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Brief Treatment of Substance Use Disorders: Why Neither Brief Nor Long is the Right Question

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1. 34 clinical trials confirm that brief can be as effective ... 1. Brief Drinker's Check-Up. www.drinkerscheckup.com. Kaiser Permanente Oregon. Miller & Berg: ... – PowerPoint PPT presentation

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Title: Brief Treatment of Substance Use Disorders: Why Neither Brief Nor Long is the Right Question


1
Brief Treatment of Substance Use DisordersWhy
Neither Brief NorLong is the Right Question
Milton Erickson Foundation Brief Therapy
Conference December 7, 2006
Michele Packard, Ph.D.
2
Why neither brief nor longis the right question
  • 1. 34 clinical trials confirm that brief can be
    as effective as longer-term treatment with
    certain populations
  • 2. What populations are likely to benefit most
    from brief interventions and which are more
    likely to require longer-term treatment?

3
  • Research efforts currently focusing on
  • treatment processes that impact outcome
  • engagement
  • retention
  • compliance
  • better outcomes
  • A B C D

4
  • Search for mediating and moderating variables
  • that influence outcomes, eg
  • Client variables
  • self-efficacy
  • coping skills
  • untreated co-occurring issues
  • Therapist variables

5
  • 5. Best Practices in the treatment of ABs
  • have been identified
  • CBT
  • Motivational Interviewing
  • Relapse Prevention
  • Community Reinforcement Approach
  • Contingency Management

6
  • ? Brief Intervention ?
  • A strategy or set of strategies designed
  • to motivate or help a person get to the
  • next step
  • 1-4 sessions
  • ? Brief Therapy ?
  • Involves a series of steps designed to
  • help a person solve a problem
  • 6-20 sessions
  • focus is on present
  • downplays psychodynamic factors
  • focus is on changing behavior

7
What Works ??8 Basic Principles
  • Rethinking substance abuse What science tells
    us and what we should do about it.
  • Principles of Therapeutic
  • Change that Work.

Miller Carroll, 2006
Castonguay Beutler, 2006
8
  • 1. Addictive behavior (AB) is reinforcing
    behavior, subject to expansions and
  • behavior, subject to expansions
  • contractions
  • neurochemical
  • behavioral
  • cognitive

9
  • AB emerge gradually and occur along
  • a continuum
  • Once well-established, ABs tend to
  • be self-perpetuating

10
Consumption alcohol related problems
None
Mild
Moderate
Substantial
Severe
Severe
Substantial
Moderate
Mild
None
Alcohol Problems
IOM, 1990
11
Spectrum of intervention response
Brief intervention
Specialized treatment
Threshold for action
Severe
Substantial
Moderate
Mild
None
Alcohol Problems
IOM, 1990
12
Populations likely to benefitfrom brief
interventions
  • 1. Patients being seen in non-specialist
  • settings
  • primary care settings
  • private practice
  • ERs
  • criminal justice
  • EAP
  • schools

13
6 Active ingredients inbrief interventions
  • F feedback
  • R responsibility
  • A advice
  • M menu of options
  • E empathy
  • S self-efficacy

F feedback R responsibility A
advice M menu of options E empathy S
self-efficacy
14
5 Steps of Brief Interventionin Substance Use
Disorders
  • 1. Introduce issues in context of clients
  • health, life circumstances,
    consequences experienced, etc.
  • 2. Screening, evaluating and assessing
  • 3. Providing feedback
  • 4. Talking about change and setting goals
  • 5. Summarizing getting an agreement
  • for the next step.

15
  • Examples of Brief Interventions
  • 1. Brief Drinkers Check-Up
  • www.drinkerscheckup.com
  • Kaiser Permanente Oregon
  • Miller Berg
  • Working with the Problem Drinker.
  • Emergency Room Settings

16
4. Motivation is central to intervention
The Nature and the Dynamics of Ambivalence
Benefits of Change
Consequences of Change
Individualized treatment plan matched to
Stage-of-Readiness
Carrots (Incentives) for Change
Obstacles (Disincentives) for Change
Miller Rollnick Motivational Interviewing
(2003)
17
The Stages of Change
Prochaska DiClemente
18
The Social Context of ChangeFactors Outside of
TreatmentThat Influence Outcomes
  • 5. AB are affected by a larger social context
    and respond to social reinforcement
  • Family
  • Friends and social networks
  • Workplace
  • Rudolph Moos, Ph.D.
  • Stanford University

19
6. AB does not occur in isolation but is part of
a cluster
20
  • The biopsychosocial model is built on the
  • foundation of Alfred Banduras
  • Social Learning Theory which asks
  • What are the factors that shape,
  • perpetuate and maintain
  • ( problem behavior) ?

21
Biopsychosocial Domains
  • Cognitive factors
  • Behavioral factors
  • Motivational factors
  • Biological factors
  • Environmental factors
  • Spiritual factors

22
  • 7. There are identified risk and protective
  • factors
  • Search Institute Peter Benson, Ph.D.
  • 40 developmental assets in youth
  • www.searchinstitute.com

23
  • 8. AB occurs within a family context
  • psychoeducational interventions are limited
  • interventions need to be within context of
  • family system and structure
  • Peter Steinglass, MD
  • The Alcoholic Family
  • Maintaining the rituals of normal family
  • life

24
The therapeutic alliancematters (a lot!)
  • ability to recognize change talk
  • able to elicit change talk
  • able to reinforce change talk
  • Desire
  • Ability
  • Reasons
  • Need Commitment

25
  • Identify ABs and intervene early
  • Enhance personal motivation and commitment to
    change
  • Make sobriety worthwhile
  • improve access to non-drug positive reinforcement
  • Enhance social support for abstinence
  • For well-established AB a period of ensured
    abstinence is ideal
  • Use Motivational Interviewing principles
  • Involve family or social system to reinforce
    abstinence
  • Address other social and behavioral problems
  • Encourage AA or other support groups or drug-free
    activities
  • Promote meaningful employment
  • Remove/reduce reinforcement for using
  • Expect gradual progress
  • Think outside the skin
  • Use Evidence-Based Treatments

SUMMARY
26
For Michele Packards Training Schedule
  • Visit our website at
  • www.sagetraining.com
  • 303.443-3920

?
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