Psychosocial Treatment of Stimulant Dependence

1
Psychosocial Treatment of Stimulant Dependence

• ASAM Conference -- New Orleans
• May 1, 2009
• Joan E. Zweben, Ph.D.
• Executive Director East Bay Community Recovery
  Project
• Clinical Professor of Psychiatry UC San Francisco

2
IN COLLABORATION WITH

• Arnold Washton, Ph.D.
• Recovery Options
• New York, NY Princeton, NJ

3
Stages of Recovery-Oriented Treatment

• 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)

4
Counselor/Therapists 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

5
Integrative Approach

• Stages of change
• Motivational interviewing
• Cognitive-behavioral techniques
• Disease model AA
• Utilization of medication tools
• Psychodynamic, insight-oriented techniques

6
Applying Evidence-Based Approaches

• Evaluate your program to determine its strengths
  and limitations who it serves well and who it
  does not
• Used evidence-based treatment interventions to
  strengthen your program in areas needed
• Avoid assuming that adding EBTs from a list will
  automatically improve outcomes

7
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

8
Key Points

• There is no single best pathway to recovery for
  everyone
• Accept that you are powerless to control
  anothers drug use
• Maintain an empathic connection the single most
  important aspect of treatment is the therapeutic
  alliance

9
Key Points

• Re-conceptualize resistance as ambivalence
• Avoid charged labels like denial, enabling,
  co-dependent
• 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.

10
Facilitating Change - I

• 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

11
Facilitating Change II

• Cognitive Behavioral Strategies (e.g., Matrix)
  teach early recovery skills and relapse
  prevention for later stages systematically, in a
  way that helps patients organize their experience
  and learn new behaviors more efficiently.
  Complements what they will learn in self-help
  groups.

12
Facilitating Change III

• Recovery-oriented psychotherapy is a vehicle for
  ongoing work to address quality of recovery
  issues. Addresses
• Developmental arrest
• Interpersonal problems
• Managing feelings
• Self esteem issues
• Co-existing disorders
• Other addictive/compulsive behaviors

13
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

14
Psychodynamic Issues in the Middle Phase

• Ongoing ambivalence about giving up alcohol/drugs
• Ive stopped using, but Im still unhappy
• Affect management self-medication
• Defining interpersonal, self-esteem, and boundary
  issues
• Shame and guilt issues

15
Psychodynamic issues in later stages

• Intimacy with autonomy
• Separation-individuation
• Affect management self-medication
• Grief and loss
• Early traumas
• Residual narcissistic controlling behaviors

16
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

17
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?

18
Utilizing The Self-Help System

• Provides a community that supports the recovery
  process
• Provides a process for personal development with
  no financial barriers
• Offers a wide range of role models
• Research shows benefits of short and long term
  participation

19
Resources

• Treatment Improvement Protocols (TIPS)
  www.samhsa.gov (especially TIP 33 35)
• East Bay Community Recovery Project
  www.ebcrp.org
• Washton, A. M., Zweben, J. E. (2006). Treating
  Alcohol and Drug Problems in Psychotherapy
  Practice Doing What Works. New York Guilford
  Press.
• Washton, A.M. Zweben, J.E. (2009) Cocaine
  Methamphetamine Addiction Treatment, Recovery
  and Relapse Prevention. New York WW Norton.