Zufall Center Worshop Harm Reduction and Other Evidence-Based - - PDF document

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Zufall Center Worshop November 12, 2019 Harm Reduction and Other Evidence-Based Treatments for Addiction Arnold M. Washton, Ph.D. thewashtongroup.com 1

Harm Reduction and Other Evidence-Based Treatments for Substance Use Disorders Arnold M. Washton, Ph.D.

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Written for office-based practitioners

Arnold M. Washton, Ph.D. Joan E. Zweben, Ph.D. New York: Guilford Publications www.guilford.com

Today’s Topics

• 1. Harm reduction paradigm
• 2. Pharmacology of opioids and other

psychoactive substances

• 3. Evidence-based pharmacotherapies
• 4. Alcohol moderation and other evidence-

based behavioral interventions

• 5. Abstinence and relapse prevention strategies

Harm Reduction- A Paradigm Shift

n Harm reduction is creating a major paradigm shift in

how SUDS are conceptualized and treated

n Alternative to disease model of SUDs and “one size

fits all” abstinence-only treatment approaches

n Recognizes a continuum of substance use problems

and a continuum of substance-related consequences

n Emphasis on therapeutic relationship and meeting

patients “where they are”

What is Harm Reduction Therapy?

n A set of therapeutic principles and practices

aimed at reducing adverse consequences (harms) associated with substance use and other risky behaviors and promoting positive change without requiring abstinence as a starting point and/or endpoint of treatment

What is Harm Reduction Therapy?

n A philosophy, clinical stance, and style of

working with substance users

n Not a set of protocols and procedures n Umbrella for integrating many different types of

therapeutic interventions

What is Harm Reduction?

u Abstinence is always the safest course! u But better to engage clients in a process of incremental

change than turn them away until they “hit bottom” or cause more harm to self and others

u Those who encounter difficulty with moderation often

become more self-motivated to abstain

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Zufall Center Worshop November 12, 2019 Harm Reduction and Other Evidence-Based Treatments for Addiction Arnold M. Washton, Ph.D. thewashtongroup.com 2

What is Harm Reduction?

Views any steps taken to reduce the risks and consequences of substance use and other risky behaviors as worthwhile steps in the right direction, whether or not abstinence is the ultimate goal

What is Harm Reduction Therapy?

n It provides a framework for helping problematic

alcohol/drug users who cannot or will not stop completely (the majority of them) reduce the harmful consequences of their substance use

n Acknowledges that abstinence is the safest and

• ften the best outcome, but does not define it

as the only acceptable goal or criterion of success

What is Harm Reduction Therapy?

n Incremental change in the direction of reduced

harmfulness of substance use is accepted and supported whether or not abstinence is the goal

n Recognizes that a trusting empowering therapeutic

alliance may need time to develop and that issues

• ther than substance use may need to be addressed

before harm reduction goals are fully achieved

n Harm reduction therapy begins and continues while

clients are still engaging in risky/addictive behaviors

What is Harm Reduction Therapy?

n Based primarily on principles and practices of

client-centered psychotherapy

n Therapeutic relationship is key n “Compassionate pragmatism” (Marlatt) n Accepts clients “where they are” in terms of

goals and readiness for change, etc.

What is Harm Reduction Therapy?

n Recognizes that there is a continuum of substance

use, substance-related consequences, and substance use goals.

n Unlike traditional “all or nothing” approaches, HR

recognizes a spectrum of substance use issues ranging from problematic use to severe dependence; and, substance use goals ranging from less risky/less harmful use to complete abstinence.

What is Harm Reduction Therapy?

n Respects that treatment goals are client-driven, not

pre-determined or imposed, that change is incremental not all or nothing, and that any and all attempts to reduce harm are worthwhile

n Attractive to a diverse client population as it

advocates an individualized approach that respects individual differences including cultural considerations and the rights of clients to choose their own goals and path to achieve those goals

What is Harm Reduction Therapy?

n Empathetic, empowering, non-judgmental, non-

coercive collaborative relationship

n Supports clients in discovering the truth about their

attachment to alcohol/drugs, its functional significance, how it impacts their life, and what goals/approaches might work best for them

n Treatment goals are client-driven, not dictated or

imposed by the clinician

What is Harm Reduction Therapy?

