ALCOHOL USE DISORDER

PART 2: MANAGEMENT
SPEAKER: DR. SAGNIK MUKHERJEE (Post-
Graduate)

MODERATORS: DR. T. GAUTHAM ( Associate

Professor)
DR. V. MURALI KRISHNA (Assistant
Professor)
NEUROBIOLOGY OF ALCOHOL ADDICTION

1. Ethanol increases extracerllular DA levels in Nacby

increasing the firing rate of VTA, rather than effect in
NAc itself.

2. Factors influencing increased firing rates:

Effects on potassium channels and GABA-A Receptors in

VTA, reducing effects on potassium channels and GABA-
A receptors in VTA.
3. Enhances inhibition at GABA synapses and reduces
excitation at glutamatergic synapses.

4, Increases GABA release by blocking pre-synaptic GABA-B

receptors and also by positive allosteric modulation of post-
synaptic GABA-A receptors, that contain δ subunits, that are
responsive to Neuro-steroids and not to BZDs.

5. Acts at pre-synaptic metabotropic glutamate receotors (mGlurs)

and pre-synaptic VSCCs.

6. Also reduces activity of glutamate at post-synaptic NMDA

receptors and at post-synaptic m-Glur receptors.
 PLOT TWIST
Alcohol also acts at opioid synapses within mesolimbic
reward circuitry.

Opioid neurons arise in arcuate nucleus and project to

VTA, synapsing on both glutamate and GABA neurons. \

The net result on opioid synapses is the release of DA in

NAc.

Alcohol des this either by directly acting on the mu-

opioid receptors or releasing endogenous beta-
endorphins.
Alcohol enhances the effect of GABA on GABA-A neuroreceptors, resulting in decreased
overall brain excitability.
Chronic exposure to alcohol results in a compensatory decrease of GABA-A
neuroreceptor response to GABA, evidenced by increasing tolerance of the effects of
alcohol.
Alcohol inhibits NMDA neuroreceptors, and chronic alcohol exposure
results in up-regulation of these receptors.
Abrupt cessation of alcohol exposure results in brain hyperexcitability,
because receptors previously inhibited by alcohol are no longer
inhibited.
ALCOHOL EFFECTS ON BRAIN
DURING INTOXICATION AND
CRAVING
Enhance inhibition at GABA-
A neurons
Decreases Glutamate
Dampen NMDA receptor
function
DURING WITHDRAWAL
Down regulation of GABA-A
neurons
Increases Glutamate
Up regulation of NMDA

• Increases dopamine and its metabolites that effects

pleasure area in ventral tegmentum.
•It also increases serotonin concentration in
synapse - upregulation of serotonin receptors
 BEHAVIORAL ASPECTS
Craving : drive to drink relate to classical conditioning and
reflect neuro-chemical changes
In neuroimaging when preferred substance is shown
activation of ventral tegmental area, ventral striatum,
amygdala, insula, medial prefrontal cortex, orbitofrontal
cortex .
During early abstinence mu receptors increase and enhance
craving.
Rewarding effects and subsequent reinforcement (stress and
tension reducing effects) after alcohol intake contribute to the
drink again after first use and to continue despite problems.
 EFFECTS OF ALCOHOL ON OTHER
SYSTEMS
GIT CVS HEMATOLOGY CNS
• Oesophagitis • HTN • Dec WBC • Cerebellar
• Gastritis (Withdrawal) • Inc MCV degenration
• Fatty liver • R/O MI • Dec Platelets • Wernicke’s
• Cirrohsis • Alcoholic • Korsakoff’s
• Hepatic Cardiomyopath
Encephalopath y
y
• Acute
Pancreatitis
Disturbance in short term memory.
Rare in age < 35yrs.

ACUTE CHRONIC
WERNICKE KORSAKOFFS
ENCEPHALOPATHY PSYCHOSIS

GLOBAL CONFUSION,
ATAXIA, Impaired memory
OPHTHAMOPLEGIA (6TH (recent > remote)
CN PALSY), Confabulation, Ataxia,
HORIZONTAL Peripheral Neuropathy
NYSTAGMUS

Reversible 20% Reversble

WHY THIAMINE DEFICIENCY ?
INTERNATIONAL F10--F19 Mental and behavioural
disorders due to psychoactive substance
CLASSIFICATION use
OF DISEASE -10 F10. -Alcohol
1. F10.0 Intoxication
2. F10.1 Harmful use
3. F10.2 Dependence syndrome
4. F10.3 Withdrawal state
5. F10.4 Withdrawal state with delirium
6. F10.5 Psychotic disorders
7. F10.6 Amnestic syndrome
8. F10.7 Residual and late onset psychotic
disorder
9. F10.8 Other mental and behavioral
disorders
 F10.0 ACUTE INTOXICATION

A transient syndrome
-due to recent substance ingestion
-that produces clinically significant psychological and
physical impairment.

