behavioral therapy in post traumatic stress disorder by dr. santosh

BEHAVIORAL THERAPY FOR THE TREATMENT OF SUBSTANCE ABUSE

Presented By: Santosh

APP. PSYCHOLOGY (U.D.S.C)

Contemporary Approaches to Substance Abuse Treatment

12-Steps Fellowships - AA, Al-Anon, ACOA, NA, CoDA, SLAATraditional Minnesota Model Inpatient Treatment - Detox, medical supervision, disease model, AA, group, drug educationIntensive Outpatient Minnesota Model Treatment - Medical supervision, individual sessions, disease model, AA, groupsTherapeutic Communities for Substance Abuse - 24-hour residential setting, norms, responsibility, encounter groupsPharmacological Therapy – Antabuse, methadone, LAMM, buprenorphine, naltrexone, etcPsychological Therapies – Group, couple, and individual therapyBehavior Therapy – Aversion therapy, cue exposure, skills training, contingency management, community reinforcementCognitive-Behavioral Therapy – Relapse Prevention, coping skills training, cognitive therapy, lifestyle modification

Brickman’s Model of Helping & Coping Applied to Addictive

Behaviors

Is the person responsible

for the development

of theaddictive behavior?

Is the person responsible forchanging the addictive behavior?

YES

NO

COMPENSATORY MODEL

(Cognitive-Behavioral)Relapse = Mistake, Error, or

Temporary Setback

YES NO

MORAL MODEL(War on Drugs)

Relapse = Crime or Lack of Willpower

SPIRITUAL MODEL(AA & 12-Steps)

Relapse = Sin or Loss of Contact with Higher

PowerDISEASE MODEL

(Heredity & Physiology)

Relapse = Reactivation of the Progressive

Disease

Biopsychosocial Factors in Development and Maintenance of Addictive Behaviors

BIOLOGICAL FACTORS• Biological vulnerability and genetic predisposition in

interaction with certain facilitating environments create problems and eventually disease.

• Pharmacological impact of excessive use of alcohol and other drugs on body chemistry, physiology , and the organ systems of the body.

• Tolerance – Increased frequency of use and higher doses over time.

• Withdrawal – Negative effects of cessation of addictive behaviors.

• Higher risk of developing specific physical disorders (diseases) associated with the chronic and excessive use of particular substances.


PSYCHOLOGICAL FACTORS• Motivation – Stages of habit initiation and stages of

habit change.• Expectancies – Positive outcomes of drug use and

self-efficacy.• Attributions – Effects of substance use and reasons

for relapse.• Sensation-Seeking – Excessive need for stimulation• Impulsivity – Inability to effectively control or restrain

behavior.• Negative Affect – Dysphoric moods such as anxiety &

depression.• Poor Coping – Deficits in cognitive and behavioral

skills or inhibitions in the ability to perform behaviors due to the effects of anxiety.


SOCIOCULTURAL FACTORS• Family History – Dysfunctional family settings

especially parental alcohol and drug problems and parental abuse or neglect of children.

• Peer Influences – Social pressure to engage in risk-taking behaviors including substance use especially when related to gang membership.

• Culture and Ethnic Background – Norms and religious beliefs that govern the use of alcohol and drugs and ethnic variations the body’s rate and efficiency of metabolizing drugs and alcohol.

• Media/Advertising – Societal emphasis on immediate gratification and glorification of the effects of alcohol and drug use.

Analysis of High-Risk Situations for Relapse Alcoholics, Smokers, and Heroin Addicts

RELAPSE SITUATION (Risk Factor)

Alcoholics (N=70)

Smokers (N=35)

Heroin Addicts (N=32)

TOTAL Sample (N=137)

Negative Emotional States 38% 43% 28% 37%

Negative Physical States 3% - 9% 4%

Positive Emotional States - 8% 16% 6%

Testing Personal Control 9% - - 4%

Urges and Temptations 11% 6% - 8%

TOTAL 61% 57% 53% 59%

Interpersonal Conflict 18% 12% 13% 15%

Social Pressure 18% 25% 34% 24%

Positive Emotional States 3% 6% - 3%

TOTAL 39% 43% 47% 42%

INTRAPERSONAL DETERMINANTS

INTERPERSONAL DETERMINANTS

Analysis of High-Risk Situations for RelapseAlcoholics, Smokers, Heroin Addicts, Compulsive Gamblers, and

