Seminar 2: Clinical

Seminar Leaders:

Ghislaine Badawi& Sarah Farstad

Supervisor:

Roisin O’Connor, Ph.D.

October 30, 2013

From Research to Practice and Back Again

 Scientist Practitioner Model (Boulder Model)    Typically a graduate training model Integration of science and practice Each constantly informs the other  What does this look like for you?

 3 minutes to think about how your research will inform treatment

Themes that Might Emerge

 Predictors of addictive behaviours span biological, psychological, and social/environmental domains    Individual level    Genetics Personality Motivation Environmental  Cultural norms Individual by Environmental   Family dynamics Social learning

Developing Treatments

 Treatments rooted in one model/theory   Empirically test: efficacy, effectiveness Pros/Cons  Biopsychosocial model of treatment (e.g., Maisto, Connors, Dearning, 2007)    Addictive problems are heterogeneous Multifaceted approach to treatment Pros/Cons

Where are we now?

 Utility of a trans-theoretical model of change  Currently available treatments

Part A

The Trans-theoretical Model of Addiction

Transtheoretical model (TTM)

 1970s: Effort to provide coherent theoretical organization to describe a predictable behavior change process  One of the dominant models of health behavior change in the field over the last 20 years.  Applied to wide range of health behaviors  Applications to substance abuse  Utility widely debated

Stages of Change

Constructs

Stages of Change Precontemplation Contemplation Preparation Action Maintenance Termination

Description

No intention to take action within the next 6 months Intends to take action within the next 6 months Intends to take action within the next 30 days and has taken some behavioral steps in this direction Changed overt behavior for less than 6 months Changed overt behavior for more than 6 months No temptation to relapse and 100% confidence

Process of Change Constructs-Experiential

Constructs Process of change Description

Consciousness raising Dramatic relief Self-reevaluation Environmental reevaluation Social liberation Finding and learning new facts, ideas, and tips that support the healthy behavior change Experiencing the negative emotions (fear, anxiety, worry) that go along with unhealthy behavioral risks Realizing that the behavior change is an important part of one’s identity as a person Realizing the negative impact of the unhealthy behavior or the positive impact of the healthy behavior on one’s proximal social and/or physical environment Realizing that the social norms are changing in the direction of supporting the healthy behavior change

Process of Change Constructs- Behavioral

Constructs Process of change

Counterconditioning

Description

Substitution of healthier alternative behaviors and cognitions for the unhealthy behavior Reinforcement management Increasing the rewards for the positive behavior change and decreasing the rewards of the unhealthy behavior Stimulus control Removing reminders or cues to engage in the unhealthy behavior and adding cues or reminders to engage in the healthy behavior Helping relationships Self-liberation Making a firm commitment to change

Process and Stages of Change

Trans-Theoretical model constructs

Constructs Description

Decisional Balance

Pros Benefits of changing Cons

Self-Efficacy

Costs of changing Confidence Temptation Confidence that one can engage in the healthy behavior across different challenging situations Temptation to engage in the unhealthy behavior across different challenging situations

Processes of change in addictive behaviors

 Drinking: Support for conceptualization of change processes   Those in action used action-related processes (post relapse cessation of drinking) AA     Support for change processes Associations between process use and recovery behaviors Greater involvement in AA  processes greater use of TTM Abstinent and moderate drinkers  change processes more engagement in

Processes of change- Research Summary

 Fewer applications of TTM processes of change construct to substance use behaviors than applications of the stages of change  Evidence more consistent than for stages of change

Decisional Balance

 Seen as important clinical tool in working with substance abuse  Few empirical examinations  Drinking: Pros and cons of alcohol use demonstrated hypothesized relationship with stage of change  Cons and declining pros  progression Increasing stage  Pros and Cons change over time

Self-efficacy and temptation

 Few studies, consistent results, tobacco and alcohol only  More alcohol involvement and earlier stages of change for drinking  higher levels of self reported temptation to drink + lower levels of confidence to abstain  Useful way of conceptualizing use of other substances?

