into a full relapse episode. It is difficult to determine whether a lapse may end up in relapse. It ultimately depends on how the client responds to high-risk situations. 34 34

Foundation of CBT: Social Learning Theory
Cognitive behavioral therapy (CBT) Provides critical concepts of addiction and how to not use drugs Emphasizes the development of new skills Involves the mastery of skills through practice Instructions Read the slide to your audience. Explain that under the cognitive-behavioural paradigm, thoughts, feelings, and behaviours are separate areas of human behaviour and cognitive processing that become associated through learning. For instance, alcohol use is a behaviour that might be linked to thoughts, feelings, and even other behaviours by personal experience and observation. When these associations become stronger over time, they may act as triggers without any substances necessarily being present at the time. Provide some examples. For instance, thinking that a cigarette will help me to relax may become a trigger to smoke. Even behaviours may become triggers for drug use. 35 35

Why is CBT useful? (1) CBT is a counseling-teaching approach well-suited to the resource capabilities of most clinical programs CBT has been extensively evaluated in rigorous clinical trials and has solid empirical support CBT is structured, goal-oriented, and focused on the immediate problems faced by substance abusers entering treatment who are struggling to control their use Instructions Read the slide to your audience. Explain that cognitive-behavioural therapy employs learning principles within a highly structured intervention with clearly defined goals that focus on the individual’s current problems. The learning principles are based on classical conditioning and operant conditioning that might occur through observation and direct experience. 36 36

Why is CBT useful? (2) CBT is a flexible, individualized approach that can be adapted to a wide range of clients as well as a variety of settings (inpatient, outpatient) and formats (group, individual) CBT is compatible with a range of other treatments the client may receive, such as pharmacotherapy Instructions Read the slide to your audience. 37 37

Important concepts in CBT (1)
In the early stages of CBT treatment, strategies stress behavioral change. Strategies include: planning time to engage in non-drug related behaviour avoiding or leaving a drug-use situation. Instructions Read the slide to your audience. Explain that in cognitive behavioural therapy the emphasis is not on being strong, but in teaching clients to be wise and make good decisions. 38 38

CBT attempts to help clients: Follow a planned schedule of low-risk activities Recognize drug use (high-risk) situations and avoid these situations Cope more effectively with a range of problems and problematic behaviors associated with using Instructions Read the slide to your audience. 39 39

As CBT treatment continues into later phases of recovery, more emphasis is given to the “cognitive” part of CBT. This includes: Teaching clients knowledge about addiction Teaching clients about conditioning, triggers, and craving Teaching clients cognitive skills (“thought stopping” and “urge surfing”) Focusing on relapse prevention Instructions Read the slide to your audience. 40 40

Foundations of CBT The learning and conditioning principles involved in CBT are: Classical conditioning Operant conditioning Modelling Instructions Read the slide to your audience. 41 41

Classical conditioning: Addiction
Repeated pairings of particular events, emotional states, or cues with substance use can produce craving for that substance Over time, drug or alcohol use is paired with cues such as money, paraphernalia, particular places, people, time of day, emotions Eventually, exposure to cues alone produces drug or alcohol cravings or urges that are often followed by substance abuse Instructions Read the slide to your audience. Explain that classical conditioning is a learning process that has three main components: A conditioned stimulus (CS), unconditioned stimulus (UCS), and a conditioned response (CR). Explain to participants that over time, a repeated stimulus (a bell ringing) paired with another event (the presentation of food) can elicit a reliable response (dog salivation). The same can be said of the addicted person. Certain stimuli or cues, for example, money, boredom, or anxiety, that are associated with use of a drug can, over time, trigger cravings for that drug. 42 42

Classical conditioning: Application to CBT techniques
Understand and identify “triggers” (conditioned cues) Understand how and why “drug craving” occurs Learn strategies to avoid exposure to triggers Cope with craving to reduce / eliminate conditioned craving over time Instructions Read the slide to your audience. Explain that clinicians should then work with clients to develop a comprehensive list of the client’s triggers (conditioned stimuli). Some clients become overwhelmed when asked to identify cues (one person reported that even breathing was associated with their drug use). Again, it may be most helpful to concentrate on identifying the craving and cues that have been most problematic in recent weeks. This list should be started during the session; the practise exercise for this session should include self-monitoring of craving, so clients can begin to identify new, more subtle cues as they arise. (Adapted from Carroll, 2002) 43 43

Operant conditioning: Addiction
Drug use is a behavior that is reinforced by the positive reinforcement that occurs from the pharmacologic properties of the drug. Once a person is addicted, drug use is reinforced by the negative reinforcement of removing or avoiding painful withdrawal symptoms. Instructions Read the slide to your audience. Explain that drug use can also be seen as behaviour that is reinforced by its consequences. Drugs may be used because they change the way a person feels (powerful, energetic, euphoric, stimulated, less depressed), the way they think (I can only get through this if I am high), or the way they behave (less inhibited, more confident) Ask participants for more examples. 44 44

Operant conditions (1) Positive reinforcement strengthens a particular behaviour (e.g., pleasurable effects from the pharmacology of the drug; peer acceptance) Punishment is a negative condition that decreases the occurrence of a particular behavior (e.g., If you sell drugs, you will go to jail. If you take too large a dose of drugs, you can overdose.) Instructions Read the slide to your audience. 2. Ask participants for examples of positive reinforcements that can strengthen a behaviour. 3. Explain that positive reinforcement occurs when a particular behaviour increases in occurrence by the consequence of experiencing or observing a positive condition. For example, if I eat when hungry, the consequence will be to feel satisfied; therefore, I will probably repeat this behaviour again in the future. 45 45