➢Changes are reversible upon elimination of substance

from the body.
➢Legal definition of intoxication in USA is alcohol
conc. > 80-100 mg/dl of blood.
 LIKELY IMPAIRMENT
➢Slowed motor performance,decreased thinking
LEVEL ability.
20-30 mg/dl ➢Increase in motor & cognitive problems.

30-80 mg/dl ➢Increase in incoordination and judgement

errors. Lability of mood, Cognitive
deterioration
80-200 mg/dl

➢Marked slurring of speech, Nystagmus,

200-300 mg/dl Blackouts.

➢Impirement in vital signs, possibly Death!.

>300 mg/dl
 ALCOHOL INTOXICATION

A reversible syndrome caused by recent ingestion of

alcohol that effects one or more of the following mental
function.
Effects of alcohol are sensitive to dose.
Early effects produce elation, excitement and more
talkative
Alcohol taken alone may intensify feelings of loneliness
and depression.
Physiological signs of intoxication and behaviour depend
Blood alcohol level.
 MANAGEMENT OF INTOXICATION
 Patient handled in an unprovoked way
 If serum glucose in doubt - IV glucose 50% +
thiamine(50-100mg)
 Careful monitoring of blood pressure, correction of
hypovolemia and acid base balance.
 Carefully exclude coincident head injury and alcohol
complications GI bleeding, hepatic failure,
pneumonia, meningitis.
 Evaluate for causes of coma in alcoholic and
concomitant drug use .
 IV vitamin B &C reduce subjective effects of
intoxication and improve performance.
 IV fructose or peritoneal dialysis accelerate fall of
blood alcohol level
PATHOLOGICAL INTOXICATION: The curious case
of Benjamin Button
 F10.3 DEPENDENCE SYNDROME

A cluster of physiological, behavioural, and cognitive

phenomena.

-in which the use of a substance takes on a much

higher priority for an individual than other
behaviours that once had greater value.
 Diagnostic guidelines for dependence
syndrome-
Three or more of the following is necessary to diagnosis in previous
ONE year.
a) Strong desire.
b) Loss of control of consumption.
c) Evidence of tolerance.
d) Signs of withdrawal on attempted abstinence
e)Progressive neglect of alternative pleasures or interests.
f)Continued drug use despite negative consequences.
 S/S ALCOHOL WITHDRAWAL SYNDROME
Time withdrawal symptoms

6 to 12 hours Insomnia, tremulousness, mild anxiety, gastrointestinal upset, headache,

diaphoresis, palpitations, anorexia

12 to 24 hours Alcoholic hallucinosis: visual, auditory, or tactile hallucinations

24 to 48 hours Withdrawal seizures: generalized tonic-clonic seizures

48 to 72 hours Alcohol withdrawal delirium (delirium tremens): hallucinations (predominately

visual), disorientation, tachycardia, hypertension, low-grade fever, agitation,
diaphoresis
 NEED FOR ASSESSMENT:

In Indian population it is helpful in

numerous ways including:
a) Screening of patients who may present only
with physical problems but do not reveal
substance use by themselves.
b) Establishing a diagnosis
c) Planning treatment
d) Referral to a specialist for further treatment
e) Assessment also serves to establish rapport
and motivate client towards seeking treatment/
reduce harmful use/ abstinence.
 HOW TO ASSESS:

ASSESSMENT

CLINICAL OTHERS

ASSESSMENT WITH
LABORATORY
INSTRUMENT
 CLINICAL AND PHYSICAL ASSESSMENT
 1. Detailed history
 -systematic inquiry into current and past substance use
(excluding alcohol)
 -assess whether person fulfills criteria of dependence of
alcohol(by ICD-10)
 -Time of recent drink
 -Collateral family history of alcohol use or psychiatric illness
 -Past abstinence attempts with history.of past treatment
response
 -physical examination including cognitive functions
 -current motivation for quitting substance should be
assessed as per accordance with Prochaska and Diclemente
stages
 -Breathanalyser : to be taken at least 20 minutes aftr last
drink and again after 1 hour
 PHYSICAL EXAMINATION

Certain specific features which may aid in the

diagnosis are:
ALCOHOL WITHDRAWAL-Anxiety, tremors,
nausea, vomiting, agitation , paroxysmal sweats,
tactile disturbances, visual disturbances, auditory
disturbances, clouding of consciousness, headache.
 MENTAL STATUS EXAMINATION-

