1. Non-Pharmacological Treatment Approaches for Substance Abuse
Dr. Jim Peck
NPIH Staff Psychologist
ISAP Co-Investigator/Clinical Research Manager

2. Overview of 2 weeks Week 1 Week 2
Why attempt to develop integrated psychotherapeutic and pharmacotherapeutic treatment approaches for addictions?
Stages of Change, Motivation/Motivational Interviewing, and Minnesota Model
Week 2
Behavioral and Cognitive-Behavioral Treatment Approaches

3. Goals of Psychotherapeutic Approaches
Develop/enhance motivation; work toward resolving ambivalence
Teach coping skills (drug use is overgeneralized)
Change reinforcement contingencies
Develop means of addressing painful affect
Improve interpersonal functioning/social support
Foster compliance with pharmacotherapy
(Carroll, 1997)

4. Stages of Change Model (Prochaska & DiClemente, 1992)
Precontemplation
No intent to change
More pros than cons to using
Contemplation
Thinking about changing
Seeking information
Preparation
Ready to change (attitude and behavior)
May begin self-regulation
Action
Actively modifying problem behaviors; learning skills to prevent relapse
Maintenance
Long-term strategies for maintaining the changes that have been accomplished

5. Stages of Change Why consider stage of change?
Presumably matching treatment approach to stage would yield better outcomes

6. Precontemplation Defensive No awareness of problem
Resistant to suggestions of problems associated with alcohol/drug use
Uncommitted to treatment
Consciously or unconsciously avoiding steps to change behavior
May seek treatment because of others’ pressure
May feel coerced by significant others
May appear in tx because they are mandated

7. Contemplation Seeking to evaluate and understand their behavior
May experience some level of distress
May be thinking about making changes
Have not taken action and are not prepared to do so
May have made previous attempts to change

8. Preparation Have intention to change behavior
Exhibit readiness to change both in attitude and behavior
Engaged in the change process and are on the verge of taking action
Decision to change has been made and they are ready to commit to the actions involved

9. Action
Firm decision to initiate change; this has been verbalized or somehow committed to.
Taking action to change behavior and environment
Ct exhibits motivation
Willing to follow suggested strategies and activities

10. Maintenance Working to sustain changes
Attention focused on avoiding relapses
May express fear/anxiety about facing high-risk situations
Less frequent but still intense cravings to use substance, particularly in response to various stressors

11. Motivation
How we conceptualize motivation will determine how we approach treatment
What are your beliefs about motivation?

12. Motivation Motivation
Is a stable trait, consistent across situations, not modifiable because it lies within the patient
Clinician’s behavior is irrelevant to patient’s motivation
Denial is standard defense mechanism for people with addictions
Resistance is the patient’s problem

13. Motivation Motivation
Is a process that happens between a patient and a clinician
Is a fluid state that changes across situations, in different environments, and is at least partially determined by interpersonal interactions
Resistance is a “therapist skill challenge”

14. Motivation People with substance use disorders often
Terminate treatment early
Continue to use during treatment
Are noncompliant with treatment
Traditional wisdom holds that:
These patients are resistant, in denial, and unmotivated
They will have to “hit bottom” before they can succeed in treatment

15. Motivation Pieces of the Puzzle
Consistently, controlled trials of brief interventions with problem drinkers show significant reductions in drinking compared to control groups
Some of these interventions are as brief as 1 or 2 sessions, for only 10 or 15 minutes
Brief intervention (4 session MET) reduced drinking as much as longer (12 weeks of CBT or 12-Step oriented tx) interventions (i.e. Project MATCH, 1993).
It may be that there are certain critical ingredients that trigger change, that can happen very quickly

16. Motivation Search for Common Elements
Miller & Sanchez (1994) – FRAMES
6 ingredients frequently present in brief interventions:
Feedback
Responsibility
Advice
Menu
Empathy
Self-efficacy
(discussed in detail later)

17. Motivation Pieces of the Puzzle
patient outcomes differ by therapist (Miller, Taylor, & West; 1980).
Degree of therapist empathy as defined by Carl Rogers predicted patients’ rates of drinking at 6 (r = .83) and 12 (r = .67) months after treatment. The more empathic the therapist, the more the patient made changes and maintained those changes over time.

