Assessment and Treatment of Addictive Behaviors

1
Assessment and Treatment of Addictive Behaviors

• Lecture 6
• Change and Functional Analysis

2
Transtheoretical Model of Change

• Founders
• James Prochaska
• Carlo DiClemente
• Origin
• 1979
• Systems of Psychotherapy A Transtheoretical
  Analysis published in 1979

3
Factors leading to its development

• Called trans-theoretical model because it brings
  together over 18 different forms of psychotherapy
• Eclectic in nature
• Instead of finding separate change processes in
  each of the 18 leading systems of therapy, only
  10 processes of change (the mechanisms people
  use) were identified
• Process were at both the level of the individual
  and the environment

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10 Processes (1-2)

• Consciousness Raising 
• Efforts by the individual to seek new information
  and to gain understanding and feed-back about the
  problem behavior / observations, confrontations,
  interpretations, bibliotherapy.
• I recall information people had given me on how
  to stop smoking
• Self-Reevaluation
• Emotional/cognitive reappraisal of values with
  respect to the problem behavior/value
  clarification, imagery, corrective emotional
  experience.
• Binging to maintain my weight makes me feel
  disappointed in myself

5
10 Processes (3-4)

• Environmental Reevaluation  
• Consideration and assessment of how the problem
  behavior affects the physical and social
  environment / empathy training, documentaries
• I consider the view that smoking can be harmful
  to the environment
• Dramatic Relief
• Experiencing and expressing feelings about the
  problem behavior and potential solutions /
  psychodrama, grieving losses, role playing
• I react emotionally to warnings about drugs

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10 Processes (5-6)

• Social Liberation  
• Awareness, availability, and acceptance by the
  individual of alternative, problem-free
  lifestyles in society / empowering, policy
  interventions
• I find society changing in ways that make it
  easier for the nonsmoker
• Self Liberation 
• Choice and commitment to change the problem
  behavior, including belief in the ability to
  change, New Year's resolutions, logotherapy
  techniques, commitment enhancing techniques
• I will make it my New Years resolution to quit X
  

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10 Processes (7-8)

• Counterconditioning  
• Substitution of alternatives for the problem
  behavior / relaxation, desensitization,
  assertion, positive self-statements
• Doing other things with my hands is a good
  substitute for smoking
• Stimulus Control
• Control of situations and other causes which
  trigger the problem behavior / adding stimuli
  that encourage alternative behaviors,
  restructuring the environment, avoiding high risk
  cues, fading
• I remove things from my home that remind me of
  gambling

8
10 Processes (9-10)

• Reinforcement Management  
• Rewarding oneself or being rewarded by others for
  making changes / contingency contracts, overt and
  covert reinforcement, self-reward
• I reward myself when I dont binge drink
• Helping Relationships 
• Trusting, accepting, and utilizing the support of
  caring others during attempts to change the
  problem behavior
• I have someone who will shoot me a disapproving
  look whenever I chant Vegas Baby, Vegas

9
Decision Balance

• Decision making was conceptualized by Janis and
  Mann (1977) as a decisional "balance sheet" of
  comparative potential gains and losses
• Two decisional balance measures, the pros and the
  cons, have become critical constructs in the
  Transtheoretical model
• The pros and cons combine to form a decisional
  "balance sheet" of comparative potential gains
  and losses
• The balance between the pros and cons varies
  depending on which stage of change the individual
  is in

10
Self-Efficacy / Situational Temptations (Bandura,
1977)

• Conceptualizes a person's perceived ability to
  perform on a task as a mediator of performance on
  future tasks
• A change in the level of self-efficacy can
  predict a lasting change in behavior if there are
  adequate incentives and skills
• The Transtheoretical model employs an overall
  confidence score to assess an individual's
  self-efficacy
• Situational temptations assess how tempted people
  are to engage in a problem behavior in a certain
  situation.

