Midterm 3 Flashcards
(125 cards)
1
Q
Key principles of effective treatment per NIH
A
●Addiction is a complex but treatable disease that affects brain function and behavior.
●No single treatment is right for everyone.
●People need to have quick access to treatment.
●Effective treatment addresses all of the patient’s needs, not just his or her drug use.
●Staying in treatment long enough is critical.
●Counseling and other behavioral therapies are the most commonly used treatment.
●Medications are often an important part of treatment, especially when combined with
behavioral therapies.
●Treatment plans must be reviewed often and modified to fit the patient’s changing needs.
●Treatment should address other possible mental disorders.
●Medically assisted detoxification is only the first stage of treatment.
●Treatment doesn’t need to be voluntary to be effective.
●Drug use during treatment must be monitored continuously.
●Treatment programs should test patients for HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as teach them about steps they can take to reduce
their risk of these illnesses.
2
Q
What are we treating?
A
●substance abuse
●other mental health issues
●other physical health issues
3
Q
What type of treatment?
A
●medication
●therapy (CBT, DBT, MI, Family based therapy, etc)
4
Q
Treatment does not reach everyone
A
●Less than 10% of adolescents with alcohol or drug
problems receive treatment (SAMHSA, 2007)
●94% of people aged 12 or older with a substance use disorder did not receive any treatment in 2021
5
Q
Need for treatment in past year 2023
A
●12 or young? 19.1
●12-17: 11.2
●18-25: 28.7
●26 or older: 18.6
6
Q
Internal barriers to treatment
A
●Stigma (other ppl opinion or our own opinion)
●Psychological reasons (e.g., depression)
●Personal beliefs
●Lack of problem recognition
●Attitudes about abuse
●Attitudes about treatment
7
Q
Public opinion
A
●80% dont want drug addict
●61% dont want heavy drinker
●34% don’t want homosexual
●10% dont want immigrant
●24% dont want someone with AIDS
8
Q
External Barriers to treatment
A
●Financial reasons (cost)
●Time conflicts
●Logistical reasons
●Limited treatment options, availability and accessibility
●Lack of knowledge, understanding about options
●Enforced treatment
●Accessibility of drugs
9
Q
Does treatment work?
A
●getting treatment is better than no treatment
●no evidence of treatment setting, length, intensity, types of populations, or types of adolescents for settings
10
Q
Developmental considerations for treatment
A
●Consider brain development
●Possibility to weigh pros/cons
●Adolescents’ need for independence, setting own goals, and control over their life
●Immediate rewards
●Limited life experience, different outlook in life, limited
consequences
●Strength of peers
●Realistic goals and approach
●Labeling
●Address at adolescents’ level
●Flexibility
●Confidentiality
11
Q
Treatment in context of Comorbidity
A
●We should be discussing substance use with our teens regardless of extend of use or impairment
●●No use
●●Experimentation
●●Abuse
●Flexible treatment plans to meet the needs of the individual pt and their unique presentation
●Do we need a substance specific treatment or standard care with substance use adjunct?
●We must ID and treat the co-morbidities: psychiatric, neuropsychological
and school based struggles
12
Q
12-17 with substance use disorder and depressive episode
A
●29% no treatment
●21% with both treatment
●48% with mental health treatment
●1.2% with substance treatment only
13
Q
Harm Reduction
A
●public health approach (minimize problems associated with use)
●lots of treatments fall under this approach
14
Q
Safe Injection Sites
A
●opened in 2003 (vancouver)
●Operated by Vancouver Coastal Health and the Portland Hotel Society.
●September 2003 and July 2008, operated under a special exemption of Section 56 of the Controlled
Drugs and Substances Act
●Allowed individuals to use on sight without prosecution
●A constitutional challenge was heard by the Supreme Court of British Columbia to keep Insite open.
●Court ruled that laws prohibiting possession/trafficking of drugs were unconstitutional because they denied drug users
access to Insite’s health services.
●Insite currently operates under a constitutional exception to the Controlled Drugs and Substances Act.
●Often a gateway to treatment
15
Q
Insite 2017 user statistics
A
●175,464 visits by 7,301 unique individuals
●537 visits on average per day to the needle exchange service
●An average of 415 injection room visits daily
●2,151 overdose interventions with no fatalities
●3708 clinical treatment interventions (wound care and pregnancy test)
●Principle substances reported were heroin (64% of instances), methamphetamine (25%) and cocaine (6%)
●28% participants women; 18% Indigenous
●InSite’s operational budget was $500,000 (provided by Health Canada)
●BC Ministry of health contributed $1,200,000 to renovate the site and cover operating costs
16
Q
Insite stats
A
●Over 3.6 million clients have injected illicit drugs under supervision by nurses at Insite since 2003.
●There have been 48,798 clinical treatment visits and 6,440 overdose interventions without any deaths.
●They connect clients with needed services
●Referrals to other social and health service agencies
●Vast majority for detox and addiction treatment.
●Admissions from Insite into Onsite, the adjoining detox treatment facility
●Fscal year 2017/18 443 clients accessed Onsite, the adjoining detox treatment facility, with an average stay of 11 days.
●Among clients, 95% or greater rated the facility’s services as excellent or good, and its staff as reliable, respectful, and trustworthy
●In 2010, 76% of residents expressed support for the facility
17
Q
Insite effectiveness
A
●Decreased
●Needle Sharing and reuse of syringes
●Fewer people injecting in public
●Increased referrals to services
●Decreased publicly discarded syringes
●No increase in police reports of drug dealing or crime; no observed increase in new initiate into drug use
●When look at decreased needle sharing, increased use of safe injection practices and increased referral to methadone
maintenance treatment.