Operant conditions (2) Negative reinforcement occurs when a particular behavior becomes stronger by avoiding or stopping a negative condition (e.g., If you are having unpleasant withdrawal symptoms, you can reduce them by taking drugs.). Instructions Read the slide to your audience. 2. Ask your audience for some other examples. 3. Explain that negative reinforcement occurs when a particular behaviour increases in occurrence by avoiding or stopping a negative consequence. For example, a rat in a cage receives a mild electrical shock on its feet (negative consequence), the rat discovers that pressing a bar stops the shocks; as a consequence, the behaviour of pressing the bar is strengthened. 46 46

Operant conditioning: Application to CBT techniques
Functional Analysis – identify high-risk situations and determine reinforcers Examine long- and short-term consequences of drug use to reinforce resolve to be abstinent Schedule time and receive praise Develop meaningful alternative reinforcers to drug use Instructions Read the slide to your audience. 2. Explain that you will be discussing each one of these techniques in the upcoming slides. 47 47

Modeling: Definition Modeling: To imitate someone or to follow the example of someone. In behavioral psychology terms, modeling is a process in which one person observes the behavior of another person and subsequently copies the behavior. Instructions Read the slide to your audience. 2. Explain that under a cognitive behavioural approach, substance abuse is a learned behaviour that developed through complex interplays of modelled behavior, classical conditioning, or operant conditioning. The same principles can be used to help the client stop substance use (adapted from Carroll, 2002, pp ). 3. Explain that modelling is a technique that will help clients learn new behaviours and coping skills through observing other people’s behaviours. If you employ techniques such as role-playing, observing videos, or observing good models acting in an adaptive way, your client can learn new behaviours. Either in individual or group settings, your conduct (or the model’s conduct) will be observed by the client and, ideally, copied by them. For instance, the client will learn to respond in new way by watching you apply techniques to avoid or deal with high-risk situations (e.g., refusing drugs from a friend). 4. Ask your audience for other examples. 48 48

Basis of substance use disorders: Modeling
When applied to drug addiction, modeling is a major factor in the initiation of drug use. For example, young children experiment with cigarettes almost entirely because they are modeling adult behavior. During adolescence, modeling is often the major element in how peer drug use can promote initiation into drug experimentation. Instructions Read the slide to your audience. 2. Provide examples such as: children learn language by listening to and copying their parents. Adults can learn to ski by watching accomplished skiers. The same may be true for many substance abusers. By seeing their parents use alcohol to cope with their problems, teenagers may learn to do the same. Teenagers often begin smoking after watching their friends use cigarettes. So to may some drug abusers begin to use after watching their friends or family members use drugs or alcohol. 3. Ask participants for other examples of the effects of modelled behaviour. 49 49

Modeling: Application to CBT techniques
Client learns new behaviors through role-plays Drug refusal skills Watching clinician model new strategies Practicing those strategies Observe how I say “NO!” Instructions Read the slide to your audience. 2. Explain that just as CBT assumes that substance use is learned behaviour and that some individuals learn to use through modelling, operant conditioning, or classical conditioning, the same learning concepts can be applied to help clients stop using. For example, modelling is used to help clients learn new behaviours, such as refusing drug offers or how to break off from a drug associate. Thus, the client learns to respond in new unfamiliar ways in high-risk situations by watching the clinician model those behaviours and by practising those strategies in role-plays with the clinician. NO thanks, I do not smoke 50 50

CBT Techniques for Addiction Treatment: Functional Analysis / The 5 Ws
Instructions Tell participants that you will now discuss the first step in cognitive behavioural therapy for addiction: the functional analysis, or 5 Ws. 51 51

The first step in CBT: How does drug use fit into your life?
One of the first tasks in conducting CBT is to learn the details of a client’s drug use. It is not enough to know that they use drugs or a particular type of drug. It is critical to know how the drug use is connected with other aspects of a client’s life. Those details are critical to creating a useful treatment plan. Instructions Read the slide to your audience. 52 52

The 5 Ws (functional analysis)
The 5 Ws of a person’s drug use (also called a functional analysis) When? Where? Why? With / from whom? What happened? Instructions Read the slide to your audience. Additional Information Following the cognitive behavioural model previously presented, it is essential in relapse prevention to identify situations and risk factors that maintain the use of drugs over time. These drug maintaining factors are divided into external and internal variables (McCrady, 2001) that make the use of drugs more likely. The clinician may interview the client to identify external and internal antecedents (A) and consequents (C) of the drug use behaviour (B) in what is called a Functional Analysis or ABC Analysis The maintaining factors are as follows: External antecedents or circumstances surrounding the use of drugs: place or places where the use of drugs usually happened, the day and time in which use usually occurs, direct or indirect peer pressure (individuals that use drugs with the client), paraphernalia, the drug itself (its sight or smell) and events that happen before and after using substances (i.e., having marital problems, etc.). Internal antecedents that might be categorized in three cognitive-behavioural levels: Physiological sensations and feelings: whether the client is aware of them or not, such as withdrawal symptoms, cravings, emotions (rage, sadness, feeling lonely), etc. Cognitions such as thoughts, ideas, positive expectations of the drug effect, planning, etc. Behaviours or client conduct repertoires such as copings skills. Consequences – may include consequences at the individual level such as decreased withdrawal symptoms or cravings, desired drug effects, decrease in negative emotions; or external consequences at a social level such as increased socialization, etc. 53 53

The 5 Ws People addicted to drugs do not use them at random. It is important to know: The time periods when the client uses drugs The places where the client uses and buys drugs The external cues and internal emotional states that can trigger drug craving (why) The people with whom the client uses drugs or the people from whom she or he buys drugs The effects the client receives from the drugs ─ the psychological and physical benefits (what happened) Instructions Read the slide to your audience. Notes You will need to review the form entitled “Functional Analysis” with your audience. 54 54