Overeaters

RELAPSE SITUATION (Risk Factor)

Alcoholics (N=70)

Smokers (N=64)

Heroin Addicts (N=129)

Gamblers (N=29)

Overeaters (N=29)

TOTAL Sample (N=311)

Negative Emotional States 38% 37% 19% 47% 33% 35%

Negative Physical States 3% 2% 9% - - 3%

Positive Emotional States - 6% 10% - 5% 4%

Testing Personal Control 9% - 2% 16% - 5%

Urges and Temptations 11% 5% 5% 16% 10% 9%

TOTAL 61% 50% 45% 79% 48% 56%

Interpersonal Conflict 18% 15% 14% 16% 14% 16%

Social Pressure 18% 32% 36% 5% 10% 20%

Positive Emotional States 3% 3% 5% - 28% 8%

TOTAL 39% 50% 55% 21% 52% 44%

INTRAPERSONAL DETERMINANTS

INTERPERSONAL DETERMINANTS

High-Risk Situation

Effective coping response

Increased self-efficacy

Decreased probability of

relapse

Ineffective coping response

Lapse (initial use of the

substance)

Increased probability of

relapse

Abstinence Violation Effect

¤ Perceived effects of the substance

Decreased Self-efficacy

¤ Positive outcome

Expectancies (for initial effects of

the substance)

A Cognitive Behavioral Model of

the Relapse Process

Relapse Prevention: Specific Intervention Strategies

High-Risk Situation

Abstinence Violation Effect

Ineffective Coping

Response

Lapse

Decreased Self-Efficacy

¤ Positive Outcome

Expectancies

Self-Monitoring ¤

Inventory of Drug-Taking Situations

¤ Drug Taking Confidence

Questionnaire

Mediation, Relaxation Training, Stress Management

¤ Efficacy-Enhancing

Imagery

Contract to limit extent of use

¤ Reminder Card (what to do if you have slip)

Description of Past Relapses

¤ Relapse Fantasies

Situational Competency Test

¤ Coping-Skill

Training ¤

Education about immediate vs. delayed effects

¤ Decision Matrix

Cognitive Restructuring

(a lapse is a mistake: coping vs.

BEHAVIORAL THERAPY FOR THE TREATMENT OF SUBSTANCE ABUSE

Describe the philosophies, practices, policies, and outcomes of the most generally accepted and scientifically supported models of treatment, recovery, relapse prevention, and continuing care for addiction and other substance-related problems.

Scientifically Supported Models of Treatment› Pharmacotherapies› Behavioral Therapies› Approaches Used by Substance Abuse Treatment

Facilities

Lori L. Phelps California Association for Alcohol/Drug Educators, 2013

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PHARMACOTHERAPIES Opioid Addiction

› Methadone› Buprenorphine› Naltrexone

Tobacco Addiction› Nicotine Replacement

Therapy (NRT) Electronic Cigarettes, gum,

patches

› Bupropion (Zyban®)› Varenicline

(Chantix®)Lori L. Phelps

California Association for Alcohol/Drug Educators, 2013 3-28

Alcohol Addiction› Naltrexone

› Acamprosate (Campral®)

› Disulfiram (Antabuse®)

› Topiramate (Topamax®)

Cognitive Behavioral TherapyCommunity Reinforcement Approach Plus VouchersContingency Management Interventions & Motivational IncentivesMotivational Enhancement TherapyThe Matrix Model

Stimulants12-Step Facilitation Therapy

Lori L. PhelpsCalifornia Association for Alcohol/Drug Educators, 2013

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BEHAVIORAL THERAPIES

Clinical or Therapeutic Approaches Used by Substance Abuse Treatment Facilities

In BriefIn 2009, the majority of substance abuse treatment facilities always or often used substance abuse counseling (96%), relapse prevention (87%), cognitive-behavioral therapy (66%), 12-step facilitation (56%), and motivational interviewing (55%).More than one third of facilities always or often used anger management (39%) or brief intervention (35%). More than one quarter always or often used contingency management/motivational incentives (27%). More than one fifth always or often used trauma-related counseling (21%).More than half of all facilities either rarely or never used or were not familiar with community reinforcement plus vouchers (86%), Matrix Model (63%), or rational emotive behavioral therapy (51%).

