Assessment

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Assessment Treatment of Alcohol and Other Drug
Problems

• Alta Bates Hospital
• Berkeley, Ca. October 13, 2008
• Joan E. Zweben, Ph.D.
• Executive Director East Bay Community Recovery
  Project
• Clinical Professor of Psychiatry UC San Francisco

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IN COLLABORATION WITH

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

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Recovery-Oriented Psychotherapy

• An Integrative Approach

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Stages of Recovery-Oriented Therapy

• 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)

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Recovery-Oriented Psychotherapy

• Framework that integrates disease model addiction
  treatment with abstinence-based psychotherapy
• Individual, group, couples therapy
• Supports, facilitates , and encourages but does
  not mandate involvement in AA
• Therapists tasks shift according to the
  patients stage of recovery
• Collaborative stance toward the patient

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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

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Integrative Approach

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

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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

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Integrative Approach

• Treatment must address more than the substance
  abuse itself
• Developmental arrest
• Interpersonal problems
• Managing feelings
• Self-esteem issues
• Co-existing Axis I II disorders
• Other addictive/compulsive behaviors

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Key Points

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

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Key Points

• Re-conceptualize resistance as ambivalence
• 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.

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Psychodynamic Issues at Different Stages
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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

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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

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Psychodynamic issues in later stages

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

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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

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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?

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Motivational Interviewingand the Stages of Change
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Facilitating Change

• 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

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Stages of Change

• Precontemplation- Not seeing the behavior as a
  problem or feeling a need to change (in denial)
• Contemplation- Ambivalent, unsure, wavering about
  necessity and desirability of change
• Preparation- Considering options for change
• Action- Taking specific steps to change behavior
• Maintenance- Relapse prevention
• Relapse- Returning to use or earlier stage of
  change

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Stages of Change
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Stages of Change Model

• Facilitates empathy- patients seen as stuck in
  a particular stage of the process rather than
  resistant
• Defines ambivalence as normal not pathological
• Leads to better patient-treatment matching by
  defining the types of clinical interventions that
  work best with patients in each stage of change
• Provides roadmap and sets the tone for more
  positive interaction with resistant patients

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Motivational Approach

• Start where the patient is
• Roll with resistance
• Avoid arguments, power struggles
• Back off in the face of resistance
• Be persuasive not confrontive
• Reframe resistance as ambivalence
• Offer choices to increase patient acceptance and
  investment
• Negotiate, dont pontificate
• Acknowledge positive drug effects
• Adjust interventions to stage of readiness for
  change

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Diagnosis
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Substance USE

• Absence of problems/consequences
• No apparent or significant risk
• No obsession or preoccupation
• Under volitional control

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Substance ABUSE

• Use is associated with significant risks or
  consequences
• Exceeds medical/cultural norms
• No obsession or preoccupation
• Under volitional control

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Substance DEPENDENCE

• Continued use despite adverse consequences
• Impaired control
• Preoccupation/obsession
• Exaggerated importance/priority
• Tolerance/withdrawal (optional)

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NIAAA Low Risk Drinking

• MEN
• No more than 14 drinks per week (2 per day) and
  no more than 4 drinks per occasion
• WOMEN
• No more than 7 drinks per week (1 per day) and
  no more than 3 drinks per occasion
• SENIORS- OVER AGE 65
• No more than one drink per day

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One Standard Drink

• One 12 oz. bottle of beer
• One 5 oz. glass of wine
• 1.5 oz of distilled spirits

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Low Risk Qualifiers

• PRESUMES ABSENCE OF
• Pregnancy
• Medical or psychiatric conditions likely to be
  exacerbated by ETOH use
• Medication that interacts adversely with ETOH
• Prior personal or family history of substance
  abuse
• Hypersensitivity to alcohol

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At Risk Drinking

• Frequently exceeds recommended limits
• No evidence yet of adverse consequences
• Drinking exposes the individual to significant
  risk
• Prime target for preventive efforts

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Problem Drinking ALCOHOL ABUSE

• Evidence of recurrent medical, psychiatric,
  interpersonal, social, or legal consequences
  related to alcohol use OR
• Being under the influence of alcohol when it is
  clearly hazardous to do so (e.g., operating a
  vehicle or other machinery, delivering health
  care services)
• No evidence of physiological dependence
• No prior history of alcohol dependence

