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Integrative Addiction Psychotherapy Scott Kellogg, PhD Diana Calvario.

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1 Integrative Addiction Psychotherapy Scott Kellogg, PhD Diana Calvario

2 Foundational Concepts

3

4 Harm Reduction Psychotherapy People use substances in problematic ways for a range of reasons People use substances in problematic ways for a range of reasons Reasons that need to be respected Reasons that need to be respected In many cases, they will need to be addressed directly In many cases, they will need to be addressed directly Sometimes before the person is ready to decrease or cease their use of substances Sometimes before the person is ready to decrease or cease their use of substances (Tatarsky) (Tatarsky)

5 Schema Mode Therapy

6 Multiplicity of Self In this model, the internal world of patients is conceived of as containing different parts, selves, modes, or identities – In this model, the internal world of patients is conceived of as containing different parts, selves, modes, or identities – Many of which may not only play a role in a patient’s suffering and drug use, Many of which may not only play a role in a patient’s suffering and drug use, But also in his or her healing and recovery. (Kellogg) But also in his or her healing and recovery. (Kellogg)

7 Mechanisms of Change Leonardo Da Vinci

8 Components of Treatment Wide Rothko (2008) by Joao Vasco Paiva

9 Therapeutic Relationship 9

10 Therapeutic Alliance A central factor in successful recovery A central factor in successful recovery Therapists demonstrate: Therapists demonstrate: Love Love Empathic Listening Empathic Listening Authenticity and Optimism Authenticity and Optimism Courage and Determination Courage and Determination Within the Context of their Personal Style Within the Context of their Personal Style

11 Motivation and Complexity

12 Patient Voices 12

13 Patient Voices “I’ve always felt like I wanted to die since I was a little kid. I don’t know why… “I’ve always felt like I wanted to die since I was a little kid. I don’t know why… I want to see a therapist or psychiatrist about it but I don’t go ‘cause I’m afraid to tell them I still do dope. I want to see a therapist or psychiatrist about it but I don’t go ‘cause I’m afraid to tell them I still do dope. I still just really love to get high.” (Welch, 2011) I still just really love to get high.” (Welch, 2011)

14 Patient Voices Addicted Woman: “People are, like, crackheads and alcoholics and whatever because they’re covering up [stuff], you know what I mean? Addicted Woman: “People are, like, crackheads and alcoholics and whatever because they’re covering up [stuff], you know what I mean? And, if they don’t deal with that… they’re not going to get anywhere. And, if they don’t deal with that… they’re not going to get anywhere. Interviewer: Are you going to have to deal with some personal [stuff]? Interviewer: Are you going to have to deal with some personal [stuff]?

15 Patient Voices Addicted Woman: Oh yeah. But …. I’m scared. …. I stay up for days, you know, because I don’t want to sleep, cause I get nightmares. Addicted Woman: Oh yeah. But …. I’m scared. …. I stay up for days, you know, because I don’t want to sleep, cause I get nightmares. Interviewer: …What’s scary about going to sleep? What gave you the nightmares? Interviewer: …What’s scary about going to sleep? What gave you the nightmares? Addicted Woman: … I’ve been like sexually abused….and raped, you know.” (Wild, 2002) Addicted Woman: … I’ve been like sexually abused….and raped, you know.” (Wild, 2002)

16 Self-Stimulation Domain Drug Use to Feel Alive, Experience Pleasure; Access Creative and Spiritual Aspects of Self Somatic Domain Drug Use to Address Brain Changes, Withdrawal, Mood Dysregulation, Cravings, and Medical Illness Self-Soothing Domain Drug Use to Treat Inner Anguish, Pain, and Psychopathology Social Identity Domain Drug Addiction Lifestyle; Addict Identity Social Justice Domain Social Oppression: Sexism, Racism, Homophobia, Disenfranchisement; Poverty Substance Use Domains

17 Motivations to Change Family/Parental/ Relational Threats Job Loss/ Economic Damage/ Prestige Threats Existential/Spiritual Concerns Health Concerns Legal Problems Role Strain/ Role Conflict