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Stages of Change

• Precontemplation is the stage at which there is
  no intention to change behavior in the
  foreseeable future. Many individuals in this
  stage are unaware or underaware of their problems
  
• Contemplation is the stage in which people are
  aware that a problem exists and are seriously
  thinking about overcoming it but have not yet
  made a commitment to take action
• Preparation is a stage that combines intention
  and behavioral criteria. Individuals in this
  stage are intending to take action in the next
  month and have unsuccessfully taken action in the
  past year
• Action is the stage in which individuals modify
  their behavior, experiences, or environment in
  order to overcome their problems. Action involves
  the most overt behavioral changes and requires
  considerable commitment of time and energy
• Maintenance is the stage in which people work to
  prevent relapse and consolidate the gains
  attained during action. For addictive behaviors
  this stage extends from six months to an
  indeterminate period past the initial action

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Alcohol Stages of Change (Short Form)

• In the last month have you had 5 or more drinks
  in a row?
• 1Yes, and I do not intend to stop drinking 5 or
  more drinks in a row
• 2Yes, but I intend to stop drinking 5 or more
  drinks in a row during the next 6 months
• 3Yes, but I intend to stop drinking 5 or more
  drinks in a row during in the next 30 days
• 4No, but I have had 5 or more drinks in a row in
  the past 6 months.
• 5No, and I have not had 5 or more drinks in a
  row in the past 6 months
• 6No, I have not had 5 or more drinks in a row
• Scoring
• 1 Precontemplation
• 2 Contemplation
• 3 Preparation
• 4 Action
• 5 Maintenance
• 6 N/A

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Self-change

• Most individuals change on their own
• b/n 31 and 131
• Many avoid treatment due to stigma
• Some data contrary to major life event as
  necessary recovery cause (Sobell, 1992)
• Cognitive appraisal may be key
• Evaluate pros vs. cons
• Alcohol success positive social support
• Drug success avoid negative cues

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Cognitive AppraisalKey Features

• Make salient costs of addiction
• Lessen perceived rewards of use
• Make apparent benefits of changing
• Identify obstacles (costs of change)

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Research Findings

• Problems arent always progressive
• Less extensive treatment may work better for less
  severe problems?
• Let clients select own goals
• Behavioral components may be key in relapse
  prevention

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Functional Analysis Treatment
17

• Trigger ? Thoughts ? Feelings ? Behavior ?
  Consequences
• Functional analysis (triggers and consequences)
• Thoughts/Feelings/Emotions
• Assertiveness and Drink/Drug Refusal
• Life Enhancement Strategies and Relapse
  Prevention

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Group 1Functional Analysis Triggersand
Consequences
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• Functional Analysis Triggers and Consequences
• Functional Analysis
• What does this mean?
• Break down Function (why, purpose)
• Break down Analysis (look at)
• Trigger ? Thoughts ? Feelings ? Behavior ?
  Consequences

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• Functional Analysis Triggers and Consequences
• Trigger ? Thoughts ? Feelings ? Behavior ?
  Consequences
• What is a trigger?
• 3 types of triggers
• Person
• Place
• Thing/Time
• 3 strategies for dealing with triggers
• Avoid
• Alter
• Substitute

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Functional Analysis Triggers and
Consequences Trigger ? Thoughts ? Feelings ?
Behavior ? Consequences Consequences Positives

Negatives List both How do they differ ---
Magnitude
--- Duration

Immediacy ---
Certainty
---
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Functional Analysis Triggers and
Consequences Trigger ? Thoughts ? Feelings ?
Behavior ? Consequences Consequences Alternative
s We cant give you a list of
alternatives What can you take from the previous
comparison
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Group 2ThoughtsFeelings and Emotions
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Thoughts

• Trigger ? Thoughts ? Feelings ? Behavior ?
  Consequences
• What is irrational thinking
• Not based in reality
• Lead to self-harm
• Based on neg beliefs / attitudes (self, others,
  future, etc)
• How do irrational thoughts cause problems?
• Person A wants to be here
• Person B doesnt want to be here
• Which thoughts and feelings go with each type of
  person?
• Who is more likely to get and stay sober