n Contrasts sharply with traditional disease model of

addiction

n Not everyone with a significant substance use

problem is an addict/alcoholic

n Abstinence is not the only acceptable goal and

indicator of success

n One size does not fit all n Accepting clients “where they are” is empowering

not enabling

What is Harm Reduction?

n Harm reduction does not try to transform alcoholics or

• thers with severe addiction problems into controlled

users

n It provides an attractive, lower-threshold starting point for

treatment that can help substance users accept the need for abstinence

n Treatment is more likely to succeed when patients

choose and are personally invested in the treatment goals and the methods used to achieve those goals

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Zufall Center Worshop November 12, 2019 Harm Reduction and Other Evidence-Based Treatments for Addiction Arnold M. Washton, Ph.D. thewashtongroup.com 3

What is Harm Reduction?

n Harm reduction has been applied to treating

problems with all types of substances

n Today’s presentation will focus on harm

reduction as a general framework for treatment and more specifically for alcohol and opioid use

n Moderate drinking strategies n Opioid substitution therapy (Buprenorphine)

Why Harm Reduction?

n Many users do no want to stop n Abstinence is seen as undesirable, unthinkable, and/or anxiety-

provoking

n Alcohol and/or other drug use has become an integral part of

their lives and they can’t imagine life without it

n Diverse population requires individualized treatments to meet

diverse needs

n Provides valuable opportunity for early intervention

Harm Reduction expands treatment options

n Opens the door to office-based treatment for SUDs as

alternative to traditional treatment programs

n Attracts patients with earlier stage and less severe

problems

n Fosters better integration, retention and outcomes in

therapy for co-occurring behavioral health problems

n Provides greater opportunities to collaborate with

physicians providing evidence-based pharmacological treatments for SUDs (e.g., Suboxone, Naltrexone, Antabuse)

Moderate Drinking Controversy

n Dangerous enabling? n Holds out false hopes, controlled drinking has been

proven to be dangerous and ineffective

n Gives permission to engage in very risky, potentially

fatal behaviors

n Denies that addiction is an incurable disease

characterized by progression and permanent loss of control

Prefatory Statement

n None of the strategies discussed today profess to transform

alcoholics into moderate drinkers

n Nonetheless, only the clients themselves can choose their

drinking goals, no matter what we think is best for them

n There is much to be said for an INCREMENTAL approach that

“starts where the patient is” and then coaxes them stepwise away from harmful drinking toward less risky drinking, moderate drinking, or no drinking at all

Prefatory Statement

u Abstinence is always the safest course! u But better to engage clients in a process of incremental

change than turn them away until they “hit bottom” or cause more harm to self and others

u Those who encounter great difficulty with moderation

• ften become more self-motivated to stop drinking at

least temporarily

Prefatory Statement

n A professionally-guided attempt at moderation is often the

best way for clients to learn through their own experience whether moderation is a realistic goal or if abstinence is a better choice

n Moderation (Harm Reduction) is one of the most effective

engagement strategies for all types of alcohol problems

n Often a stepping-stone toward abstinence

Case Vignettes

n Roberto (22 yo graduate student). “I’m not sure what to do. I know

that sometimes I drink way too much, although most of the time I’m able to limit my drinking and it’s not a problem. I don’t want to stop drinking completely. I’d like to just cut out the heavy drinking and stop the problems it’s causing with my girlfriend.”

n Jessica (31 yo accountant, newlywed). “Now that I’m married, I

guess I need to get a handle on my drinking. I get pretty buzzed when I go out with my co-workers a couple of times a week. We all have a great time. My husband says that he doesn’t want to start a family until I get my drinking under control. I’m not quite ready to give up the good times and live a sober life.”

Case Vignettes

n Walter (68 yo retired attorney). “Before retiring several years

ago, I never drank the way I do now that I have so much leisure time. Work was my whole life and I never developed

• ther interests. Now, I sit home alone and pass the time by

sipping wine until my wife gets home from work. When my doctor told me that my liver enzymes are elevated, he suggested that I come see you. My wife agrees. How long will it take for my liver enzymes to return to normal, if I cut back

• n my drinking without stopping completely.?”

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Zufall Center Worshop November 12, 2019 Harm Reduction and Other Evidence-Based Treatments for Addiction Arnold M. Washton, Ph.D. thewashtongroup.com 4

Case Vignettes

n Chelsea (29 yo graphic artist). “I’ve been smoking marijuana

jus about every day since my first year of college. I never thought it was a problem until a year ago when I started vaping and using edibles. At first, I enjoyed the stronger effects, but over time I’ve become more lethargic and

• depressed. I’ve tried many times to reduce or quit, but so far

I’ve not been able to stick with it for more than a week at a

• time. What do you suggest I do.?”