18 Decisional Balance

19 The heart of Addiction Psychotherapy The heart of Addiction Psychotherapy Assesses the many forces supporting the drug use Assesses the many forces supporting the drug use And the forces favoring change and/or recovery And the forces favoring change and/or recovery

20 Positives of Drug Use Immediate physical pleasure (10) Escape/Feeling more “ there ” (10) Feels more emotion (10) Reduces social anxiety (6) Shuts out critic (7) People will know “ real ” self (7) Positives of Change Feel a greater sense self discipline (9) Would be more productive (10) Help him be more comfortable with self (8) Greater confidence (6) Negatives of Drug Use Feels guilty (7) Others are concerned (6) Not as productive (10) Feels like it a crutch (10) Feels bad (7) Health Problems (7) Negatives of Change Would not enjoy life as much (9) Would be ignoring a part of himself (10) Breaking up with something he loves – a hard breakup (9) Decisional Balance

21 Multiplicity of Self Dancing of the Selves By Brenda Clews

22 Positive Goals; Desire for Something Better Violates Personal Moral Standards Concerns About Health And Wellbeing Provides Great Pleasure; Feels Alive; Hedonic Experience Reduces Inner Pain; Depression and Anxiety Facilitates Social Interaction Improve Relationships With Significant Others

23 Goal Setting and Problem List Development

24 Therapeutic Strategy Work with Drug Use First? Work with Drug Use First? Work with Underlying Problem/ Psychopathology First and Monitor the Drug Use? Work with Underlying Problem/ Psychopathology First and Monitor the Drug Use? Do Both Simultaneously? Do Both Simultaneously? Drug Use Goals: Drug Use Goals: Harm Reduction, Moderation, “Nonaddictive” Use, or Cessation? Harm Reduction, Moderation, “Nonaddictive” Use, or Cessation?

25 Institutional Goals Embrace them Embrace them Ally with Patient Against Them and Use Harm Reduction Strategies (Wallace) Ally with Patient Against Them and Use Harm Reduction Strategies (Wallace)

26 Vertical and Horizontal Interventions

27 Interventions Vertical Interventions Vertical Interventions Those that are used to address and treat the underlying issues and co-occurring psychopathology Those that are used to address and treat the underlying issues and co-occurring psychopathology Horizontal Interventions Horizontal Interventions Those focused on controlling and/or discontinuing drug use Those focused on controlling and/or discontinuing drug use

28 Vertical Interventions

29 Relational

30 Cognitive

31 Behavioral Dr. B. F. Skinner

32 Experiential

33 Existential

34 Meditative/Self-Soothing ; ;

35 Horizontal Interventions

36 Substance-Use Management 36

37 37 Substance Use Management Helping people use drugs in ways that are safer Helping people use drugs in ways that are safer Including Including Reducing the amount consumed Reducing the amount consumed Changing methods of use Changing methods of use Reducing the time of involvement Reducing the time of involvement Changing the context of use Changing the context of use Drug substitution (Dan Bigg, 2008) Drug substitution (Dan Bigg, 2008) Overdose Prevention/Naloxone Overdose Prevention/Naloxone

38 Relapse Prevention

39 39 Relapse Prevention Involves working with patients to: Involves working with patients to: Understand triggers and cues Understand triggers and cues Identify high-risk situations Identify high-risk situations Develop such coping skills as: Develop such coping skills as: Cognitive Restructuring, Relaxation Therapy, Distraction, Social Support Cognitive Restructuring, Relaxation Therapy, Distraction, Social Support Assertiveness – Drink and Drug Refusal Assertiveness – Drink and Drug Refusal Awareness/Mindfulness/Urge Surfing Awareness/Mindfulness/Urge Surfing

40 Ideal Use Plan “If you were to use drugs or alcohol in such a way as to maximize the pleasure and benefit you gain from them while minimizing the pain and danger involved, what would that look like?” “If you were to use drugs or alcohol in such a way as to maximize the pleasure and benefit you gain from them while minimizing the pain and danger involved, what would that look like?” Can they implement this? Can they implement this? What interferes or stops this from happening? What interferes or stops this from happening? (Tatarsky & Kellogg, 2010) (Tatarsky & Kellogg, 2010)

