Providing Substance Abuse Treatment in Private Practice Joan E. Zweben, Ph.D. Executive Director: East Bay Community Recovery Project Clinical Professor of Psychiatry; UC San Francisco IN COLLABORATION WITH Arnold Washton, Ph.D. Recovery Options New York, NY & Princeton, NJ Today’s Topics Addiction Treatment versus Psychotherapy Recovery-Oriented Therapy: Integrative Model Psychodynamics of Addiction & Recovery Motivational Interviewing & Stages of Change Assessment Techniques Stage-Specific Treatment Interventions Addiction Treatment & Psychotherapy Rift between psychotherapy and mainstream addiction treatment Different beliefs about the fundamental nature of addiction Many addiction treatment programs subscribe to a biopsychosocial model; some are rigidly disease model Prevailing view among psychotherapists is either a learning/behavioral model or a psychodynamic model Many believe that if the behavior is learned, it can be unlearned, changed, or controlled or that insight will produce change Rift between psychotherapy and mainstream addiction treatment Psychodynamic therapists tend to view addiction as merely a symptom of underlying psychological problems or unresolved conflicts Therapists who search for the “root causes” of an active addiction can be compared to a paramedic rushing to the scene of an accident with injured victims lying bleeding on the ground and taking time out before attending to the victims to ask what caused this accident to happen. Rift between psychotherapy and mainstream addiction treatment Seeing addiction as a symptom fosters the unrealistic belief that once the underlying problems are resolved the person can return to using alcohol or drugs moderately. Psychodynamic therapy can be very helpful during latter stages of recovery when abstinence is reasonably secure, but in the early stages it can serve as a form of enabling and also stimulate further alcohol/drug use when highly charged emotional issues are uncovered too early in the recovery process. Rift between psychotherapists and mainstream addiction treatment field In the early abstinence stage, the emergence of highly charged issues (e.g., childhood traumas) threatens to overwhelm the addict’s shaky sense of self and fragile commitment to abstinence. Feelings that have been medicated and numbed for years by alcohol/drugs often emerge once the chemical blanket is removed. Mainstream addiction treatment has traditionally downplayed the psychological aspects of addiction and devalued the role of psychotherapy in fostering long- term recovery. Some believe that AA alone is enough. Recovery-Oriented Psychotherapy An Integrative Approach Stages of Recovery-Oriented Therapy 1. Assessment with motivational feedback 2. Engaging the client who is actively using 3. Negotiating an abstinence contract 4. Helping the client to stop using (early abstinence) 5. Consolidating abstinence, changing lifestyles, developing adaptive coping skills (relapse prevention) 6. Addressing developmental/interpersonal issues (psychotherapy) Recovery-Oriented Psychotherapy Framework that integrates disease model addiction treatment with abstinence-based psychotherapy Individual, group, & couples therapy Supports, facilitates , and encourages but does not mandate involvement in AA Therapist’s tasks shift according to the patient’s stage of recovery Collaborative stance toward the patient Therapist’s Role Facilitate change Mobilize motivation Non-judgmental coach, advisor, and guide Educator Voice of reason and reality Safety net and backstop Steady, reliable resource Supply ego functions that the patient lacks Stance of the Therapist Primacy of the therapeutic alliance Respect for patient’s autonomy while providing forthright feedback Respect for change as a process Respect for individual differences Awareness of transference & countertransference dynamics Countertransference Abrupt or unilateral changes in the treatment plan Rejecting, controlling, stereotyping behaviors Disengaged or over-involved Rescue fantasies Preoccupation, dreams, anxiety Emotionally depleted- “burnt out” Hoping that the patient cancels or no shows Excessive self-disclosure Need to be idealized What NOT to do Warn of dire consequences Impose negative consequences Take an authoritarian stance Reject and/or abruptly terminate the patient Ally with others against the patient Change treatment plan out of anger or frustration Act out savior & control fantasies Act out other countertransference dynamics Integrative Approach Stages of change Motivational interviewing Cognitive-behavioral techniques Disease model & AA Adaptive “self medication” model Psychodynamic, insight-oriented techniques Using Different Strategies at Different Stages 1. Initially, focus on motivational issues and treatment engagement 2. Once the client becomes willing to change, utilize cognitive-behavioral strategies to facilitate transition from active use to stable abstinence 3. As recovery proceeds, incorporate insight-oriented techniques to address broader issues, but always keeping addiction issues in focus Integrative Approach Treatment must address more than the substance abuse itself: Developmental arrest Interpersonal problems Managing feelings Self-esteem issues