Psychosocial Treatments for Substance Use Disorders: Strategies and Interventions

Amalia Bullard Ph.D.

Amalia Bullard Ph.D.

Kansas City VA Medical Center

Kansas City VA Medical Center

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Objectives

Objectives



Psychosocial interventions with

Psychosocial interventions with

empirical support

empirical support



Treatments with promise

Treatments with promise



Integrated treatment of co-occurring

Integrated treatment of co-occurring

disorders

disorders



Mechanisms of change

Mechanisms of change



Role of therapeutic alliance and

Role of therapeutic alliance and

therapist characteristics

therapist characteristics



Importance of continuation of care

Importance of continuation of care

Psychosocial Interventions with

Psychosocial Interventions with

Empirical Support

Empirical Support



Motivational Interviewing

Motivational Interviewing



Cognitive Behavioral Interventions

Cognitive Behavioral Interventions



Contingency Management

Contingency Management



12-Step Facilitation

12-Step Facilitation



Community Reinforcement

Community Reinforcement

Approach

Approach



Behavioral Couples and Family

Behavioral Couples and Family

Therapies

Therapies

Motivational Interviewing (MI)

Motivational Interviewing (MI)

A goal-oriented, client-centered

counseling style for eliciting

behavior change by helping

patients to explore and resolve

ambivalence.

Motivational Interviewing

Motivational Interviewing

Having more

effective

conversations

about

changing

substance use

Patients don’t do what they

should

 because:

Don’t know what they

need to be doing

Lazy or weak willed

Denial or don’t believe

what I have to say

Solution

 = Tell them

what to do

Solution

 = Tell them

why doing what I say is

so important

Solution

 = scare,

convince, persuade,

them to do what I say

The Righting Reflex

The Righting Reflex



The desire to fix what seems

wrong with people and to set

them promptly on a better course.



What could possibly be wrong

with that?

Ambivalence - getting stuck on

Ambivalence - getting stuck on

the road to change

the road to change



Simultaneously wanting and not wanting

something, or wanting both of two

incompatible things



Change talk and sustain talk



Getting stuck in ambivalence

○

Think about changing… think about not

changing… stop thinking about it

Ambivalence the Internal

Ambivalence the Internal

Committee

Committee



What happens when an ambivalent person

meets a provider with a righting reflex?



Argue for one side and the person is likely to

take up the other side and defend the opposite.



Most people tend to believe themselves and

trust their own opinions more than those of

others.



If you are arguing for change and your patient is

arguing against it, you’ve got it exactly

backwards.

Tug of War

Tug of War

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An Alternative MI

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The Spirit of Motivational

The Spirit of Motivational

Interviewing

Interviewing

“If you treat an individual as he is, he

will stay as he is, but if you treat him as

if he were what he ought to be and

could be, he will become what he ought

to be and could be.”

Johann Wolfgang Von Goethe

The Spirit Mind-set/Heart-set

The Spirit Mind-set/Heart-set



Partnership



Acceptance



Compassion



Evocation

Key Principles of MI

Key Principles of MI



Express (sincere) empathy



Develop discrepancy



Roll with resistance



Support Self-efficacy

Evoking Motivation for Change



Ambivalence resolves by tipping the

balance in favor of change.



People tend to become more committed

to what they hear themselves saying.



The importance of speaking one’s

motivation aloud in the presence of

another person.

Change Talk and Sustain Talk vary with

Counselor Approach Glynn and Moyers 2010

Cognitive Behavioral

Cognitive Behavioral



Targets intrapersonal & interpersonal

triggers



 social pressures, cravings, conflict in

relationships



Coping skills training



drug refusal skills



Builds sober healthy activities

Relapse Prevention

Relapse Prevention



A Cognitive behavioral approach

addressing the relapse process in

order to prevent relapses and

minimize harm of relapses that do

occur



Relapse – return to use/drinking following

period of abstinence or period of lower

level of use/drinking

Relapse Prevention

Relapse Prevention

Relapse is not

viewed as an “end-

state,” but rather

as a process that

begins before use

of the substance

and continues

afterward.

