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

OR 95% CI

BSCT 1.75 1.02-3.02

MET 1.88 1.28-2.77

M/FT 1.94 1.37-2.73

CCST 2.11 1.53-2.92

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 priorityWilling: the importance of changeAble: 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