2. Contemporary Approaches to
Substance Abuse Treatment
12-Steps Fellowships - AA, Al-Anon, ACOA, NA, CoDA, SLAA
Traditional Minnesota Model Inpatient Treatment - Detox,
medical supervision, disease model, AA, group, drug
education
Intensive Outpatient Minnesota Model Treatment - Medical
supervision, individual sessions, disease model, AA, groups
Therapeutic Communities for Substance Abuse - 24-hour
residential setting, norms, responsibility, encounter groups
Pharmacological Therapy – Antabuse, methadone, LAMM,
buprenorphine, naltrexone, etc
Psychological Therapies – Group, couple, and individual
therapy
Behavior Therapy – Aversion therapy, cue exposure, skills
training, contingency management, community reinforcement
Cognitive-Behavioral Therapy – Relapse Prevention, coping
skills training, cognitive therapy, lifestyle modification
10. Brickman’s Model of Helping &
Coping Applied to Addictive
Behaviors
Is the person
responsible
for the
development
of the
addictive
behavior?
Is the person responsible for
changing 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
Power
DISEASE MODEL
(Heredity &
Physiology)
Relapse = Reactivation
of the Progressive
Disease
12. 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.
13. Biopsychosocial Factors in Development
and Maintenance of Addictive Behaviors
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.
14. Biopsychosocial Factors in Development
and Maintenance of Addictive Behaviors
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.
20. 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
25. 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.
27. 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
3-27
29. Cognitive Behavioral Therapy
Community Reinforcement Approach Plus
Vouchers
Contingency Management Interventions &
Motivational Incentives
Motivational Enhancement Therapy
The Matrix Model
Stimulants
12-Step Facilitation Therapy
Lori L. Phelps
California Association for Alcohol/Drug Educators, 2013
3-29
BEHAVIORAL THERAPIES
30. Clinical or Therapeutic
Approaches Used by Substance
Abuse Treatment Facilities
In Brief
In 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%).
31. BEHAVIORALTHERAPIES
Lori L. Phelps
California Association for Alcohol/Drug Educators, 2013
3-31
Behavioral Couples Therapy
Behavioral Treatments for
Adolescents
Multisystemic Therapy
Multidimensional Family Therapy
for Adolescents
Brief Strategic Family Therapy
32. Competency 6
Recognize the importance of family, social
networks, and community systems in the
treatment and recovery process.
Families often do not understand
substance use disorders or recovery
Family education and opportunities to
express their concerns during the recovery
process are critical
Lori L. Phelps
California Association for Alcohol/Drug Educators, 2013
3-32
33. 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
Lori L. Phelps
California Association for Alcohol/Drug Educators, 2013
3-33
34. 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).
Lori L. Phelps
California Association for Alcohol/Drug Educators, 2013
3-34
Competency 7
35. 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)
Lori L. Phelps
California Association for Alcohol/Drug Educators, 2013
3-35
39. Empirical Support:
Review of 24 RCTs
Kathleen 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,
40. • 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)
41. 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)
43. The Abstinence Violation Effect
Emotional- guilt, blame, failure, etc.
Cognitive- Internal, stable, global,
uncontrollable
Self-awareness increase
Comparison to Internalized
Standards- greater difference, more guilt
Behavioral Reaction- dominant habitual
response
Cognitive Reaction- resolve discrepancy
48. Relapse Prevention
Specific 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
49. RELAPSE PREVENTION
Specific 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?”