Questions clinicians can use to learn the 5 Ws
What was going on before you used? How were you feeling before you used? How / where did you obtain and use drugs? With whom did you use drugs? What happened after you used? Where were you when you began to think about using? Instructions Read the slide to your audience. Explain to your audience that the cognitive-behavioural approach assumes that substance abuse can be better treated if clinicians focus on current maintaining factors. The model theorizes that external antecedents of drug use that have been previously conditioned through repeated pairing have an important role in determining subsequent drug use. Cognitions, physiological responses, and emotions mediate the relationship between the external antecedents and the behaviour of using substances and even play a role in determining subsequent use of drugs. In addition to this, the consequences of the use of drugs might be physiological, psychological, or interpersonal in their origin (McCrady, 2001). 55 55

Functional Analysis or High-Risk Situations Record
Antecedent Situation Thoughts Feelings and Sensations Behaviour Consequences Where was I? Who was with me? What was happening? What was I thinking? How was I feeling? What signals did I get from my body? What did I do? What did I use? How much did I use? What paraphernalia did I use? What did other people around me do at the time? What happened after? How did I feel right after? How did other people react to my behaviour? Any other consequences? Instructions Read the slide to your audience. Explain to your audience how to use the “Functional Analysis” form. Notes Use next slide to explain the form to your audience 56

CBT Techniques for Addiction Treatment: Functional Analysis & Triggers and Craving
Instructions Introduce CBT Techniques for Addiction Treatment (Functional Analysis & Triggers and Craving) by reading the title. 57 57

“Triggers” (conditioned cues)
One of the most important purposes of the 5 Ws exercise is to learn about the people, places, things, times, and emotional states that have become associated with drug use for your client. These are referred to as “triggers” (conditioned cues). Instructions Read the slide to your audience. As noted previously, clinicians should then work with clients to develop a comprehensive list of the client’s triggers. Some clients become overwhelmed when asked to identify cues (one client reported that even breathing was associated with cocaine use for him). Again, it may be most helpful to concentrate on identifying the craving and cues that have been most problematic in recent weeks. This list should be started during the session; the practise exercise for this session should include self-monitoring of craving, so clients can begin to identify new, more subtle cues as they arise. (Adapted from Carroll, 2002) 58 58

“Triggers” for drug use
A “trigger” is a “thing” or an event or a time period that has been associated with drug use in the past Triggers can include people, places, things, time periods, emotional states Triggers can stimulate thoughts of drug use and craving for drugs Instructions Read the slide to your audience. Ask your audience to Keep in mind that the general strategy of “recognise, avoid, and cope” is particularly applicable to craving. After identifying the clients’ most problematic cues, clinicians should explore the degree to which some of these can be avoided. This may include breaking ties or reducing contact with individuals who use or supply drugs, getting rid of paraphernalia, staying out of bars or other places where drugs are used, or no longer carrying money. Provide the following example: “You’ve said that having money in your pocket is the toughest trigger for you right now. Let’s spend some time thinking through ways that you might not have to be exposed to money as much. What do you think would work? Is there an amount of money you can carry with you that feels safe? You talked about giving your check to your mother earlier; do you think this would work? You’ve said that she’s very angry about your drug use in the past; do you think she’d agree to do this? How would you negotiate her keeping your money for you? How could you arrange with her to get money you needed for living expenses? How long would this arrangement go on?” 4. Explain that clinicians should spend considerable time exploring the relationship between alcohol and drugs with clients who use them together to such an extent that alcohol becomes a powerful drug cue. Specific strategies to reduce, or preferably, stop alcohol use should be explored. 5. Explain to your audience that common triggers include being around people with whom one used drugs, having money or getting paid, drinking alcohol, social situations, and certain affective states, such as anxiety, depression, or joy. Triggers for drug craving also are highly idiosyncratic, thus identification of cues should take place in an ongoing way throughout treatment (Carroll, 2002). 59 59

External triggers People: drug dealers, drug-using friends
Places: bars, parties, drug user’s house, parts of town where drugs are used Things: drugs, drug paraphernalia, money, alcohol, movies with drug use Time periods: paydays, holidays, periods of idle time, after work, periods of stress Instructions Read the slide to your audience. Ask participants to provide more examples of external triggers. 60 60

Internal triggers Anxiety Anger Frustration Sexual arousal Excitement
Boredom Fatigue Happiness Hunger Instructions Read the slide to your audience. Ask participants to provide more examples of internal triggers. 61 61

Triggers & Cravings Trigger Thought Craving Use Instructions
Read the slide to your audience. Explain to your audience how a trigger can initiate some thoughts about using drugs which leads the client to have cravings and finally to use the substance. Tell your audience that you will review this sequence in the following slides. 62 62

The Clinician’s Role To teach the client and coach her or him towards learning new skills for behavioral change and self-control. Instructions Read the slide to your audience. 2. Explain that the role of the clinician is to teach and coach the client towards learning new skills for behavioural change and self-control. The client ultimately should learn to be his or her own coach in the behavioural change process to achieve abstinence or reduction of drug use (Addy & Ritter, 2000) 3. Explain that the role of the clinician is also to teach the client how to avoid feelings of shame when recurrence or relapse occurs and to encourage him/her to keep seeking help and keep attending the treatment sessions. 63 63

The role of the clinician in CBT
CBT is a very active form of counseling. A good CBT clinician is a teacher, a coach, a “guide” to recovery, a source of reinforcement and support, and a source of corrective information. Effective CBT requires an empathetic clinician who can truly understand the difficult challenges of addiction recovery. Instructions Read the slide to your audience. 2. Explain that the CBT process revolves primarily around the relationship between the counsellor and the client. It is this relationship that leads to growth and change. The counsellor works “with” the client, and a sense of partnership and collaboration prevails. In essence, the counsellor functions as an ally or guide who helps the client change himself or herself, rather than as an expert who “fixes” all the client’s problems (Ranganathan, Jayaraman & Thirumagal) 3. Explain to your audience that the CBT primary goal is to initiate abstinence or reduction in substance use and prevent relapse by addressing potential precipitants of relapse and high-risk factors and teaching the individual coping mechanisms and the necessary skills to effectively exercise control. The secondary goal is to help the client recover from the damage addiction has caused in his life. The client is encouraged to achieve and maintain abstinence and then to develop the necessary psychosocial skills to continue recovery as a lifelong process. 64 64

