Transcript It Takes a Village to Resolve an Addiction…And Certain

It Takes a Village to
Resolve an
Addiction…And Certain
Kinds of Villagers
Barbara S. McCrady
Center on Alcoholism, Substance Abuse, and Addictions
University of New Mexico
Presented at the Addiction Summit
“A Climate for Change”
Melbourne, Australia
10 July 2008
Individuals Live in Complex Social
Environments
Family of Origin
Work
Community
Organizations:
>Religious
>Social
>Service
Friends
Sex
Age
Race
Ethnicity
Religion
Sexual orientation
Family History
Genetics
Temperament
Personality
Psychopathology
Nuclear Family
>Spouse
>Children
Individuals Live in Complex Social
Environments
Family of Origin
Work
Community
Organizations:
>Religious
>Social
>Service
Friends
Sex
Age
Race
Ethnicity
Religion
Sexual orientation
Family History
Genetics
Temperament
Personality
Psychopathology
Nuclear Family
>Spouse
>Children
Purpose of Talk
 To
briefly review what we know about
social support and alcohol/drug use
disorders
 To discuss selected findings from outside
our field that might help us think more
broadly about how social support works
 To pose some questions
 To present some modest propositions
Positive Social Support
“It takes a village to hold a world.” Photograph courtesy of Diane Walker
Harry Harlow’s Monkeys
Wire Milk Mother
Cloth Mother
Social Support and Health
“Social bonding and soothing behaviors mitigate the destructive
effects of negative environmental events and promote enhanced
health and well-being (Berscheid, 2003). Indeed, social isolation
is now considered a major health risk (House, Landis, &
Umberson, 1988). Moreover, married people tend on average to
be happier and healthier than unmarried people (Wood, Rhodes,
& Whelan, 1989), and among married individuals, higher
marital quality is associated with decreased risk of infection,
faster recovery from injury, and a lower rate of mortality following
a diagnosis of life-threatening illness.”
Coan et al., 2006
Alcohol/Drug Use and Positive
Social Support
Ethanol consumption (g/kg)
Monkeys and Drinking
4
3
Nursery
Reared
Mother
Reared
2
1
0
1 2 3 4 5 6 7 8 9 10 11 12
Months
Davenport, Maxey, Daunals, & Friedman, 2008
Social Support and the
Resolution of SUDs
 Having
more social support is associated
with better drinking outcomes


Support from the most important person
Number of supportive persons
 Having
more nondrinking friends is
associated with better outcomes
 Both alcohol specific and general support
are important
Quality of Relationships is
Associated with SUD Outcomes
 Family
adjustment
 Family cohesion
 Active, recreational orientation
 Low conflict
 Quality of marriage
 Specific marital support
When Social Support Goes Awry
The Four Horsemen of the
Apocalypse
 Criticism
 Defensiveness
 Stonewalling
 Contempt
When Social Support Goes Awry for
Alcohol and Drug Users
Negative Family Functioning
1.2
Proportion Abstinent
1
0.8
Low Expressed
Emotion
High Expressed
Emotion
0.6
0.4
0.2
0
100
200
300
Days Since Entering Behavioral Couples Therapy
O'Farrell et al. (1998)
Negative Social Environmental
Predictors of Outcome
 Support
for drinking predicts negative
outcomes
 Having more drinking friends is associated
with poorer outcomes
 Certain partner behaviors predict a
negative response to treatment



withdrawing from the drinker
avoiding dealing with drinking
tolerating drinking
Social Support and Treatment
Social Support and Treatment
 Involving
a concerned significant other in
treatment improves outcomes



For persons who have not sought treatment
themselves
For men and women with alcohol or drug use
disorders
For teens
Influencing Problem Recognition
and Help-Seeking
Unilateral Family Therapies
70
% engaged
in treatment
60
50
40
30
20
10
0
Miller et al., 1999
Al-Anon
facilitation
Unilateral
(CRAFT)
Johnson
Intervention
Engaging Families in Treatment Alcohol Behavioral Couples Therapy

Focus on primary intimate relationship
 Based on cognitive-behavioral approaches to:



Alcohol use disorders
Distressed relationships
Three major treatment elements



Teach abstinence skills
Teach partner behaviors to cope with drinking and
support change
Improve intimate relationship
Alcohol Behavioral Couples
Therapy and Abstinence
Percent Days Abstinent
100
90
80
70
60
50
40
30
Treatment
Follow-up
20
10
0
* 8* 9* 10
* 11* 12* 13
* 14* 15* 16* 17* 18*
1 2 3 4 5 6 7
Months
McCrady, Epstein, Cook, Jensen, & Hildebrandt, 2008
ABIT
ABCT
Alcohol Behavioral Couples
Therapy and Heavy Drinking
Percent Days Heavy Drinking
40
35
30
25
ABIT
ABCT
20
15
10
Treatment
Follow-up
5
0
* 8* 9* 10
* 11
* 12
* 13 14 15* 16* 17* 18*
1 2 3 4 5 6 7
Months
McCrady, Epstein, Cook, Jensen, & Hildebrandt, 2008
Social Support in
Detoxification
A
simple meeting with the person in a
detoxification program and a concerned
other to recommend continuing care
resulted in:


92% entering continuing care
vs
62% who received treatment as usual
O’Farrell, Murphy, Alter, & Fals-Stewart, 2008
A Pause
The first half of the talk:
 We
have a fundamental drive to connect
and be connected
 Positive social support plays a powerful
role in change in addictions
 Social influences also play a powerful role
in perturbing the process of change
 Treatments that involve significant others
lead to better outcomes
What’s to come:
 Three



questions to contemplate:
How does social support actually change a
person’s behavior?
How do people elicit or repel social support?
How do people effectively provide social
support?
How Does Social Support
Change a Person?
Social Support Affects Brain
Function
Responses measured in fMRI when
•Husband hand-holding
•Research assistant hand-holding
•No hand-holding
Coan, Schaefer, & Davidson, 2006
Social Support Affects Brain
Function

The unpleasantness of the threat was lower
when anyone held the woman’s hand
 Neural activation to the threat was lower when
her husband held her hand than when no one
held her hand in:


Right dorsolateral prefrontal cortex, left caudate–
nucleus accumbens, and superior colliculus
Neural activation to threat was lower when
anyone held her hand in:

Ventral anterior cingulate cortex, posterior cingulate,
right postcentral gyrus, and left supramarginal gyrus
fMRI Results
Coan et al., 2006
How Does Social Support Change a
Person with an Alcohol/Drug Problem?
 Does





it impact psychological functioning?
Motivation?
Self-efficacy?
Outcome expectancies?
Coping skills?
Affect regulation?
 Does
it damp down craving responses to
alcohol cues?
 Does it impact neural function?
Social Support Affects
Motivation

Unpublished research from McCrady graduate
student, Dorian Hunter-Reel:



Used structural equation modeling to test the impact
of pretreatment social support on 3-month motivation
Then tested the impact of 3-month motivation on 9month drinking outcomes in a sample of women with
alcohol use disorders
Pretreatment support for drinking was a negative
predictor of 3-month motivation
 Motivation partially mediated the relationship
between support for drinking and 9-month
drinking outcomes
Social Support Affects Self-Efficacy
Abstinence
SelfEfficacy
.21 (SD = .08) *
AA
Exposure
.30 (SD = .05)
.33 (SD = .11) *
Positive
Outcome
Reduced to = .21 (SD = .06)
Forcehimes & Tonigan, in press
Does Social Support Affect
Neurocognitive Function?
A



study in progress:
Exposure to alcohol cues for persons with
alcohol use disorders in an fMRI
Present these alcohol cues with and without
intimate other present and holding the
drinker’s hand
Examine changes in brain function in regions
associated with reward
Ladd, McCrady, Hutchison, & Tonigan, in progress
How do People Elicit or Repel
Social Support?
What does a Person do to Have
Good Social Supports?
 How
does a drinker/drug user find social
networks that will support nonproblem
alcohol or drug use?
 How does a drinker/drug user engage
others to provide support?
 We don’t have answers to these questions
What Does a Person Do that Makes
it Hard to Obtain Social Support?
 Can
a drinker or drug user drive others
away through alienating behaviors (other
than those associated with the substance
use)?
Alienating Interpersonal Behaviors
Variable
B
SE B
Step 1: Baseline
Percent Drinking Days
0.39
0.08
0.43
Step 2: Tx Condition
5.77
4.76
0.11
0.01
Step 3: Baseline
Alienating Interpersonal
Behaviors
1.06
0.36
0.03
0.07**
** p < .01
Hunter Reel, McCrady, & Epstein, 2007
Beta
Adjusted R2
Change
0.13**
What Do Other Persons do to Provide
Effective Social Support?
Providing Effective Social Support
 Having
a sponsor is one of the strongest
predictors of success in AA

But, we know nothing about effective and
ineffective sponsoring
 We
know that having a supportive family
enhances outcomes, but we have not
isolated effective family behaviors
Implications for Change
Some Modest Propositions





We should consider the universality of the need
for bonding, attachment, and love in thinking
about the change process
Treatment should create an environment of
bonding and attachment
Treatment should help individuals learn to elicit
support from others
We should help individuals in the social support
system learn to delicate balance between
“enabling” and effecting change
We should find more ways to bring treatment to
people in their existing social environments
Some Research Needs

Study the psychological interface between the
social environment and the individual – what
happens at a psychological level?
 Study the brain functions that underpin positive
social support to learn to enhance the impact
and understand more about how it goes awry
 Study people who are particularly effective at
eliciting positive social support
 Study people who are particularly effective at
providing positive social support, even in the
face of negative behavior
It Takes a Village to Resolve an Addiction…
And Certain Kinds of Villagers