Co-existing Axis I & II disorders Other addictive/compulsive behaviors Key Points There is no single best pathway to recovery for everyone Accept that you are powerless to control another’s drug use; let go of your control fantasies Maintain an empathic connection; the single most important aspect of treatment is the therapeutic alliance Key Points Re-conceptualize resistance as ambivalence Start where the patient is- NOT where you want him/her to be Listen to your clients. They will tell you what they are ready or not ready to do. Psychodynamic Issues at Different Stages Psychodynamic Issues in the Early Phase Therapeutic alliance Warmth, empathy, positive regard Trust, respect, concern Unconditional acceptance Consistency & availability Counteract internalized self-loathing, shame, guilt Support self-efficacy, autonomy, reduce dependency fears Environment of safety: accountability, limits, realistic feedback, boundaries Psychodynamic Issues in the Middle Phase Ongoing ambivalence about giving up alcohol/drugs “I’ve stopped using, but I’m still unhappy” Affect management: “self-medication” Defining interpersonal, self-esteem, and boundary issues Shame and guilt issues Psychodynamic issues in later stages Intimacy with autonomy* Separation-individuation* Affect management: “self-medication” Grief and loss Early traumas Residual narcissistic & controlling behaviors Couples Issues Choosing a mate while actively addicted Power dynamics: control and dominance Equality: no longer willing to be discounted Out of synch: personal responsibility for behavior/problems, having an “observing ego” Lingering resentments: especially infidelities !! Jealousy: support system, therapist, group Will he/she still want me? Will the relationship survive recovery? Good Prognostic Signs Joined prior to onset of the addiction Willing to learn about addiction/recovery and use opportunity to enhance his/her own life Willing to enter couples or individual therapy and Al-Anon to address his/her own unresolved issues Will the relationship survive recovery? Poor Prognostic Signs Joined while addiction was active Unrelenting anger, hostility, resentment Refuses to take any responsibility whatsoever for contributing to the mess Unable to see the need for personal change: it’s all his/her fault, not mine ! Unwilling to go for therapy or to Al-Anon Relapse Dreams Can occur at any stage Wake up not sure whether they have actually used Worst fear is that the dream is prophetic In early stage often due to ambivalence and self-doubt In middle stage often due to fears about relapse- “Is there something moving me toward relapse??” In latter stages often stimulated by unresolved issues and/or being overwhelmed with feelings Relapse Dreams What feelings were stimulated by the dream? Why did this dream occur at this particular point in time? What could the dream be telling you about where you need to strengthen your recovery plan? What issues/problems may have given rise to the dream? Does the dream signal unresolved or renewed ambivalence about giving up alcohol/drugs? Motivational Interviewing and the Stages of Change Facilitating Change Motivational Interviewing offers a way to conceptualize and deal more effectively with problems of patient resistance and poor motivation Stages of Change Model provides a framework for determining the readiness of patients to change their behavior and for matching treatment interventions accordingly Stages of Change Precontemplation- Not seeing the behavior as a problem or feeling a need to change (“in denial”) Contemplation- Ambivalent, unsure, wavering about necessity and desirability of change Preparation- Considering options for change Action- Taking specific steps to change behavior Maintenance- Relapse prevention Relapse- Returning to use or earlier stage of change Stages of Change Stages of Change Model Facilitates empathy- patients seen as “stuck” in a particular stage of the process rather than “resistant” Defines ambivalence as normal not pathological Leads to better patient-treatment matching by defining the types of clinical interventions that work best with patients in each stage of change Provides “roadmap” and sets the tone for more positive interaction with “resistant” patients Motivational Approach Start where the patient is Roll with resistance Avoid arguments, power struggles Back off in the face of resistance Be persuasive not confrontive Reframe resistance as ambivalence Offer choices to increase patient acceptance and investment Negotiate, don’t pontificate Acknowledge positive drug effects Adjust interventions to stage of readiness for change Diagnosis Substance USE Absence of problems/consequences No apparent or significant risk No obsession or preoccupation Under volitional control Substance ABUSE Use is associated with significant risks or consequences Exceeds medical/cultural norms No obsession or preoccupation Under volitional control Substance DEPENDENCE Continued use despite adverse consequences Impaired control Preoccupation/obsession Exaggerated importance/priority Tolerance/withdrawal (optional) NIAAA “Low Risk” Drinking MEN No more than 14 drinks per week (2 per day) and no more than 4 drinks per occasion WOMEN No more than 7 drinks