Substance Abuse and Marriage
Therapy
Substance Abuse
Behavioral Interventions
n
Aversive counterconditioning
based on classical conditioning.
n
Pair aversive experience (electric shock, induced nausea,
negative images) with drinking or alcohol-related stimulus. Goal
to make drinking a negative experience.
n
Well-controlled trials of effectiveness of aversive counterconditioning are infrequent.
Behavioral Interventions
n
Cue exposure – develop hierarchy of cues that are triggers
for use, then expose patient to them in lab or other controlled setting (very
similar to systematic desensitization for anxiety disorders) where they do not
have the option of using.
Contingency Management
Higgins Contingency Management
approach (Higgins et al 1991; Higgins & Budney
1993)
4 principles:
–
Drug use and abstinence must be swiftly and accurately
detected;
–
Abstinence is positively reinforced;
–
Drug use results in loss of reinforcement;
–
Emphasis on development of reinforcers that compete with reinforcers
of drug use.
Contingency Management
n
Urine specimens required 3x/week
n
Abstinence (measured by urinalysis) reinforced with a voucher
system
n
Patients receive points redeemable for items consistent with
a drug-free lifestyle, such as movie tickets, grocery vouchers, sporting goods
(not cash, for obvious reasons!)
n
Approach demonstrated to be very effective with cocaine users
through studies throughout the 1990’s.
Cognitive-Behavioral
Interventions
n
Relapse Prevention developed by Alan Marlatt
and colleagues (Marlatt & Gordon, 1985)
n
Includes identification of high-risk situations for relapse
n
Instruction and rehearsal of coping strategies
n
Self-monitoring and behavioral analysis of substance use
n
Strategies for recognizing and coping with cravings and
thoughts about using
n
Planning for emergencies and coping with lapses
Relapse Prevention
n
Marlatt &
Gordon’s approach originally designed as maintenance program for those
who had gone thru intensive treatment for substance use.
n
Goal was to extend and enhance therapeutic gains and reduce
possibility of recycling back thru treatment
Relapse Prevention
n
Does not view people who lapse back to substance use as tx failures who are victims of an
underlying disease process.
n
Instead, views lapses as errors or temporary setbacks to be
expected from someone learning new coping behaviors.
n
Viewed this way, lapses may provide valuable lessons in
preventing future such episodes.
Relapse Prevention
n
Focus on unlearning maladaptive behaviors and learning more
adaptive behaviors often utilizes metaphors.
n
Relapse rates are particularly high during 1st 3
months.
n
Must plan for difficult situations (flat tires, engine
problems, bad weather, etc)
n
First few days are very risky for giving in to cravings or
urges.
n
Cravings and urges are mediated by positive outcome
expectancies of the immediate effects of the substance.
Relapse Prevention
n
Need to assess positive outcome expectancies early in
treatment.
n
Clients may have come to rely on a substance to modulate mood
or behavior due to their beliefs about the effects of that subject e.g.
drinking to mediate social anxiety.
n
Reliance on substance due to beliefs about effects
rather than the actual pharmacological effects represents part of psychological
dependency.
Relapse Prevention
n
Many clients perceive cravings to be physiologically based.
n
If we frame them as being a cognitively-based desire for immediate
gratification, we can then help them to find other, healthier means of
gratification.
n
Also teach clients to externalize their urges to use
(“I’m experiencing a craving for a hit”, rather than “I need a hit”).
n
Detachment allows more objectivity and more successful use of
cognitive and behavioral coping strategies.
Relapse Prevention
n
Teach clients that cravings, like an ocean wave, will build
in intensity, peak, and then subside.
n
Challenge for them is to learn how to “surf” these waves
without wiping out (“urge surfing”).
Relapse Prevention
n
Negative emotional states (intrapersonal) such as anger,
boredom, anxiety, frustration, depression accounted for 35% of relapses.
n
Social pressure (direct or indirect verbal pressure)
accounted for 20%.
n
Interpersonal conflict (ongoing conflictual
relationships or recent conflict) accounted for 16%.
Relapse Prevention
Relapse
n
Other lapses were due to:
n
Urges and temptations (8%)
n
Testing personal control (5%)
n
Positive emotional states (4%)
n
Negative physical states (3%)
Relapse Prevention
n
Lapse should be debriefed/analyzed
with counselor ASAP.
n
Reframe lapse as a mistake but a valuable learning
opportunity, rather than a failure.
n
Assess attributions and cognitive distortions such as catastrophizing about the lapse.
n
Stress the riskiness of the
situation and inadequate coping ability rather than inadequate effort.
Behavioral/CBT
Overall, contingency management
and CBT have highest levels of empirical support for treatment of opioid and cocaine dependence of any treatment approaches.
Marriage Therapy
Significance of Marital
Discord
n
Between 50-67% of married adults divorce
n
Marital problems represent the single most frequent problem
for which people seek out mental health services
n
Divorce and marital separations rank as one of the most
significant stressors and has also been shown to increase people’s risk for
physical and mental illness
Three Steps to BMT
n
Increasing Positive Exchanges
n
Communication Training
n
Problem Solving
Why Start with Increasing
Couples Positive Exchanges
n
Changes in problems do not automatically increase positive
exchanges
n
Negative spouse behaviors tend to diminish even if they are
not the focus
n
May increases receptivity to tackle more demanding marital
changes
n
The focus on the positive serves to reduce the spouses’
deprivation and thus may increase the perception that the relationship is worth
the effort
n
Comparatively easy to implement
Targets for Communication
Training
n
Empathy and listening skills
n
Validation
n
Learning to talk about feelings
n
Learning to express negative feelings appropriately
n
Expression of positive feelings
n
Feedback
n
Coaching and modeling
n
Behavioral rehearsal
Problem Solving
n
Third Component of BMT is problem solving
n
Teach couple how to:
n
identify
problem
n
brain
storm solution
n
Implementation
n
behavioral
experiements
Efficacy Data for BMT
(Hahlweg & Markman,
1988)
n
Meta-analysis
n
17 studies comparing BMT to either a wait-list group or
placebo control group
n
Average effects size was .95 (83% of the BMT patients were
better off than controls)
n
Chance of improving was 72% for BMT versus 28% for controls
n
Rate of improvement attributable to BMT is about 40%
Moderators of Treatment
Outcome for BMT
n
Commitment
n
Younger age (after controlling for duration of marriage)
n
Emotional engagement
n
Non-traditionality (peer marriage)
n
Convergent goals for the marriage
Integrative Couple Therapy
(Jacobson & Christensen, 1996)
Problems With
BMT Cont.
n
BMT is based on two critical assumptions that are probably
misguided:
n
Therapy should promote couple compromise and accommodation
n
Marital distress is caused by interaction skill deficits
Basic Assumption of IBCT
n Some
relationship conflicts cannot be resolved and thus the intervention focus needs
to be on helping couples foster acceptance
Goals of IBCT
n
Get the couple to adopt a formulation of their difficulties
based on a careful evaluation that will help allow them stop blaming their
partner and open themselves up to both acceptance and change
Strategies for Promoting
Acceptance
n
Teach couple a different method for discussing a problem
n
Teach partner’s to increase their tolerance of the other’s
negative behaviors
n Assist
each partner in self-care
Change Techniques in ICBT
n
Behavior exchange techniques
n
Communication training
n
Conflict resolution training
Pilot Study on Efficacy of IBCT