18. Motivation Pieces of the Puzzle
Problem drinkers’ level of resistance related to a single therapist characteristic: confronting. The more the randomly assigned therapist confronted, the more the patient drank, even up to a year later (Miller et al., 1993).
Challenges traditional 12-Step tx approaches

19. Motivation Putting the Pieces of the Puzzle Together
Positive change is a natural process that a therapist does not originate or own but can facilitate.
Enduring change can be triggered by a combination of an awareness that there is a problem and a belief that there is a way out, facilitated by a supportive and empathic therapeutic relationship.

20. Motivation Putting the Pieces of the Puzzle Together
This can occur even in a single session, which is good news because length of substance abuse treatment tends to be short.
Change is usually facilitated not by therapist confronting, directing, or pushing, but by listening reflectively to the patient and evoking the patient’s own motivation for change and healing.

21. Motivation Quantifying/measuring Motivation
Instruments that assess stage of readiness to change such as URICA (University of Rhode Island Change Assessment) can indicate level of patient motivation

22. Motivation Quantifying/measuring Motivation
SOCRATES (Stages of Change Readiness and Treatment Eagerness Scale) also assesses stage of change, but appears to actually measure 3 underlying factors:
Recognition of problem
Ambivalence
Taking steps toward change.

23. Motivation Enhancing Motivation
patients further along on readiness for change may benefit from action-oriented approaches focused on skill development and strategies for behavior change.
Taking this approach with patients less ready to change is likely to be ineffective.
What to do with these folks?

24. Motivation Enhancing Motivation-FRAMES
Back to FRAMES acronym
Feedback – refers to personalized feedback or health-relevant information based on careful assessment (not educational material about harmful effects of alcohol/drugs)
Personal feedback may include: results of lab tests, calendar recording days of use, measures of motivation, etc.

25. Motivation Enhancing Motivation-FRAMES
Feedback (cont’d)
Is patient ready to hear feedback?
How feedback is presented affects patient’s ability to hear it. Can be helpful to ask permission to give feedback.
Helpful to listen reflectively to patient’s response to feedback.
Feedback can trigger patient self-reflection, which may increase motivation.

26. Motivation Enhancing Motivation-FRAMES
Feedback (cont’d)
Initial evaluation/assessment can provide source of feedback, as can systematic follow-up over time.
In healthcare systems, patient knowing that clinician will check back with them in a few months seems to enhance outcome.

27. Motivation Enhancing Motivation-FRAMES
Responsibility
Conveying individual responsibility with tone of trust and respect is common element in effective brief interventions.
Respectfully remind patient that they are ultimately in charge of what happens, including whether or not to change, and if so, how.
Reinforce whatever responsibility patient has already taken.

28. Motivation Enhancing Motivation-FRAMES
Responsibility
Informed consent process, in either treatment or research, helps remind patient that they are the one responsible for making choices about their life.
Informed consent can be important part of rapport-building.
Clarifying ground rules and limits to confidentiality helps structure the interaction and empowers the patient to decide how much to disclose.

29. Motivation Enhancing Motivation-FRAMES
Advice
Have to be careful with this one-it can be a roadblock to listening and developing rapport.
Clear and respectful advice appears to be important component in enhancing motivation to change harmful lifestyles.

30. Motivation Enhancing Motivation-FRAMES
Menu of Options
Advice about changing more likely to be carried out if patient has a variety of options to choose from.
Menu also increases patients’ perception of personal choice and control, which promotes intrinsic motivation and can foster optimism.
Can be helpful to offer menu of change goals, as well as change methods.

31. Motivation Enhancing Motivation-FRAMES
Empathy
May be the most crucial of the FRAMES elements.
Creates environment conducive to change, instills sense of safety, of being understood and accepted, and reduces defensiveness.
Sets the tone within which the entire communication occurs. Without it, other components may sound like mechanical techniques.