1. General appearance and behaviour-Level of

consciousness and orientation – Provides clue regarding
withdrawal/intoxication ,General demeanour, Eye to eye
contact, Abnormal movements ex tremors can be seen in
substance withdrawal.
2. Psychomotor activity-Can be affected in substance
related delirium (ex hypoactive or hyperactive) or
substance related mood disorder etc.
3. Speech-Spontaneity, tone, tempo and volume of
speech,relevance, coherence, reaction time and prosody.
 MENTAL STATUS
EXAMINATION(contd.)
4. Thought-
-In form and stream Assess for
circumstantiality, tangentiality, thought
block, incoherence, verbigeration, word
salad,neologism and perseveration
-ContentReferential/Persecutory/
Grandiose/Hypochondrical
ideation/delusions,depressive
cognitions,death wishes and suicidal
ideation.
-Possession Assess for thought alienation,
 MENTAL STATUS
EXAMINATION(contd.)
5. Mood-Subjective and objective
component, range, reactivity, congruence
to thought process and appropriateness to
environment
6. Perception-
Sensory distortions - under
substance intoxication
Sensory deceptions - can occur under
both substance intoxication and
withdrawal.
7. Cognitive function assessment-
 ASSESS MOTIVATION

As per Prochaska and DiClemente's classification the

stages of motivation are:
❑precontemplation
❑contemplation
❑ preparation
❑action
❑ relapse
 LABORATORY TESTS AND OTHER
HISTORY TAKING ASSESSMENTS
CBC, RTF, LFT, Serum Electrolytes, PT-INR, Urinaey
Drug Screen, Serology for viral markers
Parameter Normal value Value in chronic
alcoholics
Mean corpuscular 80-98μm3 >100 µm3
volume or mean
cellular volume,

AST & ALT <45 U/L AST:ALT, 2:1

Serum level of γ- Men 4-25 U/L >30 U/L
glutamyl transferase Women 7-40 U/L

Serum level of uric 0.24-0.51μmol/L >.6 μmol/L

acid
Carbohydrate- <60mg/l >1.3% of total transferrin
deficient concentration
transferrin
Megaloblastic anemia, Low platelet count,
Specificity and sensitivity of alcohol biomarkers in relation to
the reported amount drunk
Parameter Sensitivity Specificity Amount drunk
MeOH 70% 98% > 0.5 ‰ for several hours

CDT 46–90% 70–100% Chronic excessive

drinking

GGT 37–95% 18–93% Chronic excessive

drinking

AST 25–60% 47–68% Chronic excessive

drinking

ALT 15–40% 50–57% Chronic excessive

drinking

MCV 40–50% 80–90% Chronic excessive

drinking

CDT. MCV 88% 95% Chronic excessive

and GGT in drinking
combination

EtG in urine 89% 99% Abstinence monitoring

EtG in hair 75% 96% Chronic excessive

drinking
(cut-off 30 pg/mg)

FAEE in hair 90–97% 75–90% Chronic excessive

drinking
(dependent on cut-off)
 PSYCHOMETRIC ANALYSIS
1. AUDIT: 10 item questionnaire.
 Q.1-3: Quantity of alcohol consumed
 Q.4-6: Signs and symptoms of dependence
 Q.7-10: behaviours and symptoms associated with harmful alcohol use
 Minimum Score 0, Maximum score of 40
 Score of >8: Hazardous of Harmful drinking

2. SAD-Q: Detailed 20 items questionnaire

Maximum score of 60
SEVERITY OF ALCOHOL DEPENDENCE
Mild <15
15-30
Moderate >30
Severe
 ALCOHOL TREMORS

