Psychosocial Treatment of Stimulant Dependence ASAM Conference -- New Orleans May 1, 2009 Joan E. Zweben, Ph.D. Executive Director: East Bay Community Recovery Project Clinical Professor of Psychiatry; UC San Francisco

IN COLLABORATION WITH: Arnold Washton, Ph.D. Recovery Options New York, NY & Princeton, NJ

Stages of Recovery-Oriented Treatment 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)

Counselor/Therapist’s 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

Integrative Approach  Stages of change  Motivational interviewing  Cognitive-behavioral techniques  Disease model & AA  Utilization of medication tools  Psychodynamic, insight-oriented techniques

Applying Evidence-Based Approaches  Evaluate your program to determine its strengths and limitations; who it serves well and who it does not  Used evidence-based treatment interventions to strengthen your program in areas needed  Avoid assuming that adding EBTs from a list will automatically improve outcomes

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

Key Points  There is no single best pathway to recovery for everyone  Accept that you are powerless to control another’s drug use  Maintain an empathic connection; the single most important aspect of treatment is the therapeutic alliance

Key Points  Re-conceptualize resistance as ambivalence  Avoid charged labels like denial, enabling, co- dependent  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.

Facilitating Change - I  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

Facilitating Change II  Cognitive Behavioral Strategies (e.g., Matrix) teach early recovery skills and relapse prevention for later stages systematically, in a way that helps patients organize their experience and learn new behaviors more efficiently. Complements what they will learn in self-help groups.

Facilitating Change III  Recovery-oriented psychotherapy is a vehicle for ongoing work to address quality of recovery issues. Addresses:  Developmental arrest  Interpersonal problems  Managing feelings  Self esteem issues  Co-existing disorders  Other addictive/compulsive behaviors

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

Psychodynamic Issues in the Middle Phase  Ongoing ambivalence about giving up alcohol/drugs  “I’ve stopped using, but I’m still unhappy”  Affect management: “self-medication”  Defining interpersonal, self-esteem, and boundary issues  Shame and guilt issues

Psychodynamic issues in later stages  Intimacy with autonomy  Separation-individuation  Affect management: “self-medication”  Grief and loss  Early traumas  Residual narcissistic & controlling behaviors

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

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?

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

Resources  Treatment Improvement Protocols (TIPS) (especially TIP 33 & 35)  East Bay Community Recovery Project:  Washton, A. M., & Zweben, J. E. (2006). Treating Alcohol and Drug Problems in Psychotherapy Practice: Doing What Works. New York: Guilford Press.  Washton, A.M. & Zweben, J.E. (2009) Cocaine & Methamphetamine Addiction: Treatment, Recovery and Relapse Prevention. New York: WW Norton.