lec 6

Question 1

Remission (DSM-5)

Answer 1

Early remission from a DSM-5 substance use disorder is defined as at least 3 but less than 12 months without substance use disorder criteria (except craving)

Sustained remission is defined as at least 12 months without criteria (except craving).

Question 2

Abstinence Programmes

Answer 2

Based on the idea that there is no “safe” amount of use.
Aim = complete cessation of use

Detoxification programmes (opioid treatment programmes
12 step self-help programmes (e.g. Alcoholics Anonymous-

Question 3

Pharmacological interventions. Medications such as:

Answer 3

Disulfiram - interferes with alcohol metabolism causing nausea & vomiting
Naltrexone – reduces craving for alcohol / blocks effects of opiods in the brain (reducing pleasure)
Methadone – reduces withdrawal symptoms

Question 4

abstience programmes success rates variables

Answer 4

Detox/12 step approaches highly dependant on motivation to change; sometimes based on coercion / mandatory
Good evidence for pharmacological aids but they are not available for all types of substance use (e.g. cannabis; amphetamines)

Question 5

Harm reduction

Answer 5

Aim of treatment at individual level is to reduce the risks associated with substance use (e.g. from needle sharing, drinking when driving) and to reduce or prevent excess morbidity and mortality.
Attempts to meet people “where they are at” with their drinking or drug use.
Pragmatic approach, assuming small changes better than none

Question 6

harm reduction goals (3)

Answer 6

Reduce negative consequences of substance use for the individual
Promote recovery (whilst accepting relapse)
Improve quality of life

Question 7

dual diagnosis assumptions (pschosis w substance misuse)
2 points

Answer 7

1. Abstinence (total cessation) is not necessary - reducing and stabilising substance use also a desirable outcome
2. Reducing substance use will lead to improved outcomes (greater treatment adherence; fewer relapses & hospitalisations etc.)

Question 8

NICE guidlines professionlas on drug use

Answer 8

healthcare professionals should routinely ask those w known drug problem about theiur drug use. if used substances ask:
The particular substance(s) used
The quantity, frequency and pattern of use
The route of administration
Duration of current level of use.

Question 9

Recommend evidence based treatment for both psychosis and substance use:

Answer 9

Psychosis: Antipsychotic medication, CBT and Family Intervention. Discuss use of substances with the service user, and carer if appropriate

Substance use: Motivational interventions; CBT; contingency management; family involvement

Question 10

Psychosocial interventions for Dual Disorders

Answer 10

Typically involve a combination of the recommended interventions (“integrated therapy”):

Motivational interviewing;
CBT (including relapse prevention);
Psychoeducation;
Family therapy /systemic therapy

Question 11

modality of Psychosocial interventions for Dual Disorders

Answer 11

Individual (one to one)
Group (with strangers / partner / family members)
Combination of above
Increasingly, mHealth (use of internet and mobile apps to deliver therapy) –

Question 12

Psychological Assessment determines:

Answer 12

Patterns of use (what substances; when used; where; how much?)
History of use; previous treatment
Motives for use
Consequences (negative AND positive) – impact of use
Motivation to address problems
Personal strengths (family support networks, education, employment  resilience and how they’re doing in life)

Question 13

Psychological Assessment seeks to:

Answer 13

To understand role played by substances in client’s life; identify factors maintaining substance use and obstacles to change / relapse risks
May take several sessions and involve significant others (e.g. family members

Question 14

Treatment plan

Answer 14

• be person centered
  -address problems and goals identified during assessment
  take into account clients motivation to address substance use and obstacles to change
  Identify treatment goals and target behaviours (abstinence?)
  Identify measurable outcomes

Question 15

Stages of Change
*image

Answer 15

Most psychological approaches take account of stage of change:
and target treatment accordingly (stage of change dictating which methods are appropriate at a particular time
IMAGE

Question 16

the stages of stages of change

Answer 16

Contemplation - still using substances, but they begin to think about cutting back or quitting substance use
Preparation - still using substances, but intend to stop. Planning for change begins.
Action - Clients choose a strategy for discontinuing substance use and begin to make the changes needed to carry out their plan
Maintenance - Clients work to sustain abstinence (or maintain reduction) and evade relapse.
Relapse - Many clients will relapse and return to an earlier stage, but they will hopefully have gained new insights into problems (e.g. unrealistic goals or frequenting places that trigger relapse).