32. Motivation Enhancing Motivation-FRAMES
Empathy
Nature of clinician-patient relationship, even in a single session, predicts treatment retention and outcome (Luborsky et al., 1985).
Rogers (1959) – skillful reflective listening that clarifies and amplifies the patient’s own experience and meaning, without imposing the clinician’s material.

33. Motivation Enhancing Motivation-FRAMES
Empathy
Empathy represents conceptual opposite of confrontational strategies.
Establishing empathy builds trust and rapport and provides a doorway through which to introduce more difficult addiction issues.
Asking about positive aspects of substance use can be a good starting point and help put patient at ease.

34. Motivation Enhancing Motivation-FRAMES
Self-efficacy
Can be conceptualized as a specific form of optimism, a “can-do” belief in one’s ability to accomplish a particular task or change.
Crucial to help patient experience their own ability to make positive changes.
Part of this is the clinician believing in the patient’s ability to change.

35. Motivation Enhancing Motivation-FRAMES
Self-efficacy
When patients asked about characteristics of good counselors, they stated that their counselor believed in them and that helped them to believe in themselves (Nelson-Zlupko et al., 1996).

36. Motivation Motivational Interviewing (Miller, 1983)
Developed in early 80’s; originally designed to be a prelude to treatment and increase patient compliance with help.
Good evidence to show that treatment outcomes are enhanced by adding initial motivational interview (Bien et al., 1993; Brown & Miller, 1993; Saunders et al., 1995).
Unexpected finding was that motivational interviewing was associated with behavior change when used as a stand-alone intervention .

37. Motivation Motivational Interviewing
MI is not so much a set of techniques as a style or way of being with patients, helping them resolve ambivalence and find resources within themselves.
Basic principles overlap somewhat with components of FRAMES.

38. Motivation Motivational Interviewing
1. Express empathy
It is a paradox but true nevertheless that acceptance facilitates change.
Approaches that emphasize that where the patient is now is unacceptable have poor track record in facilitating change.

39. Motivation Motivational Interviewing
2. Develop Discrepancy
Help patient to become more aware of the discrepancy between their addictive behaviors and their more deeply-held values and goals.
Part of this is helping patient to recognize and articulate negative consequences of use. More effective if the patient does this, not the clinician.
Explore values and life goals and then ask patient to reflect on how their addictive behavior fits into them.

40. Motivation Motivational Interviewing
3. Avoid Argumentation
In general, it is unhelpful to argue with patients. Confrontation elicits defensiveness, which predicts a lack of change.
Particularly countertherapeutic for clinician to argue that there is a problem while patient argues that there is not.
No evidence that patient needs to accept diagnostic label (e.g. “addict” or “alcoholic”) for change to occur.

41. Motivation Motivational Interviewing
4. Roll with Resistance
Seemingly resistant responses from patients are met not with opposition but with acceptance and an invitation to try new perspectives.
The ambivalence about treatment, about change, that is usually interpreted as “resistance” is probably a normative response to giving up accepting ways of being and choosing new ones.

42. Motivation Motivational Interviewing
5. Support Self-efficacy
Clinician must support the patient’s belief that they can change.
A realistically optimistic belief in the possibility of change can be a powerful instigator and motivator of change.
Ultimately, patient is responsible, but the sense of hope that the clinician can generate is very important.

43. Disease Model
Disease: “dysregulation of homeostasis resulting in a predictable constellation of disabling symptoms”
Heart of disease model of addiction: addiction is a physical illness, not a matter of willpower nor the result of a deeply ingrained habit of recurrent excessive consumption.

44. Disease Model
Model has evolved over time; current iteration of disease model incorporates psychological, social, and cultural factors that interact with a genetic component to produce addiction.
Exact biological etiology for most chronic diseases such as alcoholism are still unknown.

45. Disease Model
Silkworth (1939: Alcohol dependence is an “illness characterized by an atypical physiological reaction to alcohol that triggers a mental obsession”.
Describes “mental anguish of the alcoholic faced with an inability to reduce or stop drinking”
“Only a pervasive personality change would alleviate the emotional turmoil and spiritual bankruptcy of the alcoholic”.

