MOTIVATIONAL INTERVIEWING. Evidence-Based Behavioral Therapy for Addictions. Therapies

Transcription

1 Evidence-Based Behavioral Therapy for Addictions Chris Farentinos, MD, MPH, CADC II Director Behavioral Health Legacy Therapies Motivational Interviewing (MI) Cognitive Behavioral Therapy (CBT) Dialectical Behavioral Therapy (DBT) Contingency Management Acceptance and Commitment Therapy (ACT) AA, NA, Smart Recovery MOTIVATIONAL INTERVIEWING 1

2 What is MI? Motivational interviewing is a collaborative conversation style for strengthening a person s own motivation and commitment to change. It is person-centered, goal oriented, and compassionately addresses the common problem of ambivalence about change. Adapted from Miller and Rollnick, 2013 Spirit of MI Collaboration Compassion Acceptance Evocation Why is MI spirit important? Miller & Baca (1983)¹ Therapist empathy predicted a surprising two-thirds of the variance in client drinking 6 months later (r=.82, p<.0001) Even after 12 and 24 months, therapist empathy continued to account for roughly one-half (r=.71) and one-quarter (r=.51) of the total outcome variance, respectively Findings replicated in subsequent studies² 1 Miller WR, Baca LM Behavior Therapy 1983;14: Luborsky et al Clinical Psychology: Science & Pract 1997;4:53-65 Valle SK J Studies Alcohol 1981;42:

3 MI Research Evidence 4 Meta-analytic reviews Burke, Arkowitz & Menchola (2003) -30 controlled clinical trials Hettema, Steele & Miller (2005) -72 studies Vasilaki, Hosier & Cox (2006) -15 studies targeting ETOH reduction Lundahl, Tollefson, Kunz, Brownell & Burke (2009) -119 studies Lundahl B & Burke B. J Clin Psychology : Getting right down to it Ineffective medical intervention with smoking Effective medical intervention with smoking DISCUSSION What did you notice? What is the difference? How would you incorporate the style in your practice? 3

4 MI in Health Care helping patients change behavior Miller and Rollnick COGNITIVE BEHAVIORAL THERAPY What is CBT? Structured, short-term, presentoriented psychotherapy for depression, anxiety, substance use disorder, OCD and other diagnosis directed toward solving current problems and modifying dysfunctional (inaccurate and/or unhelpful) thinking and behavior. The name refers to behavior therapy, cognitive therapy, and therapy based upon a combination of basic behavioral and cognitive principles 4

5 Roots of CBT John B. Watson s and B. F. Skinner conditioning animal and human studies. Belief: psychology is a purely objective experimental branch of natural science. Its theoretical goal is the prediction and control of thought patterns and behavior. Introspection or insight forms no essential part of its methods. CBT skills CBT is focused on the present, time-limited, and problem-solving oriented Patients learn specific skills Skills are: > identifying distorted thinking, > modifying beliefs, > relating to others in different ways, and > changing behaviors CBT Practice Together, therapist and patient develop an action plan or homework for patients to implement solutions to problems or to make changes in their thinking and actions. Effective for anxiety, depression, substance use disorders. Practice challenge: when patient is in an earlier stage of change, unmotivated. Presupposes that patient want to change. 5

6 DIALECTIC BEHAVIORAL THERAPY What is DBT? Dialectical Behavior Therapy -The art of holding two things in balance that seem to cancel each other out, but are actually both true -BOTH accepting what is AND working towards change -For patients this often relates to competing needs. For example, wanting a better life and continuing to do the same destructive things Differences & Similarities between DBT & CBT (Dialectics) CBT emphasis is more change-based DBT emphasizes acceptance of current behavior AND change to be more effective DBT does not emphasize thoughts as much as affect regulation, because it places responsibility for behavioral change closer to the emotions themselves However DBT fully embraces cognitive behavior therapy principles DBT appropriates some aspects of Buddhism 6

7 Applying DBT to Substance Abuse Based on the assumption that substance abuse functions as a means to regulate emotions People drink/ use to feel good or to feel better The goal is to help people eliminate or reduce problematic substance use through the development of more effective strategies to regulate emotions Effective Relapse Prevention (teach people to fail well) Biosocial Theory: Disorder of emotion regulation Emotional Vulnerability Environmental Invalidation (toxic stress) Emotional Dysregulation High Emotional Vulnerability & Invalidating Environments High sensitivity Perceived inability to tolerate intense emotions High reactivity Slow return to baseline Hyper vigilance 7

8 Primary DBT Dialectic Acceptance Change Primary DBT Dialectic Validation Problem Solving The goal of DBT is to help people Build a life worth living! But how?! By decreasing emotion dependent (reactive) behavior and increasing values-based and goal directed (receptive) behavior It s possible AND it s a process 8

9 Building the Middle Path: Incorporating Acceptance AND Change Distress Tolerance Mindfulness Acceptance Emotion Regulation Interpersonal Effectiveness Change Core Skills to Teach: Mindfulness Observe & Describe Nonjudgmental Observe & Describe (Building Awareness): What skills Observe = Noticing Describe = Putting a nonjudgmental label on it Sensing tension, anxiety in hands Observe Oh right, this is tension that I m feeling Describe 9

10 Nonjudgmental (not good/bad/right/wrong) Not assigning value to others or yourself Relates to both negative and positive judgments (either/or thinking) Use OD skills instead (observe, describe) Reduces reactivity Incorporates radical acceptance Short Mindfulness Exercise Debrief: What did you notice? What was hard? What was easy? How could this be used in your practice? CONTINGENCY MANAGEMENT 10

11 Contingency Management CM involves giving patients tangible rewards to reinforce positive behaviors such as abstinence Voucher Based Reinforcement augments other community based treatments by rewarding clean UAs with vouchers Voucher values are low at first but increase with negative UAs. Positive UAs reset the value Contingency Management Prize incentive is similar but uses chance to win cash prizes drawing from a bowl prizes worth $1 to $100. Each negative UA increases the number of draws The abstinence-based incentive procedure provided a mean of $203 in prizes per participant, and was efficacious in improving retention and associated abstinence outcomes (Petry, N. M. et. Al, 2005) ACCEPTANCE AND COMMITMENT THERAPY 11

12 ACT (Acceptance and Commitment Therapy) Mindfulness based behavioral therapy ACT assumes that the psychological processes of normal human mind are destructive and create suffering Symptom reduction is not a goal of ACT Core principles develop psychological flexibility > Defusion, acceptance, contact with the present moment, the observing self, values, committed action MUTUAL HELP FELLOWSHIPS Alcoholics Anonymous Is an international mutual aid fellowship founded in 1935 by Bill Wilson and Dr. Bob Smith in Akron, Ohio. Primary purpose is "to stay sober and help other alcoholics achieve sobriety". Wilson and Smith developed AA's Twelve Step program of spiritual and character development. AA's Twelve Traditions were introduced in 1946 to help the fellowship be stable and unified while disengaged from "outside issues" and influences. 12

13 Alcoholics Anonymous The Traditions recommend that members and groups remain anonymous in public media, altruistically helping other alcoholics and avoiding affiliations with any other organization, avoiding dogma and coercive hierarchies. Narcotics Anonymous, Marijuana Anonymous, Dual Diagnosis Anonymous and other groups have adopted and adapted the Twelve Steps and the Twelve Traditions to their respective primary purposes. Smart Recovery Self Management and Recovery Training Founded in 1994 by psychologists as an alternative to AA Based on principles of Rational Emotive Therapy, which is a behavioral cognitive therapy Group has a facilitator, work book, homework over 1,200 face to face meetings and online meetings Thank you! 13