Dilemma

n A client with an alcohol problem that meets DSM-5 criteria

Alcohol Use Disorder (moderate to severe, without physical dependence) asks for your help with controlled drinking

n The client has not succeeded at multiple self-guided

attempts to reduce his alcohol consumption and has already suffered significant alcohol-related consequences

n You state that abstinence clearly would be the best choice n The client says absolutely not n What would you do?

What would you do?

1. State unequivocally your grave concerns about the adverse effects that drinking is already causing and that continued drinking is likely to result in even more severe consequences. 2. Tell the client that in good conscience and in keeping with principles of good practice you do not want to support unrealistic goals and “enable” further drinking 3. Suggest a joint meeting with client’s spouse in the hopes of gathering more information to support a request for abstinence

What would you do?

4.

Encourage the client to attend AA meetings for social support and learn how others are dealing with their drinking problem

5.

Explore the pros/cons of drinking, moderating, and abstaining

6.

Express your willingness to work with the client on initial harm reduction (moderation) goals and see how it goes

7.

Encourage the client to try a short-term “experiment” with abstinence and negotiate a trial period (e.g., 2-4 weeks?)

8.

Offer to schedule another appointment to continue the discussion without pressuring the client for an immediate decision

Dena

n 55 year-old married businesswoman n Referred by couples therapist that she and husband had

been seeing for 2+ years

n Dena drinks 2-3 glasses of wine every evening after work

and 5-8 glasses each Sat and Sun. Sometimes adds mixed drinks (martinis) at dinners with friends

n She had several episodes of binge drinking two years ago

and under extreme pressure from her husband and two adult daughters went to a 28-day inpatient rehab which she absolutely hated and did not find helpful.

Dena

n Family pressuring her to go to inpatient rehab after she

drove home drunk from a dinner with friends

n “I know that I drink too much, but I’m not an alcoholic.

Going away to rehab again is absolutely out of the

• question. I don’t want to give up drinking. I want to

moderate and make sure I don’t overdo it. My husband and daughters are driving me crazy about drinking too much.”

Dena

n I conveyed to Dena my concerns about the severity of

her drinking problem, but expressed my willingness to help her try to moderate rather than abstain

n I explained to her the potential benefits of a temporary

“experiment” with abstinence (e.g., 30 days?) as an ideal first step after which we would jointly develop a moderate drinking plan. I emphasized that taking a break from drinking would help to reduce pressure from her family and give her some time to sort out what she wanted to do about her drinking

Dena

n Dena agreed to immediately stop drinking for 30 days n We discussed a variety of abstinence strategies to help her

refrain from drinking

n We identified drinking triggers and how to manage them,

time planning and activities to reinforce sobriety, etc.

n In the next meeting, her husband came along to let me

know that he didn’t agree at all with my treatment philosophy about moderate drinking. He felt strongly that Dena should give up drinking for good since all of her attempts to moderate her drinking up to this point had failed.

Dena

n I empathized with his concerns and emphasized that

the next 30 days would be very informative and that Dena would surely benefit from his support. He reluctantly agreed.

n Dena joined one of my alcohol moderation groups and

remained abstinent for 30 days following which she elected to extend her abstinence to 90 days before starting on a moderate drinking plan

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Zufall Center Worshop November 12, 2019 Harm Reduction and Other Evidence-Based Treatments for Addiction Arnold M. Washton, Ph.D. thewashtongroup.com 5

Dena

n I also saw her for weekly individual therapy which focused

mainly on her conflicted feelings about her husband of 30 years including her lingering hostile dependency on him; and, dealing with both of her daughters moving far away from home for graduate school and jobs

n Except for two heavy drinking episodes (but no driving

under the influence), Dena has stuck with the moderation plan at this point for almost two years

n Her husband is very satisfied with her progress and

apparently no longer thinks that Dr. Washton is nuts

Edwin

n 55 y.o. forensic accountant n Very challenging, intelligent, with a very serious alcohol problem

for at least 5 years

n Diagnosis: Alcohol Use Disorder (severe), with mild physical

dependence, no health-threatening alcohol withdrawal

n Strong family history of alcoholism and alcohol-related deaths n Edwin pushed my risk tolerance to the limit n Here are the details.....

