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It Takes a Village to Resolve an Addiction…And Certain Kinds of Villagers Barbara S. McCrady Center on Alcoholism, Substance Abuse, and Addictions University.

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Presentation on theme: "It Takes a Village to Resolve an Addiction…And Certain Kinds of Villagers Barbara S. McCrady Center on Alcoholism, Substance Abuse, and Addictions University."— Presentation transcript:

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

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

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

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

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

6 Harry Harlows Monkeys Wire Milk Mother Cloth Mother

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

8 Alcohol/Drug Use and Positive Social Support

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

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

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

12 When Social Support Goes Awry

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

14 When Social Support Goes Awry for Alcohol and Drug Users

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

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

17 Social Support and Treatment

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

19 Influencing Problem Recognition and Help-Seeking Al-Anon facilitation Unilateral (CRAFT) Johnson Intervention % engaged in treatment Unilateral Family Therapies Miller et al., 1999

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

21 Alcohol Behavioral Couples Therapy and Abstinence Treatment Follow-up Months Percent Days Abstinent ************ ABIT ABCT McCrady, Epstein, Cook, Jensen, & Hildebrandt, 2008

22 Alcohol Behavioral Couples Therapy and Heavy Drinking TreatmentFollow-up Months Percent Days Heavy Drinking ********** McCrady, Epstein, Cook, Jensen, & Hildebrandt, 2008

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

24 A Pause

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

26 Whats to come: Three questions to contemplate: Three questions to contemplate: How does social support actually change a persons behavior? How does social support actually change a persons behavior? How do people elicit or repel social support? How do people elicit or repel social support? How do people effectively provide social support? How do people effectively provide social support?

27 How Does Social Support Change a Person?

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

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

30 Coan et al., 2006 fMRI Results

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

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

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

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

35 How do People Elicit or Repel Social Support?

36 What does a Person do to Have Good Social Supports? How does a drinker/drug user find social networks that will support nonproblem alcohol or drug use? How does a drinker/drug user find social networks that will support nonproblem alcohol or drug use? How does a drinker/drug user engage others to provide support? How does a drinker/drug user engage others to provide support? We dont have answers to these questions We dont have answers to these questions

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

38 Alienating Interpersonal Behaviors Variable B SE B Beta Adjusted R2 Change Step 1: Baseline ** Percent Drinking Days Step 2: Tx Condition Step 3: Baseline ** Alienating Interpersonal Behaviors ** p <.01 Hunter Reel, McCrady, & Epstein, 2007

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

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

41 Implications for Change

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

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

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


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