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Thoughts

• Types of irrational thinking
• Negative self-statement
• Ex - I am
• Unrealistic expectations
• Ex - Ill just have a couple drinks
• Assuming the worst
• Ex - No matter what, no one will ever trust me
  again
• Catastrophizing
• Ex Overreacting blowing things out of
  proportion
• Mind-reading
• Filling in blanks with negatives

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Thoughts

• Put up behavior chain and list thoughts
• Guidelines
• Stop
• Become aware
• Dispute irrational thought (where is evidence)
• Develop more rational thought
• Replace with new thought
• Take action

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Feelings / Emotions

• Difference between feelings and emotions
• Feelings inside
• Emotions are what is expressed
• Only emotions can be directly controlled
• Use steam cooker analogy
• What can be done to express emotions
• Put up behavior chain and list Feelings

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Group 3Assertiveness Drink/Drug Refusal
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• Assertiveness and Drink/Drug Refusal
• Trigger ? Thoughts ? Feelings ? Behavior ?
  Consequences
• Focus on behavior
• Assertiveness
• Focus on behavior
• Skills require training, practice, and time
• Classification
• Passive---------------------------Assertive-------
  ------------------------Aggressive
• -
  -
• Kiss ass Calm accomplished
  abusive
• Low self esteem easy going achieving obnoxious
• Low confidence well liked focused high conflict

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Assertiveness (1)

• Focus on behavior
• Skills require training, practice, and time
• Classification (where does everyone place
  themselves)
• Passive---------------------------Assertive-------
  ------------------------Aggressive
• -
  -
• kiss ass Calm accomplished
  abusive
• low self esteem easy going achieving
  obnoxious
• low confidence well liked focused
  high conflict
• taken advantage of less conflict
  leader high stress
• needs not met undercontrol
  independent low control
• unexpressed feelings less stress
  in control poor
  relationships
• difficulty w/ conflict more focused
  needs are met violent
• misunderstood out of trouble
  problem solver pushy

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Assertiveness (2)

• Summary
• Get needs met and attend to needs of others
• Best of both personality types
• Peope who abuse substances generally not
  assertive
• Closer to middle may reduce need to use and
  improve self-esteem

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Drink/drug Refusal

• Trigger ? Thoughts ? Feelings ? Behavior ?
  Consequences
• FOCUS ON BEHAVIOR
• Just Say No campaign
• Doesnt work why?
• Calculate yes time and no duration
• Skills require training, practice, and time
• Saying Yes vs Saying No
• Whats hard about it
• What are you good at saying no to (why goto
  consequences part of FA)

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Drink/drug Refusal

• Guidelines
• Make no first word
• Offer a one line explanation (is it ok to lie)
• Request an alternative
• Confront broken record
• Leave (have you put yourself in a position to do
  this)
• Do these guidelines change over time?

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Group 4Life Enhancement Strategiesand Relapse
Prevention
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Life Enhancement Strategies

• Summary
• Difference between quitting vs. lifestyle
  change
• Dry drunk example (psychological dependence)
• Cite FA group and discuss function of SA
• Importance of developing alternatives

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Life Enhancement Strategies

• What types of alternatives are there?
• Long term goals/life areas
• Family
• Social
• Intimate
• Education/training
• Employment/career
• Hobbies/recreation
• Volunteer work/charity
• Physical/health issues
• Spirituality
• Psychological/emotional issues

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Problems with these goals?