per week (1 per day) and no more than 3 drinks per occasion SENIORS- OVER AGE 65 No more than one drink per day One “Standard” Drink One 12 oz. bottle of beer One 5 oz. glass of wine 1.5 oz of distilled spirits “Low Risk” Qualifiers PRESUMES ABSENCE OF: Pregnancy Medical or psychiatric conditions likely to be exacerbated by ETOH use Medication that interacts adversely with ETOH Prior personal or family history of substance abuse Hypersensitivity to alcohol “At Risk” Drinking Frequently exceeds recommended limits No evidence yet of adverse consequences Drinking exposes the individual to significant risk Prime target for preventive efforts “Problem Drinking” ALCOHOL ABUSE Evidence of recurrent medical, psychiatric, interpersonal, social, or legal consequences related to alcohol use; OR Being under the influence of alcohol when it is clearly hazardous to do so (e.g., operating a vehicle or other machinery, delivering health care services) No evidence of physiological dependence No prior history of alcohol dependence “Alcoholism” ALCOHOL DEPENDENCE BEHAVIORAL syndrome characterized by: Compulsion to drink Preoccupation or obsession Impaired control (amount, frequency, stop/reduce) Alcohol-related medical, psychosocial, or legal consequences Evidence of withdrawal- not required Evidence of tolerance- not required Assessment Techniques Assessment Goals Assess nature and extent of substance use Assess nature and extent of substance-related problems and consequences Assess patient’s stage of readiness for change Formulate an initial diagnosis Provide motivation-enhancing feedback based on assessment results Assessment Domains Typology of use Positive benefits Negative consequences Need for medical detoxification Other addictive behaviors Prior attempts to stop or cut down Prior treatment and self-help experience Diagnostic signs of substance dependence disorder Family history of alcohol/drug problems Stage of readiness for change Typology of Use Types of substances Amount/frequency Administration route (oral, intranasal, pulmonary, i.v., i.m.) Temporal pattern (continuous, episodic, binge) Environmental precursors (external “triggers”) Emotional precursors (internal “triggers”) Settings and circumstances linked with use (people, places..) Linkage with use of other substances (e.g., cocaine-alcohol) Linkage with other compulsive behaviors (sex, gambling, spending, eating, etc) Positive Benefits of Use What first attracted you to this drug? How has it helped you? Does it still work as well? What would be the potential downside of not using it? Negative Consequences Medical Job,Financial Relationships Legal Psychological Sexual Medical “Red Flags- ALCOHOL Hypertension Blackouts Injuries Chronic abdominal pain Liver problems Sexual dysfunction Sleep problems Depression/anxiety Medical “Red Flags” COCAINE Chronic nasal/sinus problems (snorting) Chronic respiratory problems (smoking crack) Sexual dysfunction Labile moods, paranoia, suicidal ideation Sleep problems Seizures Abuse of alcohol and sedatives Medical “Red Flags”OPIOIDS For Rx opioids: requests for increased doses, frequent refills, multiple prescribers, “lost” prescriptions Sexual dysfunction Amenorrhea Sleep problems Constipation Liver problems Biochemical Indicators of Alcohol Abuse Most markers are late stage and not very reliable indicators of alcohol problems Best used in combination to confirm diagnosis & establish baseline for follow up GGT gamma-glutamyltransferase MCV mean corpuscular volume AST aspartate aminotransferase Urine Toxicology- Drugs Detects only recent use (past few days) No information about amount, frequency, or chronicity of use No information about problem severity Best used as a clinical tool to monitor treatment progress Psychosocial Consequences Vocational: Work life adversely affected? Relationships: Family/marital relationships or home life been adversely affected? Legal: Any legal trouble? (e.g., DWI) Psychological: Mood or mental functioning been adversely affected? Suicidal thoughts or actions? Sexual: Sex drive or performance been adversely affected? Cocaine or amphetamine-related hypersexuality and acting out behavior? Need for Medical Detoxification Benzodiazepines, alcohol, opioids Abrupt withdrawal from alcohol/benzos can be life threatening and must be managed medically Opioid withdrawal is uncomfortable, but not life threatening, except when another medical condition could be exacerbated (e.g., heart problems) Negotiating Goals and Strategies for Change If patient seems willing to consider change Suggest “experiment” with total or partial abstinence Suggest reduction of at least 50% Suggest alcohol reduction to below “at risk” levels Suggest gradual tapering toward abstinence (“warm turkey”) Value of “Experiment” with Abstinence Provides useful clinical data Role of substance use in patient’s life Reliance on “self medication” to cope Experience things through a “different set of eyes” Impact of abstinence on mood, affect, coping ability Identify internal and external triggers of use Indication of how easy/difficult it is to stop using Stage-Appropriate Goals Precontemplation- Increase awareness, raise doubt Contemplation- Tip the balance toward change Preparation- Select