The role of the clinician in CBT
The clinician is one of the most important sources of positive reinforcement for the client during treatment. It is essential for the clinician to maintain a non-judgemental and non-critical stance. Motivational interviewing skills are extremely valuable in the delivery of CBT. Instructions Read the slide to your audience. 65 65

Match material to client’s needs
CBT is highly individualized Match the content, examples, and assignments to the specific needs of the client Pace delivery of material to insure that clients understand concepts and are not bored with excessive discussion Use specific examples provided by client to illustrate concepts Instructions Read the slide to your audience. Explain the importance of adapting the materials to the client’s needs and that CBT is highly individualized. The clinician should carefully match the content, timing, and nature of presentation of the material to the client. Do not belabour topics or rush through material in an attempt to cover all of it in a few weeks. The pace is determined by the client’s needs. Some clients may need several weeks to truly master a basic skill while others may need only a few sessions. It is more effective to slow down and work at a pace that is comfortable and productive for your client than to risk the therapeutic alliance by using a pace that is too fast. (Source: Carroll, 2002.) 66 66

Repetition Habits around drug use are deeply ingrained
Learning new approaches to old situations may take several attempts Chronic drug use affects cognitive abilities, and clients’ memories are frequently poor Basic concepts should be repeated in treatment (e.g., client’s “triggers”) Repetition of whole sessions, or parts of sessions, may be needed Instructions Read the slide to your audience. Explain that learning new skills and effective skill-building requires time and practise. Drug users have very defined routines around acquiring, preparing, using the drug, and recovering from it. It is important for the clinician to recognise how difficult it is for them to change these patterns especially when they encounter the withdrawal symptoms. In addition to this, clients usually seek help after long periods of chronic use. Drugs may affect their attention, memory, and other cognitive skills and make it difficult for them to understand, memorize, and use new skills to cope with their drug dependence. Therefore repetition of sessions or parts of sessions may be necessary for clients that do not easily understand the concepts or the rationale of the treatment. Therefore, the clinician should feel free to repeat the sessions as many times as needed. It is important to recognise how uncomfortable it is to learn new habits and new approaches. Moreover most clients come to treatment after a long period of use and chronic use affects cognitive abilities. (Source: Carroll, 2002.) 67 67

Practice Mastering a new skill requires time and practice. The learning process often requires making mistakes, learning from mistakes, and trying again and again. It is critical that clients have the opportunity to try out new approaches. Instructions Read the slide to your audience. Explain that in cognitive behavioural therapy, practising is a central component since it is an important part of the learning process. Mastering a new skill requires time and practise. The learning process often requires making mistakes and trying again over and over until the skills are mastered. In CBT, practise of new skills is a central, essential component of treatment. The degree to which the treatment is skills training over merely skills exposure has to do with the amount of practise. It is critical that clients have the opportunity to try out new skills within the supportive context of treatment. Through firsthand experience, clients can learn what new approaches work or do not work for them, where they have difficulty or problems, and so on. CBT offers many opportunities for practise, both within sessions and outside of them. Each session includes opportunities for clients to rehearse and review ideas, raise concerns, and get feedback from the clinician. Practise exercises are suggested for each session; these are basically homework assignments that provide a structured way of helping clients test unfamiliar behaviours or try familiar behaviours in new situations. However, practise is only useful if the client sees its value and actually tries the exercise. Compliance with extra-session assignments is a problem for many clients. Several strategies are helpful in encouraging clients to do homework. 68 68

Give a clear rationale Clinicians should not expect a client to practice a skill or do a homework assignment without understanding why it might be helpful. Clinicians should constantly stress the importance of clients practicing what they learn outside of the counseling session and explain the reasons for it. Instructions Read the slide to your audience. Explain that giving a clear rationale of the homework or other assignments is critical. Many people do not practise their homework or drop out because they do not understand the importance of the suggested assignments and practising them. It is critical that clients know the reasons why you are making a specific recommendation or assignment. Clinicians should not expect a client to practise a skill or do a homework assignment without understanding why it might be helpful. Thus, as part of the first session, clinicians should stress the importance of extra-session practise. 69 69

Communicate clearly in simple terms
Use language that is compatible with the client’s level of understanding and sophistication Check frequently with clients to be sure they understand a concept and that the material feels relevant to them Instructions Read the slide to your audience. Explain that clinicians should be careful to use language that is compatible with the client’s level of understanding and sophistication. Clinicians should check frequently with clients to be sure they understand a concept and that the material feels relevant to them. Reading your client’s signs is also important, for example lack of eye contact, overly brief responses, or failure to come up with examples or homework. These signals may indicate that your client does not understand or is not well suited to the materials that you presented. 70 70

Monitoring Monitoring: to follow-up by obtaining information on the client’s attempts to practice the assignments and checking on task completion. It also entails discussing the client’s experience with the tasks so that problems can be addressed in session. Instructions Read the slide to your audience. Explain that following up on assignments is critical to improving compliance and enhancing the effectiveness of these tasks. Checking on task completion underscores the importance of practising coping skills outside of sessions. It also provides an opportunity to discuss the client’s experience with the tasks so that problems can be addressed in treatment. Explain that in general, clients who do homework tend to have clinicians who value homework, spend a lot of time talking about homework, and expect their clients to actually do the homework. The early part of each session must include at least 5 minutes for reviewing the practise exercise in detail; it should not be limited to asking clients whether they did it. If clients expect the clinician to ask about the practise exercise, they are more likely to attempt it than are clients whose clinician does not follow through. Explain that if any other task is discussed during a session (e.g., implementation of a specific plan to avoid a potential high-risk situation) clinicians need to be sure to bring it up in the following session. For example, “Were you able to talk to your brother about not coming over after he gets high?” 71 71