• Better understand goals (category mistake)
• Consider immediacy and certainty
• Return to extremes graph

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Focus on activities w/ immediate certain small
rewards

• Over time these activities lead to completion of
  larger goals
• Generate examples of short term activities
• Dont get frustrated, this is new to you
• If alternatives were obvious, youd be doing them
• Ask others who live a sober happy life what they
  do

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Relapse Prevention

• What are your thoughts about these data?
• why do we show you this?
• Its not easy

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Relapse Prevention

• Pro-lapse vs. Re-lapse
• Pro-lapse getting back on track
• Re-lapse return to previous behavior
• Thoughts and feelings at each stage
• What would you say to a friend who relpased

pro
lapse
re
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Relapse Prevention

• Warning Signs
• Stop taking antibuse
• Around high risk people
• Cravings
• Romanticizing Previous substance use
• Uncomfortable emotions
• Withdrawing / isolating from others
• Temper outbursts
• Plan
• Call people who dont use (e.g. sponsor)
• Be real truthful about inner thoughts and
  emotions
• Stop and think about negative consequences

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Life Enhancement Treatment for Substance Use
LETS ACT!

• Modified BAT-D for chronic substance using
  population currently receiving residential
  substance use treatment
• 6 sessions over two-weeks 2 weekly maintenance
  sessions
• Small group format (3-5 patients)
• First three sessions 1 hour Last three
  sessions 30 minutes
• Vocabulary simplified
• Complex concepts and forms eliminated, replaced,
  or modified
• Earlier sessions focus on modifying behavior in
  treatment, while later sessions gradually moved
  toward post-discharge planning and goals.

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Session 1

• Introduction and Life Values and Goals
• Introduce treatment rationale
• Discuss individual life values and goals
• Begin self monitoring of current activities and
  daily mood ratings
• Progressive Muscle Relaxation

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Treatment Model
Negative Feelings Sadness, Anger, Loneliness,
Frustration
Substance Use
Behavioral Activation Productive, Enjoyable, And
Rewarding Behavior
Positive Feelings Happiness, Fulfillment, Sense
of Accomplishment
Decreased substance use, Reduction in depressive
symptoms
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Planned Relaxation

• Rationale and Techniques
• Stress and tension can be overwhelming and lead
  to a desire to use substances
• Review and Practice in Session
• Behavioral relaxation postures
• Deep breathing exercises
• Homework Practice relaxation at least 5 minutes
  per day

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Session 2

• Identifying Activities
• Review self monitoring and daily mood ratings
• Identify activities in corresponding life areas
• Introduce behavioral contracts
• Progressive Muscle Relaxation

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Identifying Activities

• Instruct patient to select activities that will
  help them towards their goals in each life area
• List them on the Selected Activities Form
• Refer to Activity Checklist for ideas
• Example 1
• Goal re-establish relationship with my daughter
• Activity Call my daughter 3x a week at 7pm to
  see how she is doing
• Example 2
• Goal Improve my physical health
• Activity Walk 30 minutes 4x a week

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Sample Contract

• Fellow resident / friend / family member Bob
• In this contract, I agree to remain sober.
  Below, I list supportive behaviors from you that
  will help me achieve this goal. Some are things
  you are already doing and others are things that
  also would be helpful. Thank you for all your
  support!
• Each time I sit in the back of the treatment
  group and dont pay attention, Bob will tap me on
  the shoulder and suggest that I move up front.
• If I get grumpy and dont talk to anyone then Bob
  will ask me to sit with him at meals and I will
  tell him what is on my mind.
• Signed
• ____________________ ______________________
  _____
• You Fellow resident / friend / family
  member

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Session 3

• Daily and Weekly Goals
• Review self monitoring and daily mood ratings
• Review behavioral contracts
• Introduce daily and weekly Goals
• Progressive Muscle Relaxation

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Daily Goals Form
Instructions For the day listed, list the life
areas you wish to work on and the activities that
will help you move toward improving that Life
Area and the amount of time you want to do each.
At the end of this day, circle whether or not the
goal was met for each activity.