the best course of action Action- Initiate change strategies Maintenance- Learn relapse prevention strategies Relapse- Get back on track with renewed commitment to change If patient is NOT willing to consider change Do not react to patient resistance as a challenge to your judgement or authority Avoid getting into arguments or debates about how much drinking or drugging is too much Avoid using the labels “addict” “alcoholic” Emphasize to patients that only they can make the decision to change- you have no desire to pressure them for change Agree to disagree: restate your concerns about need for change Your primary goal is to maintain an ongoing dialogue about their alcohol/drug use and continue to assess Working with Patients in the Precontemplation Stage GOAL: Help patients see that maybe there is a problem Don’t expect immediate agreement or action Avoid getting into debates or power struggles Discuss the pros/cons: the “good things” and “not so good things” about using alcohol/drugs Acknowledge positive benefits of use Ask patients to keep daily diary of substance use to heighten awareness of when/how much they use Working with Patients in the Precontemplation Stage Re-state your concerns about medical and psychosocial consequences Suggest bringing in a family member/significant other Ask: What would have to happen for you to decide that your use has become a problem? Discuss discrepancies between patient’s view versus others’ view of the substance use Agree to disagree, but continue the dialogue Working with Patients in the Precontemplation Stage Columbo Technique: “Maybe I’m not entirely correct. I suppose it’s possible that your substance use is not nearly as serious as it might appear. I wonder where I may have gone wrong?” At all cost, don’t antagonize or alienate the patient Don’t give up assuming that you are just wasting your time: subliminal change still may be occurring! Express your interest and curiosity, keep the door open, ask permission to continue the dialogue, resist your temptation to pressure for change Working with Patients in the Precontemplation Stage Avoid prescribing action-oriented strategies Acknowledge positive benefits of alcohol/drug use Draw connections between substance use and presenting complaints Educate about some of the subtle, insidious effects of substance use on values, priorities, self-esteem, coping abilities, mood, personal growth Ask about the extremes- the worst, the most Help patients assess the potential and not-so-obvious risks of continuing to use (play the tape forward, what if...) Working with Patients in the Contemplation Stage GOAL: Reduce ambivalence and facilitate movement toward change Don’t jump ahead: If you push too hard for change, the patient will retreat and defend the use Discuss fears and drawbacks about reducing or stopping use Discuss potential barriers to reducing or stopping use Working With Patients in the Contemplation Stage Being of “two minds” about stopping Being unsure, undecided, wavering Therapist: “Speak to me from the side of you that still feels positively about your alcohol/drug use and wants to continue using, despite the problems that it appears to be causing you.” Working with Patients in the Contemplation Stage Normalize ambivalence Acknowledge positive benefits of substance use Help the patient tip the balance in favor of change: Review the “good” and “not so good” things about use Review same for any prior periods of abstinence Highlight discrepancies : where you are now versus where you want to be (values vs. actions) Discuss expectations and anticipated difficulties with changing Working with Patients in the Contemplation Stage Emphasize personal choice- this is your decision Propose a brief “experiment” with abstinence or moderation What are you willing to consider doing at this point? Suggest keeping a diary of use Working with Patients in the Contemplation Stage Ask the “Miracle Question” (Berg & Miller) “How would your life be different if by tomorrow morning your substance use had miraculously disappeared? What would you notice? What would others notice?” Working with Patients in the Preparation Stage GOAL: Choose a realistic plan of action with goals that feel achievable to the patient Compliment for planning to take action Acknowledge any positive steps taken thus far Negotiate specific goals and time frame Explore what has worked and not worked in past Discuss menu of treatment options and offer recommendations, but respect patient’s autonomy to choose Working with Patients in the Preparation Stage Discuss the practical “nuts-and-bolts” of how the patient’s goals will be accomplished Discuss potential obstacles and how to overcome them Working with Patients in the Action Stage Support a realistic view of change through small steps Create structure, support, and safety net (e.g., frequent visits, drug testing, family involvement, linkage with AA) Acknowledge difficulties in the early stages of change Convey optimism and hope while working through initial setbacks Assist the patient in finding new reinforcers of positive change Action Stage Strategies to Help the Patient Stop Using External Triggers Internal Triggers Impulse (Craving) Control Onsite Alcohol & Drug