Praise approximations
Clinicians should try to shape the client’s behavior by praising even small attempts at working on assignments, highlighting anything that was helpful or interesting. Instructions Read the slide to your audience. Explain that just as most clients do not immediately become fully abstinent upon treatment entry, many are not fully compliant with practise exercises. Clinicians should try to shape the client’s behaviour by praising even small attempts at working on assignments, highlighting anything they reveal was helpful or interesting in carrying out the assignment, reiterating the importance of practise, and developing a plan for completion of the next session’s homework assignment. 72 72

Example of praising approximations
I did not work on my assignments…sorry. Well Anna, you could not finish your assignments but you came for a second session. That is a great decision, Anna. I am very proud of your decision! That was a great choice! Instructions Use the slide as an example of a clinician praising approximations. Ask another person from the audience to read out loud Anna’s words on the slide. Read the words of the clinician or ask a participant to play that role. Oh, thanks! Yes, you are right. I will do my best to get all assignments done by next week. 73 73

Nothing is more motivating than being
Develop a plan A specific daily schedule: Enhances your client's self-efficacy Provides an opportunity to consider potential obstacles Helps in considering the likely outcomes of each change strategy Nothing is more motivating than being well prepared! Instructions Read the slide to your audience. Explain that a solid plan for change enhances your client's self-efficacy and provides an opportunity for them to consider potential obstacles and the likely outcomes of each change strategy. Furthermore, nothing is more motivating than being well prepared—no matter what the situation, a well-prepared person is usually eager to get started. A sound plan for change can be negotiated with your client by the following means: Offering a menu of change options Developing a behaviour contract Reducing or eliminating barriers to action Enlisting social support Educating your client about treatment Initiating the plan on a specific date Preparing relatives and friends to move into action Notes: See Module 1 for additional information (Source: SAMHSA TIP 35, 1999.) 74 74

Stay on schedule, stay sober
Encourage the client to stay on the schedule as the road map for staying drug-free. Staying on schedule = Staying sober Ignoring the schedule = Using drugs Instructions Read the slide to your audience. 75 75

Develop a plan: Dealing with resistance to scheduling
Clients might resist scheduling (“I’m not a scheduled person” or “In our culture, we don’t plan our time”). Use modeling to teach the skill. Reinforce attempts to follow a schedule, recognizing perfection is not the goal. Over time, let the client take over responsibility for the schedule. Instructions Read the slide to your audience. 76 76

Part Four: Motivational Interviewing
A second Example of an Evidence Based Practice

Definition of Motivation
The probability that a person will enter into, continue, and comply with change-directed behavior 78 78

Motivational Interviewing
Many people who engage in harmful substance use do not fully recognize that they have a problem or that their other life problems are related to their use of drugs and/or alcohol. 79 79

It seems surprising that… people don’t simply stop using drugs, considering that drug addiction creates so many problems for them and their families. Instructions You might invite participants to share their opinions (either verbally or anonymously on paper) on why people keep using drugs despite the harmful effects on their lives and the lives of their family members. Drug or alcohol dependence is like many other chronic relapsing conditions – diabetes, heart disease, high blood pressure. Talk about the difficulty people have adhering to treatment regimen’s for these conditions and then draw a parallel to trying to stop the use of drugs and alcohol. 80 80

People who engage in harmful drug or alcohol use often say they want to stop using, but they simply don’t know how, are unable to, or are not fully ready to stop. 81 81

Understanding How People Change: Models
Instructions Introduce this section by explaining that you will review two theories on understanding how people change their drug use: the traditional approach and the motivating-for-change approach. Traditional approach Motivating for change 82

The Traditional Approach
The Stick Change is motivated by discomfort. If you can make people feel bad enough, they will change. People have to “hit bottom” to be ready for change Corollary: People don’t change if they haven’t suffered enough Notes (Sources: Slide adapted by Jeanne Obert, 2006, from Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. New York: Guilford Press.) 83 83

You better! Or else! Instructions You might want to ask participants if they agree with the following statement: “Do you think that if the punishment for using drugs is big enough, people will stop using?” You may want to limit a group discussion on this topic to about 5-10 minutes. Also, give examples of treatment or corrections systems in your area that are designed to use “the stick” to change behaviour. Note: The “stick” method does sometimes work. We are presenting an alternative way of thinking – not the “right” way. (Sources: Slide adapted by Jeanne Obert, 2006, from Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. New York: Guilford Press.) If the stick is big enough, there is no need for a carrot. 84 84

Someone who continues to use is “in denial.” The best way to “break through” the denial is direct confrontation. Notes The traditional approach supports the idea that someone who continues to use drugs is in denial and so there is a need for direct confrontation in therapy. (Sources: Slide adapted by Jeanne Obert, 2006, from Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. New York: Guilford Press.) 85 85

Another Approach: Motivating
Motivation for change can be fostered by an accepting, empowering, and safe atmosphere People are ambivalent about change People continue their drug use because of their ambivalence Notes The motivational approach is based on the following assumptions about the nature of motivation: Motivation is a key to change. Motivation is multidimensional since it encompasses the internal urges and desires felt by the client, external pressures and goals, thoughts, perceptions of risks and benefits, etc. Motivation is dynamic and fluctuating. Motivation is influenced by social interactions. Motivation can be modified and improved. Motivation is influenced by the clinician's style (e.g., establishing a helping alliance with the client that leads to better outcomes vs. confronting the client, which can increase resistance to change). So the clinician's task is to elicit and enhance motivation within the client, not to confront or punish him or her. (Sources: Slide adapted by Jeanne Obert, 2006, from Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. New York: Guilford Press. Trainer’s notes adapted from DHHS/SAMHSA-TIP 35, 1999) Instructions Ask the audience: What are some of the ways that you make people feel motivated? (Sources: Slide adapted by Jeanne Obert, 2006, from Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. New York: Guilford Press.) The carrot 86 86