What is Harm Reduction?

n A framework for addressing substance use and other

risky behaviors

n Aims to reduce the harmful consequences of these

behaviors without requiring abstinence as either the starting point or endpoint of treatment

n Views any steps taken to reduce the risks and

consequences of substance use and other risky behaviors as steps in the right direction, whether or not abstinence is the ultimate goal

What is Harm Reduction?

n Recognizes that there is a continuum of substance

use problems and a continuum of substance-related consequences

n Recognizes that treatment strategies and goals are

patient-driven not diagnosis-driven

n Offers an alternative to traditional approaches that

lowers barriers to treatment entry and extends the reach of treatment to substance users who are unwilling or unable to embrace abstinence

What is Harm Reduction?

n Harm reduction does not try to transform alcoholics or others

with severe addiction problems into controlled users

n It provides an attractive, lower-threshold starting point for

treatment that can help people with severe problems accept the need for abstinence

n Treatment is more likely to succeed when patients choose and

are personally invested in the treatment goals and the methods used to achieve those goals

What is Harm Reduction?

u Abstinence is always the safest course! u But better to engage clients in a process of incremental

change than turn them away until they “hit bottom” or cause more harm to self and others

u Those who encounter difficulty with moderation often

become more self-motivated to abstain

What is Harm Reduction?

n Harm reduction has been applied to treating

problems with all types of substances

n Today’s presentation will focus on harm

reduction for alcohol and opioid use

n Moderate drinking strategies n Opioid substitution therapy (Buprenorphine)

Why Harm Reduction?

n Many users do no want to stop n Abstinence is seen as undesirable, unthinkable, and/or anxiety-

provoking

n Alcohol and/or other drug use has become an integral part of

their lives and they can’t imagine life without it

n Diverse population requires individualized treatments to meet

diverse needs

n Provides valuable opportunity for early intervention

Rationale for Abstinence Alternatives

n Abstinence alternatives for nondependent drinkers remain very

hard to find in the U.S., although more widely available in other developed countries (e.g., Europe, Australia, etc.)

n At least 90% of treatment programs in U.S. are based on an

abstinence-only disease model of addiction

n Harm reduction, moderate drinking, and other abstinence

alternatives are rapidly gaining greater acceptance in the U.S.

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Zufall Center Worshop November 12, 2019 Harm Reduction and Other Evidence-Based Treatments for Addiction Arnold M. Washton, Ph.D. thewashtongroup.com 6

Rationale for Abstinence Alternatives

n Clinicians can encourage abstinence without making it a

pre-condition of providing treatment

n A professionally guided attempt at moderation is often

the best way for clients to learn through their own experience whether or not moderate drinking is a realistic goal.

n Those unable to succeed at moderation often become

more motivated to stop drinking

Starting “Where the Patient Is”

n Although total abstinence is the safest goal, only the

client can choose, no matter what we think is best!

n Treatment goals must be patient driven, not diagnosis

• r clinician driven!

n Many patients refuse abstinence, but are willing to try

moderation

Starting “Where the Patient Is”

n Any steps taken to reduce alcohol-related harm are

steps in the right direction

n Some patients are willing to try an “experiment” or

temporary trial with abstinence

n First and foremost goal is to engage them in a process

• f incremental positive change

Clinical Role of Moderation Strategies

n Stand-alone treatment for mild to moderate alcohol

problems

n Front-end engagement strategy for those with more

severe alcohol problems

n Attract patients initially resistant to formal treatment,

but more accepting of professional “coaching” as a way to address their drinking problem

Clinical Role of Moderation Strategies

n Patients who want to reduce but do not want and may

not need to stop drinking completely

n Patients who want a professional assessment and

recommendations about their drinking behavior (Is it really a “problem”?)