Relapse Prevention

Relapse Prevention



Patients relapse because they lack

cognitive & behavioral skills to cope with

immediate determinants/ covert

antecedents



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Relapse Prevention

Relapse Prevention



Examine previous use/drinking episodes

in order to identify what the immediate

determinants and covert antecedents

have been in the past



What new information and strategies are

needed in to order address weaknesses in

patients’ cognitive and behavioral skill set?

Immediate Determinants

Immediate Determinants

Covert Antecedents

Covert Antecedents



Increase risk of relapse by increasing

chance of exposure to high risk situations



Seemingly irrelevant decisions

○

call cousin “to see how he’s doing,” keep alcohol

in the house for guests



Lifestyle factors

○

imbalance of “wants” vs “shoulds”

○

lack of pleasurable or meaningful activities



Urges/cravings

○

desire for immediate gratification

Relapse Prevention Strategies

Relapse Prevention Strategies



Examine previous episodes for high risk

situations and teach new coping skills



Positive Expectancies



Enhance self-efficacy



Retrain thinking about lapse and relapse to

help combat abstinence violation effect



Teach lapse management by creating

lapse-response plan

Contingency Management

Contingency Management

A behavioral

approach to reinforce

abstinence from

substance use

The goal s to provide

patients with a period

of abstinence

Contingency Management

Contingency Management



Based on principles of operant conditioning



Positive reinforcers increase probability

of behavior

○

Raises/awards, allowances/privileges,

treats/food



Punishers decrease probably of behavior

○

Poor evals/demotions,

detention/grounding

Contingency Management

Contingency Management



Based on principle that behavior will

increase if followed by a reward



Positive reinforcement is more effective

than punishment for lasting behavior

change



Behavior to increase when reward is immediate,

tangible, consistent, and unique to the target

behavior



Natural rewards for abstinence are delayed,

intangible, and inconsistent

How Does CM Work?

How Does CM Work?



Set specific target behavior

(abstinence from specific

substance)



Measure this target behavior

frequently and objectively

(2x/week UDS testing)

How Does CM Work?

How Does CM Work?



Provide immediate, tangible,

desirable rewards when the target

behavior occurs (fishbowl draws for

negative UDS results)



Increase size of reward for consistent

performance of target behavior (increased # of

draws up to 8)



Withhold the reward when the target behavior

does not occur – based on UDS only



Reset the size of reward for next occurrence of

target behavior

Contingency Management

Contingency Management



The fishbowl contains 500 prize slips:



250 (50%) “Good Job!” = $0



209 (41.8%) “Small” = $1



40 (8%) “Large”= $20



1 (0.2%) “Jumbo” = $100



Earn 1 draw for the first negative sample

and increase up to 8 draws with consistent

abstinence



When abstinence is not verified, no draws

are earned, and draws reset to 1 for the

next negative sample

Contingency Management

Contingency Management



12 week protocol - excused and unexcused

absences



Patients earn an average of about $240

over the 12 weeks



Can be utilized with other target behaviors

(e.g., attendance)



Can be implemented by LIPs and non-LIPs



Few contraindications – can be used in

conjunction with other treatments



Fun treatment for providers and patients

12-Step Facilitation (TSF)

12-Step Facilitation (TSF)



Based on the principles of Alcoholics

Anonymous (AA) and the “Disease

Model” of addiction



Assumes that substance use

disorders are chronic diseases that

require lifelong commitment to

abstinence

12-Step Facilitation

12-Step Facilitation



Manualized approach designed to

enhance ongoing involvement in 12

step meetings



Can be used as a stand-alone

treatment or used in conjunction with

another model

12-Step Facilitation

12-Step Facilitation



Introduces patients to the principles of

the 12-step model, learn about options

for meetings in their area, and begin to

set goals for getting involved in NA/ AA.