46. Disease Model
This “personality change” was described by William James in Alcoholics Anonymous (1955) as involving a gradual yet significant change in consciousness, or a “spiritual awakening”.
This spiritual aspect of AA is what some clients refer to as the program being “religious”

47. Disease Model
Alan Leshner (former Director of National Institute on Drug Abuse):
“Addiction is a brain disease and it matters” (1997)
At some point during drug use, a molecular “switch” in the brain marks a change from use or abuse to addiction (dependence). Brain becomes fundamentally altered, producing drug effects and behaviors that are different from “pre-disease” state. May mark the point at which the change in neural pathways described last week takes place.
Important to remove stigma and moral overtones from conceptualization of addiction

48. Disease Model
Brain changes lead to “loss of control”, hallmark symptom of disease model.
Because it is a disease, no blame placed on individual, but it is made clear in treatment that the patient has a responsibility for participating fully in recovery-that their “illness” can’t simply be “cured” with a medication.

49. Disease Model Maintenance
In addition to reinforcing properties of substance itself, disease is maintained by emergence of elaborate defense system that denies severity of drinking or using behavior and its consequences.
Minimization
Rationalization
Blame others
Intimidation, angry defensiveness, manipulation often seen

50. Disease Model Treatment
From the disease model evolved the Minnesota Model of treatment.
Also known as the Hazelden model.
Holistic approach that uses multidisciplinary team for assessment and treatment
Incorporates some of major tenets of Alcoholics Anonymous
Originally developed for use in residential tx settings

51. Disease Model Components of Minnesota Model
Mental health care
Psychotherapy and non-addictive psychotropic meds used
Spiritual care
People struggling with addictions have often abandoned values and beliefs they once held important. Finding meaning and strength beyond personal willpower helps people learn new ways of living w/out substances.

52. Disease Model Components of Minnesota Model
Chemical dependency counseling
Individual and group counseling
Counselor coaches, mentors, and teaches by taking active role as agent of change
Similar to an AA sponsor

53. Disease Model Minnesota Model - Treatment
Builds on methodology of 12 Steps of AA:
Education-information
Therapy-focus on psychological issues producing “negative” affect
Fellowship – “interpersonal value of self-help that builds a group motivation to modify self-defeating behavior, gain support for ongoing change, and establish resources for continuous learning.”

54. Disease Model Minnesota Model - Treatment
Treatment approach is designed to promote access to and participation in 12-step groups after residential treatment.
Since there is no biological cure, consistent, lifelong maintenance of behavioral change is required to prevent relapse.

55. Disease Model Minnesota Model - Treatment
Initial tx goals focus on recognition and acceptance of the problem.
Promote self-discovery rather than denial
Recognize need to accept help from other people
Step 1 – “We admitted we were powerless over alcohol-that our lives had become unmanageable.”

56. Disease Model Minnesota Model - Treatment
Goals of Step 1 treatment:
Self-awareness of extent and severity of drinking/using behavior
Cost-benefit analysis of continued addictive behavior compared to making changes necessary for recovery
Recognition of addiction as a disease, beyond control of normal willpower
Reduction of shame and self-blame

57. Disease Model Minnesota Model - Treatment
Step 2: “Came to believe that a Power greater than ourselves could restore us to sanity.”
Higher Power conceptualized as self-defined, highly personalized experience not the same as a particular religious belief system
For some, represents God/supernatural source, for others it is nature, a particular counselor or sponsor, or AA itself.

58. Disease Model Minnesota Model - Treatment
Goals of Step 2:
Development of spiritual understanding that helps shape and give meaning to life and promotes hope
Development of realistic optimism about capacity to recover by utilizing available resources
Less cynicism
Foundation for self-efficacy and stronger sense of self
Start to connect more with other people

59. Disease Model Minnesota Model - Treatment
Step 3: “Made a decision to turn our will and our lives over to the care of God as we understood Him.”
Steps 2 and 3 together are about surrendering
Connotes a willingness to trust an evolving sense of spirituality to the extent of being willing to relinquish dysfunctional behaviors in favor of suggested new behaviors.