●Incremental net savings was more than $18 million
●Number of life-years gained 1,175
18
Q
E-cig and health controversy: Pro
A
●Serves as tobacco harm reduction – better than the alternative
●May help with smoking cessation, but does not reduce cravings
●E-smoke contains just 5 chemicals; tobacco smoke contains 9,000 (lower toxicants than tobacco)
●Vapor is close to regular water vapor compared to tobacco smoke = no significant risk especially to bystanders
●E-cigarettes have much lower risk of lung cancer, other cancers, lung disease, & heart disease than regular cigarettes → saves tens of thousands of lives a year
●Low to no nicotine delivery, especially if not used extensively
19
Q
E-cigs and health controversy: cons
A
●Detectable levels of carcinogens
●Quality control process when manufacturing the e-cigs
is inconsistent or non-existent
●Some e-cigs are labeled as having no nicotine, but actually have low levels of nicotine
●Nicotine levels vary based on the cartridge and amount may not actually match what is listed on the box
●Other harmful chemicals and tobacco-specific impurities are found
●E-cigs are only slightly better at helping people quit than other NRT products (e.g., gum)
●2014 CDC Study examined the total number of calls to poison centers for e-cigs
●Sept 2010: 0.3%
●Feb 2014: 42%
●42% involved people age 20 and older
●Most common complaints: vomiting, nausea & eye irritation
20
Q
E-cigs (and teens)
A
●Marketed aggressively to young people
●Legacy found that e-cigarette ads reached 29.3 million teens and young adults from 1/2013-11/2013 (including 58% of 12-17 year olds)
●Flavors to entice (bubble gum, pina colada, cherry crush, chocolate)
●Other factors to consider:
●●Product placement in movies or entertainment
●●Celebrity endorsement or promotion
●●Re-normalization of smoking and de-stigmatizing
21
Q
Are E-cigs beings used to reduce harm in teens?
A
●76% of the teens also smoked regular cigarettes
●Current e-cigarette use was negatively associated with
abstinence over 30 days, 6 months and 1 year
●teens are not using e-cigs as tobacco replacement, but in addition to cigarettes
●if adolescents smokes e-cigs, they were more likely to smoke conventional cigarettes and to smoke more heavily
22
Q
Multidimensional Family Therapy
A
●Comprehensive outpatient family-based treatment
●Multiple domains: youth, parents, other family members, social network
●Developed for adolescents with substance use and related
behavioral/emotional problems
●Delivered in the home or community
●Implemented since 1985
●Delivered throughout the US and internationally
●Diverse ethnic and SES backgrounds
●Variety of contexts: Master’s level therapists, case managers
23
Q
MDFT Overview
A
●12 – 16 weeks given weekly or twice weekly
●Manually-driven, with assessment and treatment in keys areas of social interaction
●Therapists work as intensive case managers to help the family receive needed services
●Housing, job training, income assistance, treatment for parents
24
Q
MDFT Goals
A
●Help adolescent develop more effective coping and problem solving skills
●Help family improve interpersonal functioning as a protective factor
●Decrease emotional distance
●Encourage parent positive reinforcement
●need to teach how to praise and how to accept praise
25
MDFT Approach: Components
●1. Engage youth and family
●2. Behavioral focus (developmentally appropriate)
●3. Generalize new skills and behaviors
●Specific Approach
●Engage teen first; gradually discuss substance use
●Work with parent(s) on stress, psychopathology, attachment to adolescent, discipline, monitoring
●Parent and adolescent coaching
●Use of contracts
●No after-care component
26
MDFT: Support
●Lower cost than standard outpatient and residential
●High engagement and motivation
●Stay in treatment longer
●(95% MDFT (90 days); 59% residential), (88% MDFT (180 days); 24% residential), (96% MDFT (120 days); 78% group therapy)
●Treats a broad range of adolescents & families, including
serious users and delinquency
●Family, peer and school functioning improve
27
MDFT: Support 2
●Superior outcomes to other treatments (family group therapy, peer group treatment, individual CBT, residential)
●Substance use is greatly reduced compared to other treatments (5 controlled trials)
●Substance use continues to decrease after discharge, up to
12 month follow-up
●Higher rates of abstinence at 12 month follow-up
●Decreased delinquent behaviors
●Arrests, convictions, probation less likely
●Out of home placements less likely
28
Multi Systemic Family Therapy
●Developed in the 1970s to treat delinquent youths
●An alternative to out of home placement / prison
●Combines aspects of empirically supported techniques: cognitive behavioral, behavioral and family systems therapies
●MST therapists work closely with the family to target problems
and implement intervention strategies
●Delivered in the youth’s natural environment (home, school,
community)
●To facilitate cooperation, engagement, retention
29
MST: Overview
●Several treatments per week for 4 months (average)
●Treatment meetings around family’s schedules
●Intensive Therapy
●2 to 4 therapists and a half time supervisor
●Low caseloads: Each therapist works with 4-6 families
●Therapists are available 24 hours a day, 7 days a week for crises
●intensive case management, 24 hour coaching
30
MST: Goals and Approach
●Places particular emphasis on:
●Improving family functioning
●Helping parents decrease adolescent’s contact with deviant
peers, perform better in school and become involved in prosocial activities
●Accessing needed family and community resources
●Accessibility and engagement to prevent drop out
●Focuses on individual needs of adolescent & family
●Work to change family interaction patterns
●Work with parents to establish effective discipline
●Peers are included as part of therapeutic process
31
MST: support
●Decrease crime and violence
●Long-term arrests reduced by 25-70%
●Out of home placements reduced by 47-64%
●Families function better
●Decreased substance use, but not sustained at follow-up
●Fewer mental health problems for serious juvenile offenders
●Missouri Delinquency Project: 22 year follow up, less violent arrests and issues (75%) and family instability (38%)
●want to prevent kids from going to juvenile to adult jail
32
Medically Supervised Withdrawal (detoxification)
●Process of ridding the system of alcohol or drugs under supervised conditions.
●Carried out in a hospital setting.