Rationale for Moderation Strategies

n Most people with alcohol problems are not alcoholics n Most are not in treatment n There are FOUR times as many problem drinkers as

alcoholics in the U.S. (NIAAA)

n For every alcoholic, there are 3 problem drinkers at risk for

developing more serious problems

Rationale for Moderation Strategies

n One size does not fit all, no approach is best for everyone n Population of problem drinkers is highly diverse: n Severity of alcohol use & its consequences n Nature and severity of co-occurring disorders n Motivation and stage of readiness for change n Desired treatment goals

Rationale for Moderation Strategies

n There are FOUR TIMES as many problem drinkers as alcoholics in the

U.S.; i.e, for every alcoholic there are at least three problem drinkers at risk for developing more serious alcohol-related health problems (NIAAA & IOM studies of primary care patients)

n Moderation is a realistic and achievable goal for many drinkers,

especially nondependent drinkers with less severe problems

n IOM suggested that treatment should be expanded to offer options

better suited to the needs of nondependent problem drinkers

n

to reduce or eliminate a person’s alcohol consumption and prevent further alcohol-related consequences.

n To create programs aimed at people on the less acute, less severe

end of the alcohol problem spectrum

Rationale for Moderation Strategies

n Unfortunately, appropriate alternatives for nondependent

drinkers remain hard to find in the U.S., although more widely available in other developed countries (e.g., Europe, Australia, etc)

n At least 95% of treatment programs in U.S. are based on an

abstinence-only disease model

n Many if not most people who seek professional help for a

drinking problem do not want to stop drinking either completely or forever and are unwilling to adopt identity of “alcoholic”

n Lifelong abstinence is not their goal

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Zufall Center Worshop November 12, 2019 Harm Reduction and Other Evidence-Based Treatments for Addiction Arnold M. Washton, Ph.D. thewashtongroup.com 7

Rationale for Moderation Strategies

n At least 95% of treatment programs in the U.S. are based

exclusively on an abstinence-only disease model

n But many if not most people who seek help for a drinking

problem do not want to stop drinking completely (or forever) and are unreceptive to seeing their problem as a “disease” or themselves as “alcoholics”

n Permanent abstinence and adopting an AA-oriented

lifestyle is simply not their goal

n Regrettably, countless people with less severe alcohol

problems stay away from treatment due to the absence of more attractive and appropriate alternatives

Rationale for Moderation Strategies

n Countless people with less severe alcohol problems

categorically avoid seeking/entering treatment not seeing themselves as needing or wanting what traditional abstinence-based disease model treatment offers/requires

n Lacking attractive treatment alternatives, many drinkers

avoid getting help while their alcohol problem and its consequences continue to get worse

n Current treatment system geared mainly toward treat

people with more severe problems (i.e, dependence rather than abuse)

n Clients with less severe and earlier-stage problems are

likely to be seen as resistant, unmotivated, and in denial

Rationale for Moderation Strategies

n Many drinkers:

n Do not want to stop drinking completely and/or permanently n Lifelong abstinence is not their goal n Do not see their problem as a disease n Reject the identity of “addict-alcoholic” n Perceive their problem as not severe enough to warrant what

traditional treatment requires

Rationale for Moderation Strategies

n IOM has suggested that alcohol treatment should be

expanded to offer options better suited to the needs of nondependent problem drinkers

n These options should aim to reduce or eliminate an

individual’s alcohol consumption so as to prevent further alcohol-related consequences

n IOM called for creation of programs at at people on the less

acute, less severe end of the alcohol problem spectrum

n Unfortunately, appropriate alternatives for problem

drinkers remain hard to find in the U.S., although more widely available elsewhere (e.g., Europe, Australia)

Rationale for Moderation Strategies

n Providing flexible alternatives to abstinence-only can attract

many more people with drinking problems into treatment before they develop more serious problems

n Moderation is a realistic and achievable goal for many

people with less severe drinking problems who are not alcoholics

n Many who start with moderation, end up choosing

abstinence, including many who would not have entered treatment at all

Non-Abstinence Goals: Rationale

n Although abstinence is the safest course, it is far better to

engage people in a process of incremental change than to turn them away until they “hit bottom” or cause more harm to self and others

n Clinicians can encourage abstinence without making it a pre-

condition of providing treatment

n A professionally guided attempt at moderation is often the best

way for clients to learn through their own experience whether moderation is a realistic goal.

n Those unable to succeed at moderation often become more

motivated to abstain

Principles of Integrative Approach

n Non-dogmatic, client-centered, atheoretical approach n Avoids adherence to any single treatment orientation or

philosophy in favor of doing “what works”

n Utilizes a toolbox of different treatment models,

approaches, strategies, and interventions some of which may seem incompatible

n Do “what works” n Above all, do no harm!