TTM Summary

 Promising approach to problem of substance abuse  Focus on working with individual’s readiness to change  Way of conceptualizing notions of denial and resistance, less pathologizing, descriptive understanding of substance abuse  Well-suited to patters of substance abuse

Unanswered questions

 Applicability to substance abuse far from established  Focused on stages of change  More research needed to address full range of TTM constructs to provide an adequate test of TTM applicability to substance abuse  Validity of TTM to substance abuse: Mixed results  Variability of measurement of TTM constructs (i.e., stages of change) - ambiguity

Variation

  Across populations  Applications of TTM to different substances carry different nuances   Illegal vs. Legal substances Readily available substance vs. controlled substance  Variation in behavior Across patient populations: insufficient research  Single-sexed samples, incarcerated, primary care, veterans, inpatients, college students  Discrepant findings: inconsistencies in the model or expected variations across populations?

Predictions vs. Description

 Mostly studies describing stages of readiness in various groups of substance abusers  Cross-sectional associations with drinking and treatment seeking behaviors  TTM provides   Different typologies of substance use and treatment seeking patterns rich clinical framework for describing substance abuse and its manifestations

Limitations

 Beyond the task of simple description…  Ability to reliably chart course of substance abuse recovery?

 Lack of longitudinal applications of the model to substance use   Can’t elucidate dynamics of processes of change Predictive meaning of movement from one stage to another  No specification of apriori hypotheses

Conclusion

 Ambitious model, integrated, comprehensive, applicable to conceptualizing substance use  Significant impact on treatment and understanding of substance use disorders   Theoretical model that has been empirically tested Mixed results  caution  Validate across range of substance abuse problems

Discussion

 What do you think about applying the transtheoretical model to substance use and abuse?

 Do you think that gender plays a role in the trans theoretical model?

 If so, in which part of the model would you expect to find gender differences?

 Do you think the model can be applied equally well to males and females?

Activity

 Choose a behavior that you would like to change or make up a behavior that could be applied to the TTM. Come up with examples for as many stages and processes of change as possible.

Part B

Alcohol and Gambling: Empirically Supported Treatments

Empirically supported treatments

 Many psychological interventions exist today  Increased emphasis on empirically supported treatments  Why should we focus on empirically supported treatments?

Addictions treatment

 Various treatment orientations:    Behavioral Cognitive Social  Treatment goals:   Abstinence Harm Reduction/Moderation

Psychosocial Treatment for Alcohol Use Disorders

 Motivational treatments  Twelve-step facilitation therapy  Cognitive-behavioral therapy: standard, relapse prevention, coping and social skills training  Behavioral therapy

Empirical Evidence

 Psychotherapy is better than no treatment  No single approach is better than others  Motivational treatments and 12-step facilitation therapy work best as adjuncts to treatment  No support for counselling, short-term psychodynamic therapy, self-help based treatment, psychoeducational interventions, mindfulness meditation NICE Guidelines, 2011

Gambling treatment: Additional considerations

 Most gamblers do not seek treatment  Cognitive distortions  Financial consequences

Psychosocial Treatment for Gambling Addiction

 Existing addictions treatments are extended to gambling  Motivational interventions  Cognitive behavioral therapy  Much less empirical evidence  CBT is showing promising results Westphal, 2008

Why does sex/gender matter?

 Most treatments are based on knowledge about men with addictions despite the fact that men and women have:    Different motivations for engaging in addictive behavior Different comorbid mental health conditions Different reasons for relapse

Discussion

 Based on the article for this week:    Why do you think women did more poorly in treatment?

Why do you think women were more dissatisfied with the treatment?

What would you suggest to improve treatment for women?

 What effect do you think gender might have on treatment outcome?  How could gender be incorporated into addictions treatment?

Activity

 1.

2.

3.

Use the resources provided to answer the following questions: What are the advantages and disadvantages of running single-gender groups for gambling treatment?

What are the advantages and disadvantages of running mixed-gender groups for gambling treatment?

When considering single-gender groups, is it equally important to offer both women-only and men-only groups?

  Women, gambling, and stormy weather PDF on: http://www.camh.ca/en/hospital/care_program_and_services/addiction_ programs/Pages/guide_problem_gambling_srv.aspx

http://www.problemgambling.ca/EN/ResourcesForProfessionals/Pages/W omenandGambling.aspx