●Allows medical personnel to monitor and treat potentially dangerous withdrawal symptoms such as convulsions.
●Medications were used in almost 80 percent of detoxification
33
Medications used with opioid addiction
●1. Methadone (Dolophine®, Methadose®),
●2. Buprenorphine (Subutex®, Probuphine® , Sublocade )
●3. Naltrexone (Vivitrol®)
34
Agonists and Antagonists
●Receptor agonist: A
substance that has an affinity
for and stimulates a cell
receptor by binding with it. It
produce actions similar to
those produced by the
addictive substance.
●Receptor antagonist: A
substance that has affinity for
the receptors and blocks that
receptor without producing
physiological effects
35
Methadone
●Opioid agonist (occupies a receptor and activates it)
●Also acts as an antagonists for the NMDA receptor (glutamate receptor) which is thought to contribute to the pain relieving effects of the drug
●Schedule II drug
●only available at federally certified Opioid Treatment Programs (OTPs) and acute inpatient hospitals
●Used in detox to prevent withdrawal symptoms during medically supervised withdrawal or for maintenance therapy
●At normal doses does not produce high or drugged feeling
●Enables heroin users to get lives back on track
●However, like other opioids, methadone is highly addictive
●Pro: Only needs to be given 1x a day
36
Naltrexone
●Naltrexone – Opioid Antagonist
●Should be clean for a minimum of 7 days before starting
●Prevents relapse used after medically supervised withdrawal
●Can lead to reduced tolerance to opioids and, therefore, increase risk of overdose
●Administered Daily (oral) or monthly (extended-release injectable)
37
What about Naloxone?
●Brand Name Narcan
●Opioid antagonist
●Used to treat opioid overdose
●Not psychoactive, not addictive, side effects are rare
●Withdrawal symptoms can onset quickly after use
●All 50 states and DC have some legislation to allow laypeople access, but laws vary greatly
●strong affinity to opioid receptor, knocks opioid out for 30-90 mins
38
Buprenorphine
●Opioid partial agonist
●Use to: Help people withdraw from heroin and methadone, Reduce the need to use heroin –buprenorphine
maintenance, Treat severe pain
●Schedule III drug: Safer than methadone, Requires waver to prescribe outside OTPs
●Multiple means of administering: Sublingual, buccal, subdermal implant, subcutaneous
extended release injection
39
Medications used in alcohol addiction
●Naltrexone (see previous slides on this for opiates)
●Acamprosate (Campral®)
●Disulfiram (Antabuse®)
40
Disulfiram
●Discourages alcohol consumption
●When combined with alcohol produces nausea, headache, heart palpitations, and vomiting
●Some cases cause dramatic drop in blood pressure
●Shock or death
●Brand name Antabuse
●Effective only if patient takes the drug
●Ideal candidates are committed to abstinence and willing to take the medication
●Given Daily
41
Acamprosate
●Helps to restore naturally occurring neurotransmitters: A neuromodulatory approach
●Decreasing cravings and urges to use alcohol
●Does not help with withdrawal symptoms
●Is recommended for individuals who have already detoxed
●Given when already abstinent
●Given 3x a day
42
Up and Coming: Vaccines
●Nicotine, cocaine, heroin
●Stimulates immune system
●Introduces a foreign substance that causes the immune system to create antibodies that attack the
substance:
●●Antibodies that shut down the substance before it reaches and stays in brain or body
●●Substance does not have the same effect
●Not preventive
●Administered after addiction
●Promising animal studies; limited consistent findings in adults
43
Psychiatric Medications
●Teat Comorbid Dx: Antidepressants, Antianxiety medications, Stimulants, Antipsychotics, Mood stabilizers
●Considerations: Avoid fast acting medications which have higher rates of abuse, Close monitoring, Psychoeducation
44
Contingency Management
●Drug abuse is considered a special case of operant behavior maintained by the reinforcing effects of the drugs involved
●Focused on the modification of voluntary behavior through reinforcement and consequences
●Provides tangible rewards contingent on objective evidence of abstinence
●Rewards for negative urinalysis
45
CM Strategy
●Aims to increase the amount of positive reinforcement from non-drug sources
●Abstinence detected by urine analysis
●Abstinence is rewarded
●Drug use → immediate loss of reinforcement
●●Theoretically, this will result in a decrease in the behavior over time
●In addition to abstinence, can reward:
●Clinic attendance
●Compliance with treatment plan
●Changes in lifestyle that may facilitate abstinence
46
Contingency Management Procedure
●Set objective/target behavior: Choose most important behavior to change, Behavior must be quantified objectively, Behavior must occur frequently
●Choose reinforcers: Must be seen as desirable by adolescents, Allow adolescents to pick the reinforce
●Behavioral contract is time-limited: Must be specific and clear, Targeted behavior, Monitoring process
●Reinforcement schedule: Reinforce immediately, Full value of reinforcer is provided immediately after
verification of target behavior
●Priming: Give a reward before implementing contract, Teaches individuals that they can earn rewards, Sparks interest in program
●Can be combined with other interventions
47
CM Reinforcement Schedule
●Fixed rate – All target behaviors receive same value of reinforcer
●Progressive rate – Subsequent target behaviors are worth
increasing values of reinforcers
●●Failure to provide evidence of target behavior sets reinforcement
schedule back to initial level
●Variable rate – Reinforcement schedule changes/not expected –
best to change behavior for long-term
48
CM Effectiveness:
●Effective in reducing smoking in adults. but smokers generally return to smoking if reinforcers are withdrawn
●●Cash payments for low carbon monoxide readings
●Engagement and participation in treatment
●Less on research on effects in adolescents (but it works)
●●Decrease in use or abstinence in marijuana, opioid and cocaine use in adolescents
●Increased attendance in treatment
49
CM as Multi-Component Treatment
●CM is best paired with other treatments
●CBT + CM > CM on smoking cessation in school-based program
●●53% versus 0% in 4 week period
●●Better results immediately post treatment (need longer-term treatments with CM)
●Group CM > standard care for attendance, treatment duration and abstinence post-treatment
●CBT+ parent-based CM > CBT + drug parent education on marijuana abstinence
●●7.6 weeks versus 5.1 weeks abstinence
●●No differences at 9 month follow-up
●●Boosts abstinence rates during and post treatment, but relapse rates are high
50
CM Concerns
●Considerations:
●●Greater effects are found when given higher reinforcers compared to lower reinforcers
●Reinforcing smoking reductions first (before reinforcing abstinence) may enhance the effects of CM during abstinence
●Concerns about rewards and payment
●●Cash versus vouchers/gift cards
●●Consider cost of treatment
51
Motivational Interviewing Background
●Derived intuitively from practice
●●Principles arose from Miller & Rollnick’s practice
●Emerged as an alternative to the directive style used for alcoholism in the 80s.