The long term goal of TSF may be

abstinence, but the short-term objective

is to encourage commitment to and

participation in 12-step groups.

Two Primary TSF Goals

Two Primary TSF Goals

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Willpower alone is not

enough

Chronic & progressive

disease

Life has become

unmanageable

Only alternative is

complete abstinence

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Reach out beyond

oneself and follow the

12- steps

Acknowledge hope for

recovery

Faith that a high

power can help when

willpower cannot

Organization & Structure TSF

Organization & Structure TSF



Includes a core program, an elective

program, and a conjoint or family

program



12 to 15 individual sessions, plus 2 to

3 conjoint sessions if needed

Organization & Structure TSF

Organization & Structure TSF



Core Program



4 Core Topics

○

Assessment, Acceptance, Surrender,

and Getting active in AA or NA

Organization & Structure TSF

Organization & Structure TSF



Elective Program



6 Elective Topics



Genograms, Enabling, People-places-

routines, Emotions, Moral inventories,

and Relationships

Organization & Structure TSF

Organization & Structure TSF



The conjoint program



Purpose is to educate the patient’s

partner about addiction and to introduce

them to the 12-step model

○

introduce to the concept of enabling and

encouraged to make a commitment to attend

six Al-Anon or Nar-Anon meetings.

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Note what AA/NA meetings the patient attended since the last session

Discuss patients reactions to those meetings

Review of slips

What if anything did the patient do to try to stay abstinent after the

slip?

What NA/NA resources could the patient use in the event of a future

slip?

Review of urges to drink or use

Review of sober days

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Introduction of new concepts for discussion

Questions and reactions to material discussed

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Which meetings will the patient attend between now and the next

session?

What should the patient read before the next session?

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What was the overview of today’s discussion?

Does the patient understand the recovery tasks that have been

suggested?

Are slogans just bumper sticker

Are slogans just bumper sticker

Psychology?

Psychology?

There is practical

wisdom captured

in these slogans

and they are

valuable to those

who participate in

the model

.

Community Reinforcement

Community Reinforcement

Approach (CRA)

Approach (CRA)

“A behavioral treatment based on the

tenants of operant conditioning and

helping patients rearrange their lifestyles

so that healthy drug free living becomes

rewarding and then competes with the

positive effects of drug and alcohol use.”

Development of CRA

Development of CRA



Punishment is an ineffective way to

modify human behavior (Skinner

1974)



SUD treatments based on

confrontation were largely ineffective

at reducing use of alcohol or drugs

(Miller and Wilbourne 2002)

CRA Procedures

CRA Procedures



Functional analysis is used to identify

internal and external triggers and to

explore the consequences of substance

use

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Who are you usually with when you use?



My 2 buddies from work

Where do you usually use?



We drink in the pub across from work; if we smoke its in my friend’s truck.

When do you usually use?



Quitting time – 5 pm

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What are you usually thinking about right before you use?



I can’t wait to get out of this crummy place and have some fun

What are you usually feeling physically right before you use?



Don’t know; maybe all tensed up

What are you usually feeling emotionally right before you use?



Stressed, frustrated, angry; but happy when I think about getting together

with my friends.

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What do you usually use?



Alcohol (Beer and Whiskey), but sometimes marijuana too

How much do you usually use?



6-pack of beer, 3 – 4 shots of Whiskey if pot – a few hits

Functional Analysis for Using Behaviors Meyers, R.J. & Sam, J.E. 1995

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What do you like about using with (your buddies)?



They’re fun to joke with about our boss; they like to have a good time

What do you like about using at (the pub)?



I can be goofy and nobody cares; nobody judges me.

What do you like about using (right after work)?



It helps me unwind; puts a good ending on a rough day.

What are the pleasant thoughts you have while using?



I guess I make believe I’m the boss, or that we have a different one.