Question 17

Pre-contemplation + method

Answer 17

Not considering change; may deny substance use a problem
Options:
To not address substance use
To persuade the client to change / challenge their position
3. To enhance motivation to change **psychologist’s preference

Method: Motivational Interviewing

Question 18

Motivational Interviewing (MI)

Answer 18

person-centred counselling method for addressing the common problem of ambivalence about change
A collaborative conversation to strengthen a person’s own motivation for and commitment to change
Seeks to elicits and explore an individual’s own arguments for change

Question 19

points about MI - 5 points
- ambivilance

Answer 19

Views ambivalence as normal
Resolving ambivalence key to change
Responsibility for change is with the client
Accepts that clients goal unlikely to be abstinence (or even reduction)
Emphasis: helping clients to understand how their substance use keeps them from achieving their goals

Question 20

MI scale analogy

Answer 20

Reasons for change (reducing / stopping substance use) need to be stronger than the reasons for staying the same in order to “tip the balance” for change

Question 21

Reasons for using (staying the same) + MI

Answer 21

Positive expectancies about effects of substance
Aim of MI: to enhance motivation to change; get client ready to make changes
Typically brief, delivered as a stand alone intervention or can be integrated with another (e.g. CBT)

Question 22

Psychoeducation

Answer 22

typically included in MI and other individual interventions (key component of brief motivational interventions)
provision of information about the impact of substance use on mental health
Psychoeducation groups designed to educate clients about substance abuse, and related behaviours and consequences; identify resources; counteract denial

Useful adjunct but not sufficient as treatment in own right

Question 23

Cognitive Behavioural Therapy (CBT)

Answer 23

Identifies antecedents of drug use (‘high risk situations’)
Focus on teaching substance user new / more effective skills for dealing with high risk situations and craving
CBT aims to change learned behaviour by changing thinking patterns, beliefs, and perceptions and assumptions
Cognitive restructuring around alcohol and drug expectancies
Assists making lifestyle changes so as to decrease need /urges for substance or to increase healthy alternatives

Question 24

Relapse Prevention techniques. clients taiught to

Answer 24

with focus on coping skills in high risk situations but specific to relapse
Clients taught to:
Understand relapse as a process
Implement damage control procedures during a lapse to minimize negative consequences / chances of relapse
Stay engaged in treatment even after a relapse

Longer term intervention, 6 – 26 sessions

Question 25

Family / systemic therapy NICE guideleines

Answer 25

Family & carers should …
have the opportunity to be involved in decisions about treatment and care
be given information and support
be offered family intervention
be offered information local family or carer support groups

Question 26

Family / systemic therapy

Answer 26

Large psychoeducation component:
Provides information about dual disorders
Teaches communication skills and builds problem solving skills in family members, including the client
Helps family develop relapse prevention strategies
increase support; reduce burden; decrease conflict

Question 27

Integrated therapy

Answer 27

Typically starts with MI (pre-contemplation > contemplation)
Moves on to CBT (action; development of behavioural action / change plan) and relapse prevention
Moves back and forth between approaches
Includes psychoeducation and can involve family intervention

Question 28

Contingency Management

Answer 28

Behaviour Modification (Based on learning theory)
Contingency management (CM) – incentivises and reinforces abstinence with the aid of vouchers, privileges, prizes or financial incentives (clear urine screen = reward)
Recommended by NICE for substance use interventions but evidence currently lacking for dual diagnosis

Question 29

Contingency Management trial

Answer 29

(Johnson et al, 2019) recruited 500+ cannabis users with psychosis. No difference in outcome between those receiving CM and control (biggest trial ever done but no effect for contingency management)
But can incentivise people to turn up for therapy