Circle the day insert the date M T w
Th F Sa Su _______________
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• Sessions 4-6 Monitoring Progress
• Review daily and weekly goals
• Integrate new activities into daily and weekly
  goals
• Progressive Muscle Relaxation
• Maintenance Sessions
• Review daily and weekly goals
• Revisit life areas and discuss post treatment
  life values and goals
• Integrate new activities into daily and weekly
  goals
• Progressive Muscle Relaxation

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Initial Study

• Participants
• 44 Participants
• Residential substance abuse treatment facility
• 86.0 African American, 62.8 Male
• Mean age 42.1 years (SD 10.3)
• Contract Lengths
• 60 days (67), 90 days (9), or 180 days (24)

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Baseline Assessment

• Approximately 2 weeks following entry into
  treatment
• M 15.2 days (SD 8.1)
• Assessment Battery
• DSM-IV Diagnoses (MINI)
• Substance Use History
• Clinician Rated Severity of Depression (HAMD)
• Self-reported Depressive Symptoms (BDI)
• Anxiety Symptoms (BAI)
• Enjoyment and reward value of activities (EROS)

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Screening Procedure

• Inclusion Criteria
• 18 years of age
• Past year Substance Dependence
• Completed 2 weeks of treatment
• Mild to moderate depression (BDI-II total score
  10)
• English Speaking
• Exclusion Criteria
• Psychotropic medication for lt 3 months
• Current DSM-IV psychotic disorder

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Treatment Assignment

• Random assignment to treatment condition
• LETS ACT (n 22)
• Treatment as Usual (n 22)
• Daily treatment groups focusing on relapse
  prevention, functional analysis, stress
  management, anger management, and spirituality
• Vocational training
• AA/NA

56
Follow-up Assessments

• Post-treatment
• Entire baseline assessment battery reassessed
• Treatment Satisfaction Questionnaire (CSQ)
• 2-Week follow-up
• BDI score
• Patients status in treatment tracked through
  administrative offices

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Screening and Retention
Screened N 55
Not Randomized BDI lt 10, N 11
Randomized N 44
LETS ACT! N 22
TAU N 22
Completed Treatment, N 20 Dropout of Treatment
Facility, N 1 Medical Discharge, N 1
Completed Treatment, N 19 Dropout of Treatment
Facility, N 3
Attended 2-Week Follow-up, N 18 Dropout of
Inpatient Treatment, N 0 Lost to follow-up, N
2
Attended 2-Week Follow-up, N 14 Dropout of
Inpatient Treatment, N 2 Lost to follow-up, N
3
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Treatment as Usual

• Post treatment
• Significant improvements in self-reported
  depressive symptoms (BDI-II)
• No improvement in clinician rated severity of
  depressive symptoms (HAMD), anxiety symptoms
  (BAI), or enjoyment and reward value of
  activities (EROS)
• 22.7 (n 5) dropped out of the treatment center
  
• Treatment satisfaction M 24.6 (SD 2.8)
• 2-week follow-up
• No significant change in depressive symptoms

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LETS ACT!

• Post treatment
• Significant improvements in depressive symptoms
  (BDI), severity of depressive symptoms (HAMD),
  anxiety symptoms (BAI), and enjoyment and reward
  value of activities (EROS)
• 5 (n 1) dropped out of the treatment center
• Treatment satisfaction M 27.6 (SD 2.8)
• Follow-up
• Significant improvement in depressive symptoms
  (BDI-II)

60
LETS ACT! vs Treatment as Usual

• Significant group x time interactions for BDI-II,
  HAMD, and EROS Scores

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Depressive Symptoms (HAMD)
62
Enjoyment and Reward Value of Activities
63
Depressive Symptoms (BDI-II)
64
LETS ACT! vs Treatment as Usual

• Significant group x time interactions for BDI-II,
  HAMD, and EROS Scores
• LETS ACT group reported significantly higher
  treatment satisfaction scores
• F(1, 38) 10.8, p lt .01, ?2 .23
• Fewer LETS ACT! participants dropped out of the
  residential treatment
• ?2(1) 3.3, p .068 B 1.82 SE 1.14 OR
  6.18