Ambivalence 87

Ambivalence Ambivalence: Feeling two ways about something.
All change contains an element of ambivalence. Resolving ambivalence in the direction of change is a key element of motivational interviewing Instructions Explain what “ambivalence” is to your audience. Ask them to provide examples. 88 88

Why don’t people change?
89

You Would Think… that hangovers, damaged relationships, an auto crash, memory blackouts ─ or even being pregnant ─ would be enough to convince a woman to stop drinking. Notes (Sources: Slide adapted by Jeanne Obert, 2006, from Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. New York: Guilford Press.) 90 90

You Would Think… that experiencing the dehumanizing
privations of prison would dissuade people from re-offending. Notes (Sources: Slide adapted by Jeanne Obert, 2006, from Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. New York: Guilford Press.) 91 91

Yet… Harmful drug and alcohol use persist despite overwhelming evidence of their destructiveness. Notes (Sources: Slide adapted by Jeanne Obert, 2006, from Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. New York: Guilford Press.) 92 92

What is the Problem? It is NOT that… They don’t want to see (denial)
They don’t care (no motivation) They are just in the early stages of change. 93 93

Why DO people change?

The Concept of Motivation
“Motivation can be defined as the probability that a person will enter into, continue, and adhere to a specific change strategy” (Council of Philosophical Studies, 1981) Motivation is a key to change Motivation is multidimensional Motivation is dynamic and fluctuating 95 95

The Concept of Motivation
Motivation is influenced by the clinician’s style Motivation can be modified The clinician’s task is to elicit and enhance motivation “Lack of motivation” is a challenge for the clinician’s therapeutic skills, not a fault for which to blame our clients 96 96

General Motivation Strategies
giving ADVICE removing BARRIERS providing CHOICE decreasing DESIRABILITY practicing EMPATHY providing FEEDBACK clarifying GOALS active HELPING Notes (Source: Miller, W. & Rollnick, S. (1991). Motivational Interviewing: Preparing people to change addictive behaviour. New York: the Guildford Press) 97 97

The Concept of Ambivalence
Ambivalence is normal Clients usually enter treatment with fluctuating and conflicting motivations Clients “want to change and don’t want to change” “working with ambivalence is working with the heart of the problem” 98 98

Where Do I Start? What you do depends on where the client is in the process of changing The first step is to be able to identify where the client is coming from 99 99

Prochaska & DiClemente
Stages of Change Precontem- plation Contemplation Preparation Action Maintenance Recurrence 100 100 Prochaska & DiClemente

Precontemplation Stage
People at this stage: Are unaware of any problems related to their drug use Are unconcerned about their drug use Ignore anyone else’s belief that they are doing something harmful Primary task– Raising Awareness 101 101

Contemplation Stage In this stage the patient sees the possibility of change but is ambivalent and uncertain They enjoy using drugs, but: Worried about the increasing problems of their use. Debating with themselves whether or not they have a problem. Primary task: Resolving ambivalence and helping the client choose to make the change 102 102

Determination Stage In this stage the patient is committed to changing but is still considering exactly what to do and how to do it Primary task: Help client identify appropriate change strategies 103 103

Action Stage In this stage the patient is taking steps toward change but hasn’t stabilized in the process Primary task: Help implement the change strategies and learn to limit or eliminate potential relapses 104 104

Maintenance Stage Definition
A stage in which the patient has achieved the primary tx goals and is working to maintain them Primary task Patient needs to develop new skills for maintaining recovery 105 105

Relapse People at this stage have reinitiated the identified behaviour. People usually make several attempts to quit before being successful. The process of changing is rarely the same in subsequent attempts. Each attempt incorporates new information gained from the previous attempts. Notes Relapse Many people who have successfully changed their behaviour may, for a number of reasons, resume their drug use or return to old patterns of behaviour. Relapsing is part of the changing process! Most people do not permanently change their addictive behaviour the first time they try. Generally, more people are successful the 2nd or 3rd time rather than the first. (Source: Adapted from Addy, Ritter, Lang, Swang & Engelander, 2000) 106 106

Relapse Someone who has relapsed is NOT a failure!
Relapse is part of the recovery process. Instructions Emphasise that relapsing does not mean failure. Relapse is part of the recovery process and it should be taken as an opportunity to learn. Talking individually to a person who has relapsed is important. Discussing what happened so that it won’t reoccur is important. Explain the Stages of Change to the person and emphasise that “failure” is when a person drops out of the process. 107 107

Helping People Change Helping people change involves increasing their awareness of their need to change and helping them to start moving through the stages of change. Start “where the client is” Positive approaches are more effective than confrontation – particularly in an outpatient setting. Instructions Remind participants that Motivational Interviewing is just one of many approaches to helping people change. The trainer is not implying that other approaches (i.e., confrontational) are wrong or should never be used. Clarify the concept that you are presenting one more tool to be available in the clinician’s arsenal of approaches to use when circumstances indicate. In order to have the tool available, it is necessary to become proficient in its use. 108 108

“People are better persuaded by the reasons they themselves discovered than those that come into the minds of others” Blaise Pascal 109

Motivational Interviewing (MI)
“MI is a directive, client-centered method for enhancing intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002) “MI is a way of being with a client, not just a set of techniques for doing counseling” (Miller and Rollnick, 1991) 110 110

Strategy Goals Resolve ambivalence Avoid eliciting or strengthening resistance Elicit “Change Talk” from the client Enhance motivation and commitment for change Help the client go through the Stages of Change 111 111

The Style Nonjudgmental and collaborative based on client and clinician partnership gently persuasive more supportive than argumentative listens rather than tells communicates respect for and acceptance for clients and their feelings 112 112

The Style (Continued) Explores client’s perceptions without labeling or correcting them No teaching, modeling, skill-training Resistance is seen as an interpersonal behavior pattern influenced by the clinician’s behavior Resistance is met with reflection 113 113