What are the pleasant emotions you have while using?



Happy, content

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What are the negative results of your using in each of these areas?



Interpersonal 

My girlfriend is getting fed up



Physical 

Headache in the morning



Emotional 

Don’t know

Functional Analysis for Using Behaviors Meyers, R.J. & Sam, J.E. 1995

CRA Procedures

CRA Procedures



Sobriety Sampling is based on belief that is

not always helpful for a therapist to tell their

patient that he or she can never drink again for

the rest of their life



Behavioral Skills Training to learn skills such

as problem solving, communication, and drink

refusal skills



Job Skills Training which simply involves basis

steps for getting and keeping a job

CRA Procedures

CRA Procedures



Social and Recreational Counseling

aimed at new sources of pleasurable

activities



Relapse Prevention to identify high risk

situation for using and how to anticipate

and cope with these situations.

Behavioral Couples and Family

Behavioral Couples and Family

Therapy

Therapy



Active involvement of the patient’s

spouse or partner



12 to 20 couples sessions over 3 to 6

months.

What makes a good candidate?

What makes a good candidate?



Married or living with a partner



Willing to accept at least temporary

abstinence



Both people are willing to work on the

issues



No high risk for violence



Generally treatment recommended

following detox, residential or IOP

Objectives

Objectives



Engage the couple



Support abstinence with recovery

contracts (daily rituals that support

abstinence)



Improving relationship by building

positive activities and improving

communication



Continuation of care and relapse

prevention

BCT Recovery Contract

BCT Recovery Contract



Rebuild trust



Reduce conflict about substance

use



Reward abstinence

BCT Recovery Contract

BCT Recovery Contract



Daily Trust Discussion



Patient states intention to stay abstinent

that day



Spouse thanks patient for efforts to stay

abstinent

BCT Recovery Contract

BCT Recovery Contract



Daily Trust

Discussion



Focus on present,

& future, not past



Self-help

involvement



Weekly UDS



Calendar to record

progress

Increasing Positive Activities &

Increasing Positive Activities &

Communication

Communication



Catch your partner doing something nice



Shared rewarding activities



Caring day assignment



Listening skills



Expressing feelings directly



Communication sessions



Negotiating for requests

Relapse Prevention

Relapse Prevention



Continuing Recovery Plan



Actions to maintain abstinence and

relationship gains after weekly couples

treatment ends



Relapse Prevention Plan



High risk situations and warning signs



Make plan to prevent or minimize relapse

Psychosocial Treatments with

Psychosocial Treatments with

Promise

Promise



The Matrix Model



IOP that combines relapse prevention, skills

training, facilitation of involvement in 12-

step, and family education



Non-confrontational approach based on

motivational interviewing & includes

individual & group therapy



Educational session designed to facilitate

medication assisted treatment and also uses

routine drug screens

Psychosocial Treatments with

Psychosocial Treatments with

Promise

Promise



Mindfulness Based Interventions



Mindfulness based stress reduction and

acceptance and commitment therapy, and

behavioral interventions to help them

become aware of their triggers

○

Mindfulness Based Sobriety

Integrated Treatment of Co-

occurring Disorders

Co-Occurring Disorders

Co-Occurring Disorders



Those that involve one or more

non-nicotine substance use

disorder and one or more mental

disorder.

Co-Occurring Disorders

Co-Occurring Disorders

Atkins, 2014

Historical perspective



Three basic and consistent findings



1. co-occurrence of mental disorders and

substance use disorders is quite common



2. co-occurring disorders is associated with

more negative outcomes including higher rates

of relapse, hospitalizations, incarceration,

homelessness, and violence



3. The history of parallel and separate services

for patients with mental disorders and SUD often

delivered fragmented and less effective care

Integrated treatment for co-

occurring disorders



The same clinician or team of providers working in one

setting, provide mental health and substance use disorder

interventions in a coordinated fashion



The services are seamless with a consistent approach,

philosophy and set of recommendations



Includes combining appropriate treatments and modifying

traditional interventions



“Recovery means that the individual with a co-occurring

disorder learns to manage both illnesses so that he or she

can pursue meaningful life goals.” (Mead et al 2000)