●Drawn from existing models of psychotherapy and behavior change. MI is grounded in:
●●Roger’s client centered approach
●●Cognitive Dissonance Theory: Creating a discrepancy between present attitudes/behaviors & future goals/values
●●Self-Perception Theory: People convince themselves to change (or not)
●●The trans-theoretical stages of change: focuses on the decision-making of the individual and is a model of intentional change
52
MI Overview:
●Most influential brief intervention (Miller & Rollnick)
●Ambivalence is a normal step toward change:
●●Individuals can remain stuck in ambivalence for a long time
●Motivational Interviewing is a:
●●Person-centered
●●Goal-directed counseling method for helping people change by
working through ambivalence
53
MI Spirit
●Collaborating together: Honors the person’s experience and perspective. Work in partnership. Does not attempt to force someone to change
●Acceptance: Respects the person’s right to decide what is best for themselves, and helps them make an informed decision
●Compassion: Has the person’s best interest in mind
●Evocation: are active listeners who draw out the client’s perspective, desires and reasons for changing. The practitioner connects health
behavior change to the things the patient cares about
54
Four Principles of MI
●Express Empathy: the therapist seeks to communicate respect by listening to understand the person’s feelings and point of view without judging, criticizing, or blaming them for their actions.
●Develop Discrepancy: motivation for change occurs when people perceive discrepancy between where they are and where they want to be.
●Respond to sustaining talk and discord (Roll with Resistance): Explore the ambivalence, without trying to get the person to admit that there is a problem. Sustain talk is part of a normal part of being ambivalent. It is not pathological.
●Support self-efficacy: help the participant see and believe they can change.
55
Ambivalence: Change vs Sustain Talk
●Ambivalence involves conflicting motivations- A state of contemplation
●Contemplating change involves thinking about the pros and cons of the options
●Sustain talk is what the patient says that favors the status quo may be a signal that the person does not believe or accept information that has been presented
●Change talk is what the patient says that favors movement in the direction of change
56
Four Processes of MI
●Engage: build relationship
●Focus: set an agenda or direction
●Evoke: Draw out reasons for change
●Plan: set a goal
57
OARS: Basic Skills of MI
●Evoke commitment to change
●Open ended questions
●Affirmations
●Reflections
●Summarizing
58
MI open ended questions
●Expand the possibilities of responses and supports evocation.
●How – What – When – Where – Why?
59
MI Affirmations
●Affirmations are statements that accentuate the positive in order to
recognize, support and encourage.
●Affirmations are a form of empathy and respect.
●A compliment or comment on a positive quality
●An expression of hope or support
60
MI Reflections
●A statement made to clarify the true meaning of what someone
is saying
●Reflects, as a mirror does, what people have said or what they are feeling
●Lets you check that you understand what has been shared
and shows your desire to understand
●Opens the door for people to keep talking. Keeps people thinking
●Supports participants’ healthy behaviors and desires to change
61
MI Summarizing
●1. Introduction
●●Let me see if I understand so far…
●●If it’s ok, let me summarize what we talked about so we can make a plan….
●2. Summarize the CHANGE TALK the person has stated
●3. Summarize the positive things they have accomplished
●4. Ask the client if they would like to add anything and what their next steps are
62
Two Approaches in MI
●Non-Motivational: not really listening with patients, judged, makes patients avoid sharing
●Motivational: listen actively, gets ppl want to talk more
63
Developmental Fit between MI and Adolescents
●Appropriate for all levels of potentially harmful substance use
from infrequent binges to dependence
●Brief intervention
●Emphasis is not on abstinence
●Moderation focus may show greater declines over time
●Adolescents do not have to accept label of substance abuser or addict
64
Developmental Fit between MI and Adolescents (2)
●Emphasis on maintaining an empathic connection and avoiding confrontation may be useful for rebellious adolescents
●Fosters developmentally appropriate goals of accepting responsibility and developing self-efficacy for self-care
●Respects adolescents and builds on need for independence
●Giving feedback may play key role
(change perceptions of normative
behavior)
65
Potential Shortcomings of MI with Adolescents
●May not recognize current dangers/costs of substance use
●Younger adolescents may not have enough abstract reasoning skills
to fully imagine future harm
●Harm reduction approach may conflict with abstinence expectations of parents, schools and legal system
66
Adaptations of MI for Adolescents
●Using multiple choice questions instead of open-ended questions for adolescents who have difficultly talking to counselor
●Making sure feedback is understood
●Use of graphics to clarify feedback
●Use of internet to deliver interventions
●●Give personalized feedback
67
Research Support of MI with adolescents
●Research supports promise of MI in reducing:
●●Alcohol-related risky behaviors and consumption, especially for
teens who started with low motivation for change
●●Effects are maintained over time:
●●Alcohol up to 24 months
●●Risky and negative behaviors up to 4 years
●●Effective for nicotine dependence and smoking
●Promising findings on computer-based approach
●Cost benefit of MI short duration
●Compared to longer classes
68
Juvenile Drug Courts
●Identified by social workers, police officers, District Attorney – for individuals who are court-involved and can benefit from treatment
●●Almost 3,000 drug courts across the U.S.