Important Considerations The clinician’s counseling style is one of the most important aspects of motivational interviewing: - Use reflective listening and empathy - Avoid confrontation - Work as a team against “the problem” Notes The success of motivational interviewing is subject to the client’s awareness of the personal consequences of their own drug use patterns. The intervention should elicit from clients their concerns about drug use and arguments for change. The clinician should focus on the attitudes and values of the client, assist the client to make their own decisions, and attempt to direct their motivation towards positive behaviour change. (Source: Adapted from Addy and Ritter, 2000) 114 114

Motivational Interviewing Determination/ Preparation
Motivating for change Maintenance Action Determination/ Preparation Notes The clinician’s counselling style is one of the most important aspects of effective motivational interviewing, and can be a powerful determinant of client resistance and change. Based on the assumption that ambivalence is normal and acceptance facilitates change, the counsellor should use reflective listening to express empathy. In motivational interviewing, a client should never feel they are being confronted by the clinician. Rather, they should feel like a collaborative effort is being made against “the problem.” (Source: Adapted from Addy & Ritter, 2000) Contemplation Pre-contemplation 115 115

Principles of Motivational Interviewing
Motivational interviewing is founded on 4 basic principles: Express empathy Develop discrepancy Roll with resistance Support self-efficacy 116 116

Principle 1: Express Empathy The crucial attitude is one of acceptance Skilful reflective listening is fundamental to the client feeling understood and cared about Client ambivalence is normal; the clinician should demonstrate an understanding of the client’s perspective Labeling is unnecessary Notes Acceptance is not the same as agreement or approval. An attitude of acceptance should not prohibit the clinician from differing with the client’s views. It is important for the clinician to respectfully listen to the client, with a desire to understand their perspective. Reflective listening is the key to demonstrating that the listener is intent on thoroughly understanding what the client is attempting to communicate. In being non-judgemental and fully present, clinicians build a working therapeutic alliance with the client and support the client’s self-esteem – an important condition for change. (Source: Miller & Rollnick, 1991). 117 117

Examples of Expressing Empathy
I am so tired, but I cannot even sleep… So I drink some wine. You drink wine to help you sleep. …When I wake up…it is too late already… Yesterday my boss fired me. So you’re concerned about not having a job. Instructions You might ask somebody from the audience to read out loud Anna’s words (white bubbles) on the slide. You might want to read the words of the clinician (blue bubbles) or ask a participant to play that role as well. Use the slide as an example of expressing empathy through reflective listening. ...but I do not have a drinking problem! 118 118

Principle 2: Develop Discrepancy Clarify important goals for the client Explore the consequences or potential consequences of the client’s current behaviors Create and amplify in the client’s mind a discrepancy between their current behavior and their life goals Notes Motivational interviewing gives the clinician the potential to help the client see the discrepancy between their drug use and their goals, without the client feeling pressured or coerced. When done successfully, this results in the client presenting the reasons for change, rather than the counsellor doing so. It is important to get the client to tell you that they need to change. People are more persuaded by what they hear themselves say than by what other people tell them. When motivational interviewing is done well, it is not the clinician but the client who explicitly states the concerns and intentions to change. (Source: Miller & Rollnick, 1991). 119 119

Example of Discrepancy
I enjoy having some drinks with my friends…that’s all. Drinking helps me relax and have fun…I think that I deserve that for a change… So drinking has some good things for you…now tell me about the not-so-good things you have experienced because of drinking. Instructions Ask somebody (different from the previous person) in the audience to read Anna’s role from the slide (white bubbles). You may want to play the role of the clinician (blue bubble) or ask a participant to play that role. Ask the audience how Anna has changed the way that she refers to her drinking. Well…as I said, I lost my job because of my drinking problem…and I often feel sick. 120 120

Principle 3: Roll with Resistance Avoid arguing against resistance If it arises, stop and find another way to proceed Avoid confrontation Shift perceptions Invite, but do not impose, new perspectives Value the client as a resource for finding solutions to problems Notes: How the clinician avoids, or deals with, resistance is one of the defining characteristics of motivational interviewing. Resistance is a two-way street. It cannot exist without the participation of both the clinician and the client. Denial is not inherent in clients but arises from the interaction with the clinician. It can be elicited or strengthened by a confrontational interviewing style. 121 121

Example of NOT Rolling with Resistance
I do not want to stop drinking…as I said, I do not have a drinking problem…I want to drink when I feel like it. But, Anna, I think it is clear that drinking has caused you problems. Instructions 1. Ask somebody (different from the previous person) from the audience to play Anna’s role (white bubbles). You may want to play the role of the clinician (blue bubble) or ask a participant to play that role. Use the slide as a sample of not rolling with resistance. 2. Ask participants to pay attention to the result of the clinician’s comment. You do not have the right to judge me. You don’t understand me. 122 122

Example of Rolling with Resistance
I do not want to stop drinking…as I said, I do not have a drinking problem…I want to drink when I feel like it. You do have a drinking problem Instructions Ask somebody (different from the previous person) from the audience to play Anna’s role (white bubbles). You may want to play the role of the clinician (blue bubble) or ask someone to play that role. Use the slide as a sample of rolling with resistance. Ask the audience to pay attention to the result of the clinician’s comment. Ask the audience the following question: “Where could the therapist go from here?” Others may think you have a problem, but you don’t. That’s right, my mother thinks that I have a problem, but she’s wrong. 123 123

Principle 4: Support Self-Efficacy Belief in the ability to change (self-efficacy) is an important motivator The client is responsible for choosing and carrying out personal change There is hope in the range of alternative approaches available Notes Many clients who have problems with drug and/or alcohol use have tried unsuccessfully to stop using on their own. They have been unable to do so. They are ashamed and embarrassed about their problem and many have been harshly judged by family members and others. They have lost a sense of hope. Restoring their self-esteem and their self-efficacy is an incredible gift that can be provided by clinicians who care. Clinicians can do this by using motivational interviewing to communicate unconditional positive regard. 124 124