Rationale for Moderation Strategies

n Empirically-supported treatment approach n Research studies conducted in universities and medical schools in

12 different countries from 1970s to present

n Actively supported and advocated by NIAAA n Sensationalized accusations of faulty research methods turned out

to be unfounded, after careful scientific review

n The fact that the founder of MM (Audrey Kishline) was involved in

a fatal DWI-related car accident says nothing about moderation strategies.

n Reportedly, at the time of the accident she was involved in AA

attempting to remain abstinent

Most heavy drinkers are not alcoholic !

n CDC health study of 138,000 survey participants (2009-

2011)

n 90% of those who self-identified their drinking as

“excessive” did not qualify for a DSM-IV diagnosis of Alcohol Dependence (“Alcoholism”)

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Zufall Center Worshop November 12, 2019 Harm Reduction and Other Evidence-Based Treatments for Addiction Arnold M. Washton, Ph.D. thewashtongroup.com 8

FDA recognizes “drinking less” as acceptable treatment outcome

n Sobriety does not have to be the main goal of treatment n Abstinence is not always attainable in clinical settings and there

can be significant benefits from reducing alcohol intake

n Percentage drinking days is a more accurate and realistic

• utcome measure than sustained abstinence yes/no

n Reducing heavy drinking to lower-risk levels helps to avoid many

• f the alcohol-related physical and psychosocial consequences

n Reduced drinking can be a stepping stone toward abstinence

Principles of Harm Reduction

n Support non-abstinence goals n Abstinence is not the only legitimate goal and should not be

a required starting point or endpoint of treatment.

n Abstinence is the ideal goal for compulsive, addictive,

destructive or dangerous use, but very often not an acceptable starting point for clients

Principles of Harm Reduction

n Engaging the active substance user in treatment is the

first and foremost goal. Join with client’s goals despite what you may think is best- but do not hesitate to non- judgmentally and non-coercively state your concerns

n The therapeutic relationship (working alliance) is key

Principles of Harm Reduction

n Any reduction in harms associated with substance use

is worthwhile

n Accept small incremental steps in the direction of

reduced harm as legitimate goals and steps in the right direction

n Small steps often lead to other small steps as

confidence builds in ability to change and that change is indeed possible

Harm Reduction Psychotherapy

n Psychological (behavioral) interventions that seek

to reduce the negative consequences associated with active substance use without requiring abstinence as the goal

n Combines the principles and methods of harm

reduction with evidence-based psychotherapies

n Recognizes the self-medication value of substances

as coping tools to manage negative emotions

Harm Reduction Psychotherapy

n Draws on contributions of cognitive-behavioral, client-

centered (motivational), and psychodynamic traditions to address the unique vulnerabilities and consequences related to each individual’s substance use

n Empowers psychotherapists from diverse backgrounds to

apply the principles and techniques of good psychotherapy to the treatment of SUDs

n The engaging non-authoritarian stance of a harm reduction

approach feels familiar and intuitively correct to professionally-trained psychotherapists

Harm Reduction Psychotherapy

n Places primary emphasis on the therapeutic

relationship

n First and foremost goal is to engage patients “where

they are” in the process of change

n Only the patient can choose which treatment goals to

pursue, no matter what the clinician may think is best

Harm Reduction Psychotherapy

n Respects individual differences (as opposed to ”one size fits

all”)

n Focus on clients’ strengths and motivations for change, not

pathology

n Recognizes the multiple meanings and adaptive functions of

substances for self-medication, emotion regulation, sense of identity, enhanced creativity, social lubricant, relief from critical inner voice, etc.

Harm Reduction Psychotherapy

n Given these positive roles, the desire to moderate and

reduce consequences without stopping altogether is understandably far more appealing than total abstinence

n Reduced use can provide opportunity to “unwrap” the

function and meaning of substance use in a person’s life before he/she is ready to even consider giving it up

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Zufall Center Worshop November 12, 2019 Harm Reduction and Other Evidence-Based Treatments for Addiction Arnold M. Washton, Ph.D. thewashtongroup.com 9

Guiding principles

n Start “where the patient is” n Adjust goals and strategies, as needed n Above all, do no harm ! n Avoid confrontation, arguments, etc