Treatment Improvement Protocol

(tip 42, Csat/samhsa)



Motivational Interviewing (MI)



Contingency Management (CM)



Cognitive Behavioral Therapy (CBT)



Relapse Prevention (RP)

Mechanisms of Change

Mechanisms of Change

Moving beyond

asking “Which

treatments

work?” to asking

“Why do certain

SUD treatments

work?”

Mechanisms of Change

Mechanisms of Change



Motivational Interviewing



Change Talk



Discrepancy

○

Both have positive impact on SUD

outcomes

▪

         Apodaca & Longabough, 2009

Mechanisms of Change



Cognitive Behavioral

Interventions



Quality verses quantity of coping

skills



Self-efficacy

                                         Kiluk, 2010

Mechanisms of Change

Mechanisms of Change



Contingency Management & Community

Reinforcement Approach



Improved treatment attendance,



Medication compliance



Increased self-efficacy

○

CRA study - higher rates of abstinence after 2

years was mediated by more AA attendance,

and increased self-efficacy

Mechanisms of Change



12-Step approaches



Increased self-efficacy



More coping skills



Improved motivation



Being a part of healthy social network

                                                Kelly et al. (2009)

Common Factors

Common Factors



Common factors may explain why the

limited evidence for specific mediators of

the effects of treatment approaches.



May also explain limited evidence for the

effectiveness of one treatment over the

other.

Common Factors

Common Factors



There may be social processes that

protect against development of a

substance use disorder.



Support, goals, structure, non-substance

related rewards, abstinence oriented role

models, development of coping skills, and

increased self-efficacy may all be active

ingredients of effective treatments for SUD.

Moos (2007)

Common Factors

Common Factors



Understanding change may lie in the

cognitive, affective, and learning

processes of those people who have

been treated

.



Stanger et al (2013) found changes in decision

making to be a key mediator of SUD treatment

outcomes.



Computer assisted CBT for SUDs.

○

suggested changes in neural systems involved in

cognitive control, impulsivity, and attention that

may account for the effects of behavioral

therapies.

Therapeutic Alliance & Therapist

Therapeutic Alliance & Therapist

Characteristics

Characteristics

The collaborative relationship and the

emotional bond between patient and

provider. It is an agreement between the

two about the specific goals for

treatment

Lebow et al. 2006

Therapeutic Alliance & Therapist

Therapeutic Alliance & Therapist

Characteristics

Characteristics

A stronger working

alliance was a

significant predictor

of better drinking

outcomes across all

three modalities in

Project MATCH.

Similar findings in a

study of patients with

Opioid Use Disorders

who were in

methadone treatment

Belding et al. 1997

Therapeutic Alliance & Therapist

Characteristics



Early therapeutic alliance predicted less

substance use during treatment but not

of post-treatment outcomes.



Alliance could be what keeps patients

engaged in treatment. Meyer et al 2005



The stronger the alliance, the longer the

patients stays in treatment Simpson et al

1997

What Makes a Strong Alliance?

What Makes a Strong Alliance?

T

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

Therapists’ interpersonal style



Not due to level of professional training, years

of clinical experience, providers own recovery

status, or the characteristics of the patients

being treated (Najavits and Weiss 1994).



Interpersonally skilled, empathic, and less

confrontational

Continuing Care Following SUD

Continuing Care Following SUD

Treatment

Treatment

“A period of less intensive treatment

following a more Intensive treatment

episode.”

“continuing” care instead of “after”

emphasizes need for ongoing active

participation & intervention

                                            McKay 2005

Continuing Care

Continuing Care

Traditional approaches to treatment view

substance use disorders (SUD) as a

condition that can be effectively treated in

a single acute episode of care.