Commonest withdrawal effect associated with general

weakness, nausea and irritability.
Tremor is of mild form in single night abstinence
Severe form 12-24 hours after several weeks of continue
drinking.
The patient is alert, startles easily, suffers insomnia and
craves the relief with further alcohol.
25% of patient have disordered sense of perception, involving
misinterpretation of familiar objects and hallucinations.
starts in 4-12hrs and last for <24 hours.
Tinnitus is common with auditory hallucinations, it starts as simple
sounds and gradually take on vocal form.
Command hallucinations - compel to attempt suicide or some
episode of bizarre behaviour.
Prolonged hallucinations strongly resemble a picture of
schizophrenia.
When hallucinations occur while continuing drinking, suggests
Visual disturbances blurring, flashes and spots are
usual
Lilliput hallucinations .
Delusions follow only the hallucinatory experiences
and do not arise autochthonously
Delusions of infidelity, paranoid delusions are most
common.
Absence of disorientation, confusion and psychomotor
over activity distinguish it from delirium tremens.
Thiamine deficiency - associated with hallucinations
 WHEN DO WE REQUIRE
PHARMACOLOGICALLY ASSISTED ALCOHOL
WITHDRAWAL
1. Regular consumption >15 Units per
day
2. AUDIT score >20
3. History of significant withdrawal
symptoms
4. CIWA-Ar score of >10 and SAWS
score of >12
WHEN IS COMMUNITY DETOXIFICATION
POSSIBLE
 WHEN IS INPATIENT
DETOXIFICATION NECESSARY
 WITHDRAWAL SEIZURES/RUM
FITS
Alcohol consumption precipitate fit in a known epileptic
* after “normal” evening drink
* commonly next morning during sobering up.
Withdrawal seizures occur when there is no epileptic
predisposition.
- after heavy drinking
- after 12-48hours of termination of long bout
- several years of alcohol addiction
Mostly 2-6 episodes / time after a single episode.
30% of seizures followed by DT.
30% of DT and 10% auditory hallucinations are precede by
seizures.
ALWAYS GTCS
 DELIRIUM TREMENS

Its is an acute medical emergency , most serious

alcohol withdrawal phenomenon, mortality upto 5%.
In untreated cases mortality is upto 20%.
Pathophysiology of DT
Cerebral edema was thought to be responsible
Strongly Primary disorder of Reticular formation
with clinical components of profound
- inattention coupled with alertness
- over activity & insomnia
- association with disturbed REM sleep
Autonomic hyperactivity is considerable diagnostic
importance.
In 1/3 patients seizures precede delirium.
Risk factors
It has multifactor - complex metabolic and neuro-
physiological pathways
Long H/O dependence or severe dependence
Multiple previous admissions/assisted withdrawals
Old age
H/O of DT alcohol related seizures.
Medical illness(Liver failure upto 90% ,GI bleeding,
Hypoglycaemia )
Clinical features
Explosive in onset

Classical triad
clouding of consciousness/confusion,
vivid hallucinations in every sensory modality,
marked tremor.
Prodromal phase is seen―onset at night with
restlessness, insomnia and fear
Symptoms peak between 72-96 hours after last drink.
Outcome:
short lived lasts <3 days
terminates with prolonged sleep, recover fully except
with residual weakness and exhaustion
Prolonged attack of delirium after recovery may
reveal an amnestic syndrome

Wernicke encephalopathy may go unnoticed

Death 15-20% mortality rate if untreated, 5%

even after treatmenrt
Due to cardiovascular collapse, infection,
hyperthermia or self injury during intense phases of
restlessness.
Pneumonia markedly increases mortality
D/D of DT
RISK FACTORS OF DEVELOPING DT
WITHDRAWAL REGIMENS

VARIABLE
FIXED DOSE FRONT
DOSE
REDUCTION LOADING
REDUCTION
PREFERRED DRUGS FOR
DETOXIFICATIOON
 FIXED DOSE REGIMEN

DAY 1 40mg QDS+ 40mg PRN 200MG/Day

DAY2 40mg QDS 160 MG/Day

DAY3 30mg QDS 120 MG/Day

DAY4 25mg QDS 100 MG/Day

DAY5 20mg QDS 80 MG/Day

DAY6 15mg QDS 60 MG/Day

DAY7 10mgQDS 40 MG/Day

DAY8 10mgTDS 30 MG/Day

DAY9 5mg QDS 20 MG/Day

DAY10 10 H/S 10 MG/Day

 SYMPTOM TRIGGERED REGIMEN

Day 1-5: 25-30 mg Chlordiazepoxide, hourly as needed

and assessed by CIWA-Ar or SAWS.
 FRONT-LOADING REGIMEN

This involves providing the patient an initially high dose

of medications, around 30-40 high dose equivalent of
Diazepam and then following Fixed Dose Schedule or,
Symptom-Triggered Regimen.
Treatment of Somatic Symptoms
TREATMENT OF DELIRIUM
TREMENS
 REFRACTORY DT
Criteria (Hack et al.) : High dosage of I/V Diazepam ( >50
mg in 1st hour, or 200 mg in first 3 hours) with poor
control of withdrawal symptoms

Management: Oral/ IV Phenobarbitol 100-200 mg/hour

(previously used in front loading regimens)

Alternative: 1.Haloperidol IM 5 mg every 30-60 minutes

2. Risperidone 1-5 mg/day or Olanzapine 5-
10 mg/day)

Last Line: Propofol infusion (0.3-1.25 mg/Kg/hour) in

ICU setting
 ALCOHOLIC HALLUCINOSIS
Occurs in clear sensorium.