Example of Supporting Self-Efficacy
I am wondering if you can help me. I have failed many times. . . Anna, I don’t think you have failed because you are still here, hoping things can be better. As long as you are willing to stay in the process, I will support you. You have been successful before and you will be again. Instructions Ask somebody (different from the previous person) from the audience to play Anna’s role (white bubbles). You may want to play the role of the clinician (blue bubble) or ask a participant to play that role. Use the slide as a example of supporting self-efficacy. (Notice the use of one of the micro-skills that we will discuss in the next workshop. The clinician supports self-efficacy in part by affirming the client.) Ask the audience to pay attention to the result of the clinician’s comment. I hope things will be better this time. I’m willing to give it a try. 125 125

Part Five: Medically Assisted Treatment
A Third Example of an Evidence Based Practice

Considerations If addiction is a chronic, relapsing, sometimes fatal illness, why are we still treating it like an academic deficit? If addiction is a disease and there is effective medication for it, then to withhold it is malpractice.

NQF Recommendations Pharmacotherapy: Medications should be recommended and available to all adult patients with: opioid or alcohol dependence and directly linked with comprehensive clinical services nicotine dependence and directly linked with brief counseling.

Pharmacotherapy Psychosocial therapy is often integral to the success of pharmacotherapy, addressing psychological and social issues that might, if left untreated, contribute to relapse after pharmacotherapy is complete.

Pharmacotherapy A variety of classes of drugs are effective in treating SUD through multiple mechanisms including: Suppressing withdrawal and discomfort and pain that accompany it Reduce craving Blocking the effects of substance use

Alcohol Dependence

Pharmacotherapy for Alcohol Dependence
Target Outcome Reduction of alcohol consumption with the goal of cessation Retention in treatment Goals Treatment of withdrawal (“detox”) Reduction of cravings and urges Substitution therapy Helpful to promote med compliance

Target Population All non pregnant (18 and older), current alcohol dependent patients Special considerations should be given before using pharmacotherapy with selected populations Those with medical contradictions, pregnant/breast feeding women, adolescents and the elderly. Helpful to promote med compliance

FDA-Approved: Disulfuram (Antabuse) Oral naltrexone (Revia) Intramuscular naltrexone (Vivitrol) Acamprosate (Campral) Helpful to promote med compliance

IM Naltrexone (Vivitrol)
FDA approved 2006 Dose: 380 mg intramuscular once monthly Mechanism: opioid receptor antagonist Results: Decreased heavy drinking days, decreased frequency of drinking Helpful to promote med compliance

Opioid Dependence

Pharmacotherapy for Opioid Dependence
Target Outcome Cessation of non-medical use of opioids Retention in Treatment

Pharmacotherapy for Opioid Dependence
Target Population All adult (and adolescents 16 and older) patients diagnosed with opioid dependence who meet clinical and regulatory indications; may consider for adolescents as clinically indicated Special considerations should be given before using pharmacotherapy with selected populations Those with medical contradictions, pregnant/breast feeding women, adolescents and the elderly.

Opioid Pharmacotherapy
Goals Detoxification: Opioid-based agonist (methadone, buprenorphine) Non-opioid based (clonidine, supportive meds) Relapse prevention: Agonist maintenance (methadone) Partial agonist maintenance (buprenorphine) Antagonist maintenance (naltrexone) Lifestyle and behavior change

Opioid Detoxification
Medications used to alleviate withdrawal symptoms: Opioids (methadone, buprenorphine) Clonidine Other supportive meds anti-diarrheals, anti-nausea agents, ibuprofen, muscle relaxants, anxiolytics

Opioid Substitution Goals
Reduce symptoms and signs of withdrawal Reduce or eliminate craving Block effects of illicit opioids Restore normal physiology Promote psychosocial rehabilitation and non-drug lifestyle

Buprenorphine for Opioid Dependence
FDA approved 2002, age 16+ Mandatory certification from DEA (100 pt. limit) Mechanism: partial opioid agonist Office-based, expands availability Analgesic properties Ceiling effect Lower abuse potential Safer in overdose

Buprenorphine Formulations
Subutex (Buprenorphine) -2mg, 8mg Suboxone (4:1 Bup:naloxone) -2mg/0.5 mg , 8mg/2mg Dose: 2mg-32mg/day sublingually

Pharmacotherapy Pharmacotherapy should be a standard component when effective drugs exist. Helpful to promote med compliance

What Pharmacotherapy Entails
Medications that have been proven to be effective for ongoing treatment of Opioid dependence (buprenorphine, methadone, etc) Alcohol dependence (naltrexone, acamprosate, etc.) Tobacco Cessation (nicotine replacement therapy, bupropion, etc) Provided in adequate doses to control cravings Controlled dispensing of doses (for opioid dependence) Helpful to promote med compliance

What Pharmacotherapy Entails
Regular biological monitoring of illicit drug use. Monitoring response/side effects Adjusting of doses when indicated. Monitoring of medical status, including coexisting conditions and medications. Provisions of empirically validated psychosocial treatment or psychosocial support (including medical management). Helpful to promote med compliance

Pharmacotherapy Who Should Perform It?
Health care workers licensed to prescribe medication Healthcare workers authorized to initiate and guide the treatment of alcohol and opioid dependent patients should offer pharmacotherapy Providers who do not prescribe pharmacotherapy should have formal arrangements to refer patients for pharmacotherapy treatment.

Pharmacotherapy Where Should It be Performed?
Substance use illness specialty settings. General and mental healthcare settings where patients are treated for substance use and illness. If dispensing medications, must been regulatory requirements at the state and federal levels.

Questions? Comments?

Evidence Based Practices: An Overview

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Evidence Based Practices: An Overview

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