Psychological interventions in addictive disorders MRCPsych addiction psychiatry seminar March 2010

General treatment principles Addiction is probably best viewed as primarily a psychological (learnt) problem Medication is an adjunct to psychosocial treatment Treatment is a co-operative venture Medication is useless without some readiness to change Treatment requires careful preparation and aftercare

Treatment aims Change substance using behaviour Address co-existing mental health disorders: –Anxiety –Depression –PTSD –Childhood sexual abuse

Elements of intervention Building motivation Cognitive restructuring Developing coping skills

Types of psychological intervention Psychotherapy Drug counselling, including motivational interviewing CBT approaches, including contigency management Therapeutic communities Self-help groups

Mesa Grande top 10 alcohol interventions Brief intervention Motivational enhancement Acamprosate Opiate antagonists Social skills training Community reinforcement Behaviour contracting Behavioural marital therapy Case management Self-monitoring

Review of the effectiveness of treatment for alcohol problems, 2006 Most people move in and out of problem drinking without treatment ‘How’ as much as ‘what’ A range of effective treatments available- from brief interventions to intensive treatments Psychiatric co-morbidity common and challenging to treat Treatment is cost effective Therapist need training

Scottish HTA report relapse prevention in alcohol dependence Effective interventions: Behavioural self-control training Motivational enhancement therapy Marital/family therapy Coping social skills training

Scottish HTA report OR95% CI BSCT MET M/FT CCST

Brief interventions Reduction vs abstinence Delivered by non-specialist Non-dependent drinkers Addresses motivation to change Self –directed FRAMES ingredients

‘FRAMES’ Feedback of risk Encouraging responsibility for change Advice Menu of alternative options Empathy Enhancing self-efficacy

Motivational interviewing ‘ready, willing and able’ Ready: a matter of priority Willing: the importance of change Able: confidence for change ‘yes, but…..’ Ambivalence

Motivational interviewing Reflective listening Pros/cons of change Confidence building Feedback Self-motivational statements Rolling with resistance

NICE guideline 51 Drug misuse: psychosocial interventions Opportunistic brief interventions focussed on motivation should be offered Staff should provide information about self- help groups Contingency management programmes should be introduced