60. Disease Model Minnesota Model - Treatment
This stage stresses introspection and self-responsibility
Slogans like “Easy does it” are taught to promote self-regulation of reactivity to environmental cues
Serenity Prayer does same thing-provides a spiritually-oriented cognition that promotes realistic appraisal of potentially problematic situations.

61. Disease Model Minnesota Model - Treatment
Step 3 treatment approaches are action-oriented and can include cognitive restructuring, assertiveness training, relaxation training, psychoeducational assignments, pastoral counseling, family conferences

62. Disease Model Minnesota Model - Treatment
Step 3 goals:
Accept and act upon feedback from trusted sources
Assess personal needs and assert them realistically without resorting to manipulation or aggressiveness
Willingness to ask for help
Seeking input from others before acting impulsively

63. Disease Model Minnesota Model - Treatment
Step 4: “Made a searching and fearless moral inventory of ourselves.”
Comprehensive self-appraisal used to evaluate major life dimensions
Inventory is confidential, allows for recognition of past mistakes and problems while considering personal strengths and resources

64. Disease Model Minnesota Model - Treatment
Step 4 often difficult and patients may begin to become aware of painful affect
Some people continue to blame others
Others become too triggered by anxiety/emotional pain and come close to relapse, must then take a break from this step and return to a previous step

65. Disease Model Minnesota Model - Treatment
If successfully negotiated, step 4 tx approaches can lead to the beginning of resolution of shame and self-reproach; growing willingness to consider one’s shortcomings that may be risk factors for relapse; develop more effective coping mechanisms or work on changing maladaptive personality traits.

66. Disease Model Minnesota Model - Treatment
Step 5: “Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.”
Provides opportunity for catharsis of long-repressed emotions
Important to provide accepting, non-judgmental environment for people to do this work
The act of disclosure to another person is thought to be the therapeutic mechanism here

67. Disease Model Minnesota Model - Treatment
Goals of Step 5 tx approaches:
Greater willingness to identify risk factors for relapse
Greater acceptance of responsibility for one’s actions
Greater awareness of disease’s impact on character development
Relief of shame, guilt, and self-reproach

68. Disease Model Minnesota Model - Treatment
Steps 1-5 are conceptualized as the initial phase of recovery
Taken together, they provide the opportunity for a “spiritual awakening”, where the person metaphorically “wakes up” to their situation and accepts guidance and counsel of others to acquire the skills for sober living.

69. Disease Model Minnesota Model - Treatment
These new attitudes and behaviors are then renewed and reinforced by Steps 6-12, which are referred to as relapse prevention steps.

70. Steps 6-12
Step 6: “Were entirely ready to have God remove all these defects of character.”
Step 7: “Humbly asked Him to remove our shortcomings.”
Step 8: “Made a list of all persons we had harmed, and became willing to make amends to them all.”
Step 9: “Made direct amends to such people wherever possible, except when to do so would injure them or others.”

71. Steps 6-12
Step 10: “Continued to take personal inventory and when we were wrong promptly admitted it.”
Step 11: “Sought through prayer and meditation to improve our conscious contact with God as we understood him, praying only for knowledge of His will for us and the power to carry that out.”
Step 12: “Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.”

72. Disease Model Minnesota Model - Treatment
Key treatment modality is the mentoring relationship between a primary therapist and individual client.
Role of counselor is that of mentor and coach, similar to AA “sponsor”
Preference in these tx settings for counselors who are either in recovery themselves or have experience with 12-Step groups such as Al-Anon.

73. Disease Model Minnesota Model - Treatment
This is one of the most widely-used forms of treatment, although outpatient programs are being promoted more than residential programs in the era of managed care
Not much research on efficacy, perhaps because of its development outside of academic settings

74. Disease Model Minnesota Model - Treatment
Strengths of the model:
Clients benefit not only from counselors but peers as well
Other people further ahead in the recovery process serve as natural role models for newer clients
Clients become part of a support group of recovering people that exists around the world; become part of something larger than themselves

75. Disease Model Minnesota Model - Treatment
Limitations of the model:
Since it relies on a multidisciplinary team, services can be time-consuming and expensive
If interpreted and implemented too dogmatically, can be presented in a confrontive, religious, or generic manner that leads to client resistance