●●Juvenile = 433; Family Treatment = 303
●Focuses on individuals who are convicted with primary problem as substance use
●Helps monitor progress
●●Check in with judge regularly
●Post Adjudication Model: Most common model, Sentence of incarceration suspended pending successful completion of drug
court, Gives court more authority to address youth non-compliance
●●Plead guilty and THEN complete the program to avoid further prosecution
69
Juvenile Drug Courts: defining components
●Possible substance abusing youth are referred
●Drug court team: judge, prosecutor, public defender, probation officer, coordinator and treatment provider
●Team develops comprehensive treatment plan to address
substance abuse, school, family and behavioral need
●Treatment provider collaborates with family to provide treatment
●Team monitors youth’s progress (school attendance, compliance with family rules, clean urine screens)
●Feedback provided to judge in hearings and judge delivers graduated rewards or
sanctions
70
Juvenile Drug Courts: Effectiveness
●Promising model
●●Limited research on effects in substance use for adolescents
●●Promising effects drug courts > family court
●●Effects stronger when combined with evidence-based programs such as Multi-Systemic Therapy or Contingency Management
●Frequency of required court appearances decreases with youth
progress
●Effectiveness of model is dependent on the quality of treatment services provided for
substance abuse, family and behavioral issues
●●Better outcomes for Whites, women, older individuals, better educated, perpetrators of less crimes. But, high risk individuals may have more to gain from
drug court appearances and treatments
●Drug Court + Other Treatments → effective (urine tests)
●●+ Community Service: 69% positive tests
●●+ Multi-Systemic Therapy: 29% positive tests
●●+ CM: 18% positive tests
●Benefits of the model may be offset by ineffective or iatrogenic effects of group-
based treatment approaches
71
Motivational Enhancement Interventions
●from Veteran Assistance
●Shorter-term and less extensive than more traditional substance abuse treatments
●Cost effective
●Among adults, these treatments are among the most powerful substance abuse interventions
●Utilizes harm reduction approach rather than exclusive abstinence-based approach
●Even in cases where abstinence would be ideal, steps toward reducing use or harm are affirmed and supported
72
ME Approach
●Can be used directly to address substance use OR to motivate patients for more extensive substance abuse treatment (a prelude to other treatments or used in conjunction with other approaches such as 12 step)
●Also helps address resistance, relational problems, moodiness, weak motivation for change
●Led by professionals and paraprofessionals
●Can range from 1 to 5 sessions
●Inpatient and outpatient
●May be used after negative event (e.g., ER visit)
73
ME Strategies
●Non-judgmental and non-confrontational
●Meets client where he/she is in terms of use
●Client-centered, but directive
●Working on jigsaw puzzle together
●Allows client to receive feedback from a therapist to elicit client’s
motivation for change, personal decision and plan for change,
actual change
●Empowers client with a feeling of self-control
●Strategies
●Open-ended questions, reflective listening, reframing, support
●Find discrepancy between current behavior & goals
●Roll with resistance
74
ME FRAMES
●Feedback of Personal Risk – personalized feedback on
consequences of use ( “You say you are having difficulty getting to work on time and that this may be related to alcohol”)
●Responsibility – emphasis on personal responsibility and
freedom to choose; person responsible for change (“Only you can make the decision to stop drinking for the next 2 weeks” )
●Advice to Change - recommendations and information on how drinking or drug patterns can be changed (“Yes, I recommend you stop drinking for 2 weeks and see if it makes a difference”)
●Menu of options for change (abstinence, reduction) (“If this turns out to be too hard, we can consider other options such as AA or a referral to another specialist team”)
●Empathy – therapist expresses caring, understanding &
warmth (“I know this will be hard for you because you feel alcohol helps you relax, and I am concerned about the amount of stress you have”)
●Self-efficacy – Instilling hope that change is possible (“Considering how difficult you find this, I am impressed with your
willingness to consider a change”)
75
College Drinkers Check Up
●Single session computer-based brief intervention to reduce
alcohol use in college students (18 - 24 year olds)
●Heavy, episodic drinkers
●Includes screening, assessment, personalized feedback, decision
making modules
●Uses FRAMES
●Compared to assessment only control group:
●●1 month and 12 month follow-up:
●●Fewer drinks per week (reduced by 45 – 55%)
●●Lower average number of drinks during two heavy drinking episodes
●●Lower blood alcohol levels during typical week
76
Functional Family Therapy
●Empirically-based and highly successful family intervention
for at-risk youth (ages 10 – 18)
●Initially developed for juvenile offenders
●Program for delinquency, substance use, violence
●Delivered across US and Internationally
●Adapted for many different settings: juvenile justice, mental
health setting, child welfare settings
●Widely recognized: 1 of 4 models named by US Surgeon General as model programs for seriously delinquent youth
77
FFT Overview
●Short-term strength based intervention based on risk and
protective factors
●12-14 (no more than 26) sessions over 3 – 4 months
●2 person-team
●Flexible delivery: wide range of interventionists
●Office or clinic based; some home-based
●Also: schools, child welfare, probation and parole offices, mental health facilities
●Cost effective ($1600 –$5000 for 12 home visits
78
FFT Goals
●Help family and youth replace maladaptive behaviors with
adaptive behaviors
●Reduce or eliminate:
●Problematic substance use
●Problem behavior in the family
●Improve family functioning
●Identify functions served by substance use and modify the
function
●Example: drug used by adolescents to get attention or to cope, escape
●Focus on changing the function to help the family be more adaptive
79
FFT 5 Treatment phases
●Therapist: Develops alliances, reduces resistance, building skills (improves communication, problem solving, coping skills minimizes hopelessness, motivates to change)