41 Contingency Management

42 Contingency Management in the Treatment of Addictive Disorders Uses positive reinforcement principles to: Uses positive reinforcement principles to: Improve retention Improve retention Decrease substance use Decrease substance use Increase group attendance Increase group attendance Improve medical compliance Improve medical compliance Encourage harm-reducing and recovery- related behaviors Encourage harm-reducing and recovery- related behaviors

43 43 Positive Reinforcement and Retention Petry et al., 2000 % Retained

44 44 Retained Through Study Treatment of Cocaine Use in Methadone Patients Silverman et al., 1996

45 Identity Theory

46 Identity Theory Addresses the questions: Addresses the questions: Why do people change? Why do people change? How do they change? How do they change? How do they maintain long-term abstinence, sobriety, or moderation? How do they maintain long-term abstinence, sobriety, or moderation?

47 Recovery Capital Identity Theory

48 Identity processes are a core component of psychosocial treatments Identity processes are a core component of psychosocial treatments People have Multiple Identities People have Multiple Identities Organized into a Hierarchy of Importance Organized into a Hierarchy of Importance

49 Identity and Recovery The core idea: The core idea: Drug use will decrease and eventually cease or moderate as: Drug use will decrease and eventually cease or moderate as: Nonaddict identities become more central, reinforcing, and important to individuals Nonaddict identities become more central, reinforcing, and important to individuals And as they compete with and replace the Addict Identity And as they compete with and replace the Addict Identity (Anderson, 1998; Biernacki, 1986; Granfield & Cloud, 1996; Kellogg, 1993) (Anderson, 1998; Biernacki, 1986; Granfield & Cloud, 1996; Kellogg, 1993)

50 The Case of N "Agape" by Jane Korins

51 51 Identity Restructuring Long-term recovery can be seen as involving identity creation and restructuring Long-term recovery can be seen as involving identity creation and restructuring Treatment programs may specifically seek to create a Recovery Identity Treatment programs may specifically seek to create a Recovery Identity “My name is Bob and I am an Alcoholic.” “My name is Bob and I am an Alcoholic.”

52 52 Individual Psychotherapy Individual Psychotherapy can involve: Individual Psychotherapy can involve: Transforming the drug-using self Transforming the drug-using self Creating or empowering competing identities Creating or empowering competing identities The Addict Identity can dialogue with the The Addict Identity can dialogue with the Work Work Family Family Religious/Spiritual Religious/Spiritual Athletic Athletic And other past, present, or future selves/identities And other past, present, or future selves/identities

53 Identity Dialogues

54 Identity and Harm Reduction Harm reduction organizations have the potential to provide users with Harm reduction organizations have the potential to provide users with New identities New identities New roles New roles

55 A needle exchange program that is run by active drug users A needle exchange program that is run by active drug users Their involvement in this process also led to positive identity changes Their involvement in this process also led to positive identity changes “Not only are user-run programs the most viable and effective way to reach active drug users, “Not only are user-run programs the most viable and effective way to reach active drug users, The users become activists through their work. The users become activists through their work.

56 Since becoming active in our organization, Since becoming active in our organization, Many council members have been able to move away from ‘unmanageable’ drug use towards the stability that maintenance brings” (Zibbell, 2005) Many council members have been able to move away from ‘unmanageable’ drug use towards the stability that maintenance brings” (Zibbell, 2005)

57 The War on Drugs interferes with Identity Creation; Therefore the War on Drugs interferes with Healing and Recovery

58 Recovery Culture

59 Strengths Seeks to create a broader culture of recovery Seeks to create a broader culture of recovery A culture that would supplant that based on drug use and addiction A culture that would supplant that based on drug use and addiction Create networks of support Create networks of support Provide identity materials and niches Provide identity materials and niches Help addicted individuals claim Help addicted individuals claim A Recovery Identity A Recovery Identity Other Identities Other Identities

60 Countertransference

61 Countertransference Working with drug-using patients in this manner can evoke strong emotions including: Working with drug-using patients in this manner can evoke strong emotions including: Love Love Admiration Admiration Fear Fear Anger Anger Grief Grief It is important to have to have places where it is safe to process these feelings It is important to have to have places where it is safe to process these feelings

62 Diana Calvario

63 Scott Kellogg, PhD


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