BEHAVIORALTHERAPIES


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Behavioral Couples Therapy Behavioral Treatments for

Adolescents Multisystemic Therapy Multidimensional Family Therapy

for Adolescents Brief Strategic Family Therapy

Competency 6Recognize the importance of family, social networks, and community systems in the treatment and recovery process.

Families often do not understand substance use disorders or recoveryFamily education and opportunities to express their concerns during the recovery process are critical


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Goals› Present accurate information about addiction, recovery,

treatment, and the resulting interpersonal dynamics.› Help clients and family members understand how the

recovery process may affect current and future family relationships.

› Provide a forum for families to discuss recovery issues.› Present accurate information about the effects of drugs.› Teach, promote, and encourage clients’ family members to

care for themselves while supporting clients in their recovery.

› Provide a professional atmosphere in which clients and their families are treated with dignity and respect.

› Encourage participants to get to know other recovering people and their families in a comfortable and nonthreatening environment


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Understand the importance of research and outcome data and their application in clinical practice.

Evidence-Based Practice (or Best Practice) Defined› Approaches to prevention or treatment that are

validated by some form of documented scientific evidence.

› Evidence often is defined as findings established through scientific research

› Evidence-based practice stands in contrast to approaches that are based on tradition, convention, belief, or anecdotal evidence (SAMHSA OAS, 2010).


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Competency 7

Best research evidence: supporting clinically relevant research, especially patient-centered research

Clinician expertise: using clinical skills and past experience to identify and treat the individual client

Patient values: integrating the preferences, concerns, and expectations that each client brings to the clinical encounter into treatment planning (Institute of Medicine)


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Evidence-Based Thinking

Lori L. PhelpsCalifornia Association for Alcohol/Drug Educators, 2013

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Figure 3.2: Evidence-Based ThinkingSource: CSAT (2007)

Empirical Support:Review of 24 RCTsKathleen M. Carroll (1996)

Relapse Prevention:

• Does not usually prevent a lapse better than other active treatments, but is more effective at “Relapse Management,” i.e. delaying first lapse and reducing duration and intensity of lapses

• Particularly effective at maintaining treatment effects over long term follow-up measurements of 1-2 years or more

• “Delayed emergence effects” in which greater improvement in coping occurs over time

• May be most effective for “more impaired substance abusers including those with more severe levels of substance abuse, greater levels of negative affect, and greater perceived deficits in coping skills.” (Carroll, 1996, p.52)

• Reviewed 17 controlled studies to evaluate overall effectiveness of the RP model as a substance abuse treatment

• Statistically identified moderator variables that may reliably impact the outcome of RP treatment

• “Results indicate that RP is highly effective for both alcohol-use and substance-use disorders”

Empirical Support: Meta-Analytic Review

Irvin, Bowers, Dunn & Wang (1999)

Moderator Variables with Significant Impact on RP Effectiveness:

Group format more effective than individual therapy format

More effective as “stand alone” than as aftercare

Inpatient settings yielded better outcomes than outpatient

Stronger treatment effects on self-reported use than on physiological measures

While effective across all categories of substance use disorders, stronger treatment effects found for substance abuse than alcohol abuse

Empirical Support: Meta-Analytic Review

Irvin, Bowers, Dunn & Wang (1999)

The Abstinence Violation EffectEmotional- guilt, blame, failure, etc.

Cognitive- Internal, stable, global, uncontrollable

Self-awareness increaseComparison to Internalized Standards- greater difference, more guilt

Behavioral Reaction- dominant habitual response

Cognitive Reaction- resolve discrepancy

Relapse PreventionSpecific Intervention Strategies

What to do if a lapse occurs• Stop, Look, and Listen• Keep Calm• Renew Your Commitment• Implement your Relapse Prevention

plan• Ask For Help• Review the situation leading-up to the

lapse

RELAPSE PREVENTIONSpecific Intervention Strategies

Coping with Lapses(Initial Use of a Substance)

• Relapse Plan with Emergency Procedures• Relapse Contract to limit extent of use• Relapse Reminder Card “What do I do in case of a lapse?”

Precontemplation Stage

Contemplation Stage

Preparation Stage

Action Stage

Maintenance Stage

Relapse Stage

Motivational Enhancement

Strategies Assessment & Treatment

Matching Relapse

Prevention & Relapse

Management

Stages of Change in Substance Abuse & Dependence: Intervention Strategies

Thank You

behavioral therapy in post traumatic stress disorder by dr. santosh

Health & Medicine