●Engagement, motivation, relational assessment, behavioral change, generalization
80
FFT Engagement
●Maximize the family’s expectation of positive change
●Risk and Protective Factors
Addressed:
●Negative perceptions about tx or past tx
●Transportation
●Therapist Availability
●Reputation of Tx agency
●Goal Attainment
●Family members show up to at least one session
81
FFT Motivation
●Create motivation for long term change
●Risk and Protective Factors Addressed:
●●Family Negativity and Blame
●●Hopelessness
●●Balance Alliances
●Therapist works on interpersonal skills such as validation, positive
reattribution reframing, relational skills
●Goal Attainment
●●Blame and negativity decreases
●●Nonverbal cues of engagement increase
●●Expression of hope increase
82
FFT Relational Assessment (Phase within a phase)
●Identify relational functions e.g. connection and hierarchy in
family
●Risk and Protective Factors Addressed:
●●Individual skills or problem behaviors
●●Intrafamilial and extrafamilial patterns of behavior
●Goal Attainment
●●Identify relational functions in the family (e.g. connectedness and
hierarchy
●●Identify patterns in problem related behaviors
●●Therapist conceptualizes alternative more positive behaviors that serve the same interpersonal function as negative behavior
83
FFT behavior change
●Facilitate individual and relational change (reduce referral problems)
●Risk and Protective Factors Addressed:
●●Youth temperament
●●Parental pathology
●●Beliefs and values
●●Developmental Levels
●●Conflict resolution and peer refusal skills
●Goal Attainment
●●Observe changes in individual behaviors and interactive patterns that reduce problem behaviors
and increase sustainable alternatives
●●Skill building
84
FFT Generalization
●Maintain and expand change;
●Risk and Protective Factors Addressed:
●●Access to community resources
●●Increase bonding and social support in school
●●Improve parental attitudes about school, peers etc
●●Access to prosocial youth and systems
●Goal Attainment
●●Anticipate and plan for future stressors in the family
●●New or strengthened relationship and communications with positive peers and community resources
●●Active participation of youth in school or vocational institution
85
FFT Support
●Effectively treats adolescents with: Disruptive Behavior Disorder, Oppositional Defiant Disorder,
Conduct Disorder, Substance Use Disorders; Delinquency or violence
●Significant and long-term reductions in re-arrests,
re-offending and violent behaviors
●●Prevents involvement in adult criminal system
●Siblings: Effective in reducing sibling involvement in high risk behaviors
●Family/Parenting: Positive effects on family conflict, communication, parenting and youth problem behavior
●High Completion Rates: Low drop out rates
86
Brief Strategic Family Therapy
●Developed in mid 1970s to address the needs of Cuban
immigrant families in Miami
●Based on studies to understand culture and values orientations of the community to address the issues
●Therapists in directive and active role
●Expanded to other groups
●Goal: To improve family relationships
●Recognizes the complex relationships in the family system
and interdependency of family members
●Behavior can be understood when examining the context in
which it occurs (the family)
87
BSFT Overview
●Strategic, pragmatic, problem-focused, planned
●Time limited, family-based approach to adolescent substance
use and related problems
●●Manualized
●●Offered in the home or clinic for 3 months
●Most work is done in sessions by asking the family to enact discussions of problems
●Focus is on the relationships within the family, not on
behavior change
●Therapist works to:
●●Diagnose ineffective interaction patterns and
●●Interrupt the patterns so that the family can learn new ways of
interacting
88
BSFT Components
●Joining or engaging
●Diagnosis (family interactions)
●Restructuring
●●Enactments
●●Reframing
●●Boundaries and alliance
89
BSFT Support
●Some support for BSFT - promising
●Probably efficacious treatment
●Need more follow-up studies
●Outcomes (compared to skills-based group)
●Decrease in problem behaviors (conduct, aggression)
●Decrease in marijuana use
●Improved family functioning
●Higher levels of engagement, compared to community-based
treatment
90
Cognitive Behavioral Therapy for Substance Abuse
●Conceptualizes substance abuse as learned behavior maintained through the environment:
●●Environmental cues are associated with drug use and become relapse triggers or cues
●●Drug and alcohol behaviors develop and are maintained in the context of what happens
before or after the behavior
●●Effects of drugs are powerful reinforcement for continued use such as:
●●●Relieving stress or depression
●●●Facilitating social interaction
●Can be provided individually or in groups
●Group treatment does not necessarily result in “deviancy training” or iatrogenic effects
91
CBT Emphasis
●Emphasis on the relationship between thoughts, behavior and
emotions
92
CBT Features
●Brief, time-limited therapy
●●Average number of sessions: 16
●Present centered (here and now)
●Practice and homework
●Good therapeutic relationship is necessary for effective therapy, but is not the focus of therapy
●Collaboration between therapist and client:
●●Therapist investigates, helps client clarify goals
●●Therapist helps client achieve own goals
●Structured and Directive
●●Therapist uses specific agendas for each session
93
CBT thought focused
●Helps recognize and understand that thoughts, not external factors
(people, situations), can lead to our feelings, worries, and behaviors
●Our interpretations of situations lead to feelings
●can our interpretations
94
CBT approach and components
●Socratic Questions
●Functional Analysis
●Modeling
●Challenging Thoughts
●Skills Training and Skill Building
●Intrapersonal Skills
●Interpersonal Skills
●Coping Skills
●Homework assignments
●Behavioral Rehearsal & Feedback
95
CBT Socratic Questioning
●Focuses on using Socratic questions to (1) question
client’s assumptions and (2) unlearn ineffective emotional and behavioral reaction
●get to core beliefs
96
CBT Functional Analysis
●Antecedent situations
●get to core beliefs again
●Insights into what may trigger or stimulate use
●●e.g., mood, thoughts, cravings, life situations
●Consequences of use
●●What may gain from using in each circumstance
●●What may lose if continue using
●Where were you and what were you doing ____?