Testing Short-Term Focus Develop Support System Clinical Value of Alcohol/Drug Testing Deterrent to impulsive use Disrupts denial Objective marker of progress Rapid identification of use Restores credibility with S.O.’s NOT intended to uncover lies; avoid “gotcha” Action Stage CAUTIONS! This is NOT the time for uncovering psychotherapy. It will likely elicit strong affects that the patient is not prepared to handle without returning to “self medication” with alcohol/drugs Contain and postpone work on highly charged issues (e.g., trauma, victimization) until stable abstinence and recovery has been attained of at least 6-12 months. Offer strategies to manage feelings, vs resolve issues. Working with Patients in the Maintenance Stage Reinforce a proactive stance toward preventing relapse; educate that relapse is a process not an event Address affect management (“self-medication”) and other psychological issues (e.g., self-esteem, boundaries, relationships, traumas) Never lose sight of the SU disorder; remain ever- vigilant for early warning signs of relapse Respond therapeutically to slips and relapses Working With Patients in the Maintenance Stage Relapse is a process that begins before the person returns to alcohol/drug use A key to preventing relapse is developing awareness of early warning signs and taking appropriate action to short-circuit the relapse process that has been set in motion Responding to Slips & Relapses Express empathy and understanding to counteract shame and guilt “Relapse Debriefing”- ask for recounting of specific events leading up to use Focus on antecedent feelings, moods, and behaviors Reframe as acting out of ambivalence- “being overtaken by the side that still wants to use” Case Example: “James” Demographics: 40 yo investment banker, married for past 5 years, wife is an attorney who stopped working last year during difficult pregnancy and now stays home with 1 yo twins Presenting problems: marital discord, depression Substance use: 2-3 martinis, 4-5 evenings per week at local bar before coming home from work. Smokes marijuana on weekends. Pattern has existed for past year. No prior or family history of SUDs James’ Presenting Complaints “My problem is that since my wife gave birth to our twins, our marriage and sex life have gone down the tubes. We are at each other’s throats from the minute I come home from work until we fall asleep from exhaustion. The only way I’m able to tolerate this situation is to drink every evening on my way home from work. But then I wake up the next morning feeling depressed. Over the past year, my depression has been getting worse and my wife has become furious about my drinking. I know I should probably do something about the drinking, but I just can’t deal with the thought of coming home at night without medicating myself first. The pot is not really a problem except that it stimulates my appetite and causes me to gain weight. I came here for help with my marital problems hoping that if I made some headway I’d be less likely to drink. I don’t think that I’m an alcoholic and I’m unwilling to even think about going to AA meetings. I also think that antidepressant medication might help me.” “James” Stage of change? For alcohol For marijuana What else would you want to know about his substance use before formulating an initial diagnosis? How would you approach him? What types of interventions would you deliberately want to avoid with James at this point? Case example: “Lorraine” Demographics: 38 yo, self-employed as freelance editor, never married, no children, lives alone Presenting Problems: low self-esteem, intense conflict with controlling parents, unsuccessful relationships with men, confusion about sexual orientation (bisexual?) Substance Use: intranasal cocaine use 1-2 times per month, stays up all night with female friend embroiled in intense conversation, drinks beer/wine to come down from cocaine, smokes marijuana occasionally to relieve work-related stress. Pattern has remained unchanged for past two years. Diagnosed with depression as teenager. Adamantly against going to a treatment program or AA. Lorraine’s Presenting Complaints “I’m here because I want to feel better about myself. Nothing makes me happy and I’m confused. I’m tired of chasing after business just to keep up with paying bills, especially since I stopped taking money from my parents. I thought my cocaine use was getting a little out of hand, but I’ve cut down recently. I’ve used it only once in the past two weeks. I seem better able to control it now. Sometimes I drink too much while doing cocaine and then feel horrible the next day. Otherwise, alcohol is not a problem for me. Pot helps me a lot. It’s a great stress reliever and I don’t want to even consider giving it up. Actually, it works a lot better for me than any of the medications I’ve been given by psychiatrists. “Lorraine” Stage of change? For cocaine For alcohol For marijuana What else would you want to know about her substance use before formulating an initial diagnosis? How would you approach her? What types of interventions would you specifically want to avoid with her at this point?
Pages to are hidden for
"Selling an Idea or a Product"Please download to view full document