However, research and clinical experience

show that this is not the case (Dennis &

Scott, 2007).

Why is Continuing Care

Why is Continuing Care

Important?

Important?

SUDs are best conceptualized as chronic

health conditions that require ongoing

maintenance and care, like diabetes and

hypertension (McLellan et al., 2000).

The need for multiple episodes of care is

the rule rather than the exception (Dennis

et al., 2005).

Why is continuing care

Why is continuing care

important?

important?

Risk for relapse

greatest in the first 90

days

Significant risk remains

during the first year

and through 5 years of

continuous abstinence

(Blodgett et al., 2014).

Why is continuing care

Why is continuing care

important?

important?



Good outcomes are contingent on

adequate treatment length



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Principles of Drug Addiction Treatment – A Research

Based Guide (NIDA, 2012)

Is Continuing Care Effective?

Is Continuing Care Effective?

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Is Continuing Care Effective?

Is Continuing Care Effective?



Continuing care interventions with longer

duration may be associated with better

outcomes (Moos et al., 2001).



Patients who engaged in continuing care

for at least 12 months demonstrated best

outcomes (McKay, 2009).



More participation in self-help activities

(e.g., 12-step meetings) may be associated

with better outcomes (Moos et al., 2001;

Bergman et al., 2015).

References

References



Back, S. E., Foa, E. B., Killeen, T.K., Mills, K.L, Teeson, M., Cotton, B.D.,

Carroll, K. M., & Brady, K. T. (2015). 

Concurrent Treatment of PTSD and

Substance Use Disorders Using Prolonged Exposure (COPE). Therapist

Guide.

 Oxford University Press.



Back, S. E., Foa, E. B., Killeen, T.K., Mills, K.L, Teeson, M., Cotton, B.D.,

Carroll, K. M., & Brady, K. T. (2015). 

Concurrent Treatment of PTSD and

Substance Use Disorders Using Prolonged Exposure (COPE). Patient

Workbook. 

Oxford University Press.



Hien et al. (2010). Do treatment improvements in PTSD severity affect

substance use outcomes? A secondary analysis from a randomized clinical

trial in NIDA’s clinical trials network. 

Am J Psychiatry 167

:95-101.



Carroll, K.M. (1998). 

A Cognitive Behavioral Approach: Treating Cocaine

Addiction. Therapy Manuals for Drug Abuse

. National Institute on Drug

Abuse.



Drake, R. E., Essock, S. M., Shaner, A., Carey, K. B., Minkoff, K., Kola, L.,

et al. (2001). Implementing dual diagnosis services for clients with severe

mental illness. Psychiatric Services, 52(4), 469 -476.



Key Elements of Treatment Planning for Clients with Co-Occurring

Substance Abuse and Mental Health Disorders (COD) (Treatment

Improvement Protocal, TIP 42: SAMHSA/CSAT)

References

References



Behavioral Health Trends in the United States: Results from the

2014 National Survey on Drug Use and Health. September 2015.



O’Farrel, T.J. & Fals-Stewart, W. (2006). Behavioral couples

therapy for alcoholism and drug abuse. New York: Guilford Press.



Miller, W.R. & Meyers, M.S.; The community reinforcement

approach. 

Alcohol Research & Health 23(2): 116-120, 1999.



Meyers, R.J., Roozen, H.G. & Smith, J.E.; The community

reinforcement approach: An update of the evidence. Alcohol

Research & Health 33(4),2014.



Nathan, P.E. & Gorman, J.M. (2015)

. A Guide to Treatments that

Work 4

th

 ed. Oxford.



Miller, W.R., Rollnick, S. (2013). Motivational Interviewing. Helping

people change. 3

rd

 Edition. New York. Guilford Press.



Arkowitz, H., Westra, H. A., Miller W.R., & Rollnick, S.  (2008).

Motivational Interviewing in the treatment of psychological

problems. New York: Guilford Press.