●What happened before you were doing ____?
●How were you feeling?
●When was the first time you were aware you wanted to use?
●What was the high like in the beginning?
●What was the high like later?
●Anything positive that happened as a result of using?
●Anything negative?
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CBT for Substance Abuse: Targeting Thoughts and emotions
●Thoughts can impact behavior (addiction) and emotions
●Thoughts = Hypotheses to test
●●Thoughts can be unproven with new evidence
●●Triggers for behavior are considered
●Challenge thoughts
●●Unlearn ineffective emotion reactions
●●Reframe
●●Question assumptions
●Replacing thoughts
98
Automatic Thoughts: Per the APA
●1. Thoughts that are instantaneous, habitual,
and nonconscious.
●2. Thoughts that have been so well learned and habitually repeated that they occur without cognitive effort
99
Automatic Thoughts
●ALL OR NOTHING THINKING. Things are black or white; “this or that” and “either/or” thinking.
●OVERINTERPRETING. Making a mountain out of a molehill.
●●OVERGENERALIZATION. See a single negative event as a never ending pattern. Use words such as “never” or “always”.
●●PERSONALIZATION. Interpret others’ behaviors as if others have negative intentions towards you or are directing their comments
directly to you.
●●EMOTIONAL THINKING. Assume that negative emotions reflect the way things really are.
●DISQUALIFYING THE POSITIVE. Reject positive experiences because they do not count.
●JUMPING TO CONCLUSIONS. Make a negative interpretation even though there are no definite facts that support your conclusion.
●MAGNIFICATION (CATASTROPHIZING) and MINIMIZATION. Exaggerate the
importance of things and shrink things that appear tiny.
●SHOULD OR MUST STATEMENTS. Using statements such as “should”, “should not”, “ought to” and “must” to motivate your and other people’s behavior.
●IF ONLY. Spend time thinking of past events wishing that you had acted or said something differently.
●IF/THEN. You place conditions on someone’s behavior and make interpretations based on
the conditions.
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CBT Thought Record
●Activating event
●consequences
●beliefs
●disputation
●evaluation: balanced thought
101
CBT: Skill building- intrapersonal
●Self-monitoring thoughts and behaviors
●Negative thinking
●●Manage negative thoughts, substitute with positive thoughts or
feelings
●●Thought stopping
●●Positive self talk
●Avoidance of stimulus cues
●●Delay decision to use, distraction, recall negative consequences
●Alter reinforcement contingencies
●●Develop positive, self-fulfilling, enjoyable activities
102
CBT: Skill building- interpersonal
●Drink/drug refusal skills
●●“No” convincingly and firmly; avoid double messages; Suggest alternative activities; change subject; ask person not to offer drugs/alcohol; role play
●Anticipate and accept criticism
●Communication skills
●●Self-disclose feelings; share positive emotions; express negative feelings appropriately; listening skills; practice and role play; involve significant others
●Social networks and support
●General social skills
●●Start conversations; nonverbal skills; assertiveness
●Coping skills training to manage and resist urges to use
●●Mood regulation, anger management, relaxation
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CBT: Skill building
●Problem-solving
●●Problem recognition, identification of components of problem, brain storm solutions, select promising approach, try it out, assess, refine plan
●Relaxation skills
●●Alternate tensing and relaxation of various muscles, imagery, slow
breathing
●Anger management
●●Calm down phrases, identifying situations, consider options to resolve situation
104
CBT: evidence
●Evidence that CBT can:
●●Increase abstinence rates
●●Decrease drinking and substance use
●●Decrease problems related to use
●Outcomes for individual and group CBT are generally better than community treatment as usual
105
CBT considerations for adolescents
●Broad developmental stage
●●Cognitive skills, autonomy versus control, communication level with parents
●Comorbidity when planning treatment
●Risk factors for relapse
●●Deviant peers, delinquent behavior, attitude to school, conduct problems, family strain
●Relapse is high
106
DBT
●Used for co-occurring substance use AND personality disorders
**less evidence for substance use only
●Created originally by Marsha Linehan for women with chronic
suicidality and self-harm behaviors (adapted CBT)
●Adaptation for Substance Use has been modified over the past
30 years
●Comprehensive treatment program
107
DBT Components
●Weekly skills training in a group setting, weekly individual psychotherapy, 24/7 phone coaching, and therapist consultation team (therapist meets with other therapist)
●Used to help manage strong emotions, difficulty with
relationships, suicidality, self harm, impulsiveness, family conflict and behavioral dysregulation
●Teaches Distress Tolerance, Emotion Regulation, Mindfulness, and Interpersonal Effectiveness
●Stresses concept of Dialectic
108
DBT more components
●Adaptations for substance use disorders include explicit dialectics
related to substance use
●Solid commitment to abstinence AND acceptance of slips as a way to
secure a pathway towards abstinence
●Avoids shame and resignation that occur during lapses preventing full
relapses
109
DBT Evidence
●Evidence in Adult Populations
●●When compared to treatment as usual, DBT-SA has significantly less drug use and significantly greater gains in global and social adjustment at post-treatment and follow up
●Adolescents
●●Pilot study with American Indians and Alaskan Natives in Residential Treatment Center
●●Measured pre-post effectiveness for primary SUD (no personality disorder)
●●96% in remission or improved at time of discharge
110
Relapse Prevention
●Adolescents have high relapse rates upon leaving substance abuse treatment
●●2/3 to 4/5 relapse within 6 months
●Relapse Prevention
●●Cognitive behavioral theory
●●Often integrated into other treatment modalities (12 step)
●●Involvement of family and support system
●Some research support for relapse prevention among adolescent
111
Relapse Prevention Techniques
●Identify and avoid high-risk situations that are emotional and behavior triggers for
substance use (people, places, events)
●Monitor cognitions that occur in response to triggers
●●May be more able to use distraction
●Actively employ behavioral coping strategies
●●Leave a situation
●●Call a sober support person
112
Relapse Prevention Strategies
●Abstinence Violation Effect (AVE)
●Explains why people who resume using substances after a
period of abstinence may experience a more serious
recurrence.
