Transcript Selling an Idea or a Product - East Bay Community Recovery
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 problems or unresolved conflicts psychological
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 there something moving me toward relapse??” “Is
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?