Harm Reduction Empowers Psychotherapists

n The engaging non-authoritarian stance advocated by

harm reduction is familiar and feels intuitively correct to professionally-trained psychotherapists from diverse backgrounds

n Psychotherapy training and skills are seen as assets not

liabilities when treating substance users

Applicable Skills of Psychotherapists

n

Psychotherapists place high value on initiating an empowering therapeutic alliance with their patients in order to engage, motivate, and retain them in treatment.

n

They are trained to be good listeners, to convey nonjudgmental acceptance, empathy, and positive regard for their patients, to work therapeutically with the patient’s resistance not against it, and to remain vigilantly aware of their own countertransference reactions as potential obstacles to the treatment.

n

Therapist characteristics matter a great deal in treating SUD’s.

n

Research points to the Rogerian qualities of therapist warmth and empathy as more reliable predictors of favorable outcomes than the therapist’s theoretical

• rientation or treatment philosophy.

Working With AMBIVALENCE

n Unhelpful to think of clients as “poorly motivated” (engenders

negative interaction)

n How you respond to ambivalence determines whether you

increase or decrease the client’s readiness for change.

n Clinicians often jump too quickly and too far ahead in pressuring

for change--- provokes resistance

n Problems of clients being “unmotivated” or “resistant” occur

when a clinician is using strategies mismatched to the client’s stage of change

Seven Key Therapeutic Tasks

1.

Establish and maintain the therapeutic alliance

2.

Engage clients where they are

3.

Utilize assessment as the start of treatment

4.

Empower and support self-management skills

5.

Embrace ambivalence and non-linear change

6.

Work collaboratively to set specific harm reduction goals

7.

Teach, guide, and support strategies for positive change

Limitations of traditional treatment

n Agency based programs n 95% are 12-step oriented, based on disease model n Geared mainly to treat addiction, not less severe problems n Group therapy is primary modality, individual therapy is scarce n Treatment plans are pre-formulated, not individualized n Patients must fit themselves into the program rather than vice

versa, especially those with emerging or early-stage problems

n Do not support non-abstinence (harm reduction) goals n Tend to view harm reduction as dangerous enabling and failure

to appreciate the necessity of abstinence as the only viable way to arrest the disease

Advantages of Office-Based Treatment

n Opportunity for early identification and intervention n Opportunity for individual therapy & small group

therapy

n Flexible, individualized approach n Attention to individual differences rather than “one

size fits all”

Especially attractive to patients who…

n

Do not suffer from severe addiction

n

Want alternatives to abstinence-only “one size fits all” approaches of mainstream treatment programs

n

Want personalized attention

n

Want to choose their own therapist

n

Have heightened confidentiality concerns

Especially attractive to patients who…

n

Are in the early stages of coming to grips with an alcohol or drug problem

n

Want an approach that is motivational, not confrontational

n

Have maintained abstinence and want psychotherapy to address emotional/psychological issues

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Zufall Center Worshop November 12, 2019 Harm Reduction and Other Evidence-Based Treatments for Addiction Arnold M. Washton, Ph.D. thewashtongroup.com 10

Especially attractive to patients who…

n

Are currently receiving group therapy in an outpatient program and want concurrent individual therapy

n

Have completed an outpatient or inpatient program and want aftercare individual and/or group therapy

n

Are in AA or other self-help programs and want psychotherapy to address underlying and co-existing issues

Evidence-Based Psychotherapies

n Motivational (Client-Centered) n Cognitive-Behavioral (skills training) n DBT, Mindfulness n Relapse Prevention Strategies n Modified Psychodynamic

Readiness to Change Paradigm

X X X

resistance ambivalence Not considering Change

Precontemplation

Thinking about change

Contemplation

Ready to Change

Preparation

T aking Action

Action

Maintaining Change

Maintenance

Is the patient’s goal to reduce or stop use?

What the research shows….

n No single treatment approach is superior to all others n 12-step approaches are neither more or less effective

than other approaches such as cognitive-behavioral, motivation-enhancement, brief therapy, or supportive therapy

n Many people overcome severe addictions without

formal treatment or 12-step programs. The phenomenon of “natural” or “untreated” recovery is well-documented in people previously addicted to heroin, cocaine, alcohol, and nicotine.

What the research shows….

n Patient engagement and retention rates are enhanced

when treatment is matched to the patient’s stage of readiness for change; i.e. when treatment “starts where

the patient is”

n Amazingly, it has taken over 30 years of research and

hundreds of millions of dollars to find out that it’s important to be nice to your patients !!