●Negative feelings occur as a result of relapse
●All or nothing thinking, guilt, shame
●Person focuses on negative feelings rather than employing
coping responses to prevent future lapses
●Abstinence seems impossible
●Person at risk for reverting to regular us
113
LSD background
●1940s-early 1960s: Research tool to gain insight into mental illness
●1950s – 1950s: Treatment of alcohol addiction
●Meta analysis found that 59% with LSD treatment had lower
levels of alcohol misuse compared to 38% receiving placebo
●1950s-1970s: treatment of depression and anxiety
●1953-1964 – CIA experimented with LSD (Schedule I drug)
●1965 LSD limited to research and 1966 LSD became illegal
●By 1970s research stopped
●Reaction to popularity, recreational use, social/political
114
LSD
●Potential to treat alcoholism,
depression, patients dealing with
terminal illness
●How does LSD change the brain?
●“a bit like shaking up a snow globe” -> weakening the brain connections and dynamics
115
What is LSD assisted therapy like?
●Supervised sessions with therapists to build trust & rapport
●Patients reports intense positive and negative emotions
●Patients addressed painful thoughts & experiences
●Patients reported mystical experiences
●Treatment was safe and had lasting effects on decreased anxiety (12 months post treatment)
●●77% reduction in anxiety
●●67% increase in quality of life
116
MDM Assisted Psychotherapy
●MDMA is not approved for medical purposes
●Goal is to get FDA approval for assisted psychotherapy
●Listed by the FDA as a Breakthrough Therapy Designation for PTSD
●Alternative treatment for PTSD, social anxiety, anxiety with life-
threatening illness
●Therapy (8-10 sessions) + MDMA
●MDMA helps decrease fear and defensiveness, increases trust, affection, empathy
●Helps patients feel comfortable with the feelings of fear and
avoidance
●Helps patients face memories
117
More MDMA assisted
●Preliminary results, with rape survivors
●Long-term effects: 1 to 5 years, with few symptoms
●Effects with war veterans
●Sustained effects in PTSD at 12-month follow-up
●During treatment: decreased symptoms of anxiety, hyper-
arousal, depression, nightmares
118
MDMA assisted psychotherapy and PTSD
●83% of participants no longer receive a diagnosis of
PTSD at 2 month follow-up and maintain benefits 3.8
years later
119
Therapeutic Effects of Psilocybin
●Active agent in “magic mushrooms”
●Classic psychedelic and it primarily activates serotonin 2A receptor in the brain
●Potential to treat
●Anxiety, PTSD, depression
●Alcohol, tobacco addiction, cocaine addiction and methamphetamine addiction
120
Psilocybin & Cancer
●Charles Grob, MD (UCLA): First study on the therapeutic effects of
psychedelics to reduce anxiety and depression in terminally ill cancer
patients
●●6 month follow-up: Significant reduction in anxiety
●●Feasibility of using psilocybin for this treatment
●Roland Griffiths, PhD (Johns Hopkins) Double blind study (psilocybin or placebo) and published a report that psilocybin could be administered safely
●●Most meaningful experiences; among top 5 spiritual experiences
●●Personal well-being, life satisfaction, positive behavior change, depression and
anxiety
●●6 month follow-up: 80% showed decline in depression and anxiety and >80% reported life satisfaction
121
Psilocybin and cancer 2
●Stephen Ross, MD, Anthony Bossis, MD and Jeffrey Guss, MD (NYU):
●To assess if psilocybin reduces cancer-related anxiety in patients with advanced cancer
●Reduced anxiety and depressions, decreases in cancer-related demoralization and hopelessness,
improved quality of life and spiritual wellbeing.
●At 6.5 month follow-up, sustained benefits (60-80% had significant reductions in anxiety and depression
122
Psilocybin & Psychiatric disorders
●Francisco Moreno, MD (U of Arizona): pilot study showing
psilocybin reduced OCD symptoms with few adverse effects
●●First clinical use of psilocybin in 30 years
●●Promising findings as alternative treatment
●Michael Bogenschutz, MD (U of New Mexico): Psilocybin +
Motivational Enhancement Therapy for treating alcohol use disorder.
●Abstinence did not increase with MET but increased after psilocybin.
Maintained at 3 years post
●NYU is also studying its use of alcohol dependence
123
Psilocybin & Psychiatric Disorders (2)
●Johnson, Garcia-Romeu, Cosimano, Griffith: psilocybin-assisted psychotherapy for smoking cessation
●●First study in using psychedelic for tobacco addiction treatment
●●2-3 psilocybin doses + CBT
●●No adverse clinical events
●●80% of participants were smoke free at 6 month follow-up
(compared to 35% for other approaches)
●Carhart-Harris & Nutt (Imperial College): researching how
psilocybin could treat depression
124
Other psychedelic research
●Ayahuasca:
●●Effects on brain function, potential use for treatment of substance use (heroine and cocaine) and other disorders
(PTSD)
●●May help reduce use by promoting personal or insightful insights or self- knowledge
●Ibogain:
●●Reduce withdrawal from opiates and eliminate substance-related cravings
125
Are Psychedelics Safe? Considerations
●Dangers are possible, when taken without precaution
●Administered in safe, controlled environment
●Patients are screened carefully
●Substances are chemically pure
●Doses are lower than recreational users may take
●Therapeutic context: the experience is vivid and focused
●Combined with therapeutic approaches
●Many hoops, approvals and licenses to conduct this treatment,
including from the DEA
●Funding challenges