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Alcoholism ALCOHOL DEPENDENCE

• BEHAVIORAL syndrome characterized by
• Compulsion to drink
• Preoccupation or obsession
• Impaired control (amount, frequency, stop/reduce)
• Alcohol-related medical, psychosocial, or legal
  consequences
• Evidence of withdrawal- not required
• Evidence of tolerance- not required

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Assessment Techniques
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Assessment Goals

• Assess nature and extent of substance use
• Assess nature and extent of substance-related
  problems and consequences
• Assess patients stage of readiness for change
• Formulate an initial diagnosis
• Provide motivation-enhancing feedback based on
  assessment results

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Assessment Domains

• Typology of use
• Positive benefits
• Negative consequences
• Need for medical detoxification
• Other addictive behaviors
• Prior attempts to stop or cut down
• Prior treatment and self-help experience
• Diagnostic signs of substance dependence disorder
• Family history of alcohol/drug problems
• Stage of readiness for change

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Typology of Use

• Types of substances
• Amount/frequency
• Administration route (oral, intranasal,
  pulmonary, i.v., i.m.)
• Temporal pattern (continuous, episodic, binge)
• Environmental precursors (external triggers)
• Emotional precursors (internal triggers)
• Settings and circumstances linked with use
  (people, places..)
• Linkage with use of other substances (e.g.,
  cocaine-alcohol)
• Linkage with other compulsive behaviors (sex,
  gambling, spending, eating, etc)

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Positive Benefits of Use

• What first attracted you to this drug?
• How has it helped you?
• Does it still work as well?
• What would be the potential downside of not using
  it?

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Negative Consequences

• Medical
• Job, Financial
• Relationships
• Legal
• Psychological
• Sexual

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Medical Red Flags- ALCOHOL

• Hypertension
• Blackouts
• Injuries
• Chronic abdominal pain
• Liver problems
• Sexual dysfunction
• Sleep problems
• Depression/anxiety

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Medical Red Flags COCAINE

• Chronic nasal/sinus problems (snorting)
• Chronic respiratory problems (smoking crack)
• Sexual dysfunction
• Labile moods, paranoia, suicidal ideation
• Sleep problems
• Seizures
• Abuse of alcohol and sedatives

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Medical Red FlagsOPIOIDS

• For Rx opioids requests for increased doses,
  frequent refills, multiple prescribers, lost
  prescriptions
• Sexual dysfunction
• Amenorrhea
• Sleep problems
• Constipation
• Liver problems

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Biochemical Indicators of Alcohol Abuse

• Most markers are late stage and not very reliable
  indicators of alcohol problems
• Best used in combination to confirm diagnosis
  establish baseline for follow up
• GGT gamma-glutamyltransferase
• MCV mean corpuscular volume
• AST aspartate aminotransferase

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Urine Toxicology- Drugs

• Detects only recent use (past few days)
• No information about amount, frequency, or
  chronicity of use
• No information about problem severity
• Best used as a clinical tool to monitor treatment
  progress

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Psychosocial Consequences

• Vocational Work life adversely affected?
• Relationships Family/marital relationships or
  home life been adversely affected?
• Legal Any legal trouble? (e.g., DWI)
• Psychological Mood or mental functioning been
  adversely affected? Suicidal thoughts or actions?
• Sexual Sex drive or performance been adversely
  affected? Cocaine or amphetamine-related
  hypersexuality and acting out behavior?

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Need for Medical Detoxification

• Benzodiazepines, alcohol, opioids
• Abrupt withdrawal from alcohol/benzos can be life
  threatening and must be managed medically
• Opioid withdrawal is uncomfortable, but not life
  threatening, except when another medical
  condition could be exacerbated (e.g., heart
  problems)

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The Specialty Treatment System

• Inpatient hospital based
• Therapeutic Communities (TCs)
• Residential treatment with less structure
• Outpatient varying levels of intensity varying
  levels of capability to address co-occurring
  disorders
• Opioid maintenance treatment system

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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

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Resources

• Treatment Improvement Protocols (TIPS)
  www.samhsa.gov
• 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.