Severe form of withdrrawal with high risk of developing

DT.

Fixed-Dose Strategy has best evidence among all 3

regimens.

Low-dose anti-psychotics may be given like CPZ 100-200

mg or Risperidone 1-3 mg to control agitation associated
with this condition.

Lasts upto 1 week to 1 month.

 WERNICKE’S ENCEPHALOPATHY

Risk Factors:

Acute Withdrawal
Malnourishment
Decompensated CLD
Multiple co-morbidities
Homelessness
CLINICAL PRESENTATION
 MANAGEMENT
For Normal Detoxification: IM Thiamine 250 mg/day for
5 days followed by oral Thiamine 300-400 mg/day (NICE-
UK and IPS Guidelines)

For suspected/established WE:

1000 mg of Thiamine three times daily for 3-5 days,

followed by 500 mg for 3-5 days longer (until no further
response is seen)
RELAPSE PREVENTION
HEAD TO HEAD 1 YEAR TRIAL OF NALTREXONE
VS. ACAMPROSATE
IPS GUIDELINES ON RELAPSE PREVENTION
 ALCOHOL RELATED PSYCHIATRIC
D/O
According to DSM 5:
Alcohol induced psychotic disorder
Alcohol induced mood disorder
Alcohol induced Anxiety disorder
Alcohol induced sexual dysfunction
Alcohol induced sleep disorder
 ALCOHOL INDUCED PSYCHOTIC DISORDER
3% in the context of intoxication and withdrawal, experience
auditory hallucinations or paranoid delusions.
The voices are unstructured, maligning, reproachful, or
threatening.
Hallucinations after withdrawal are rare and distinct from
alcohol withdrawal delirium.
Suspicion about partner is more in alcoholic individuals
 ALCOHOL INDUCED MOOD DISORDER
80% people with alcoholism have H/O intense depression
Intense sadness markedly improve with several days to 1
month of abstinence.
These condition rapidly improve with abstinence 2-4
weeks.
To view and deal temporary sadness through education
and CBT.
Wait at least 2 to 4 weeks before starting anti-depressants.
 ALCOHOL INDUCED ANXIETY DISORDER
Anxiety disorder common in acute and protracted withdrawal.
80% have panic attacks during at least 1 withdrawal episode
During the first 4 weeks of abstinence - symptoms resembling
social phobia or agoraphobia.
When psychological or physiological symptoms of anxiety are
observed they diminish and disappear with time alone
(weeks or months).
Anxiety increases relapse of alcohol drinking
 ALCOHOL INDUCED SEXUAL DYSFUNCTION
Sexual dysfunction due to alcohol is considered when
evidence of intoxication or withdrawal .
Small doses enhance sexual performance by
decreasing inhibition
anxiety
temporary elevation of mood.
Continuous use causes impaired erectile engorgement and
orgasmic and ejaculatory capacities.
 ALCOHOL & SUICIDE
Prevalence of suicide in alcohol-related disorders is 10 to 15
%
Factors associated with suicide include
presence of a major depressive episode,
weak psychosocial support systems,
serious coexisting medical condition,
unemployment
living alone
 ALCOHOL INDUCED DEMENTIA

Long continuous use of alcohol directly causes severe

cognitive impairment.
Alcoholics who have thought to have alcohol dementia
are having
– korsakoff syndrome
– coincident vascular dementia
– multiple head injuries or
– Alzheimer’s type of dementia
Psychological evidence
Severe alcoholics - compromised on broad range of
psychological functions
 MARCHIFAVA BIGNAMI DISEASE

Extensive demyelination affects the corpus callous and

adjacent Subcortical white matter, optic tracts and
Cerebellar peduncles.
It presents with – ataxia
– dysarthria
– epilepsy
– severe impairment of consciousness
– more slowly progressive forms with dementia
– spastic paralysis of the limbs
A nutritional origin in frequent H/O dietary deprivation.
 CENTRAL PONTINE MYELINOSIS

Acute and fatal complication of alcoholism.

It presents with – bulbar palsy
– quadriplegia
– loss of pain sensation in limbs
and trunk
Vomiting, confusion, disordered eye movements and
coma are common.
Some show locked in syndrome (with mutism and
paralysis but relatively intact sensation and
comprehension )
May occur in liver diseases not due to alcohol
- Wilson disease
- after liver
transplantation/haemodialysis
hyponatremia - severe burns, hyperemesis gravidarum, and
diuretic therapy.
It is due to over rapid correction of hyponatremia, as pons is
vulnerable to rapid changes in electrolyte balance.
The lesion lies in centre of pons and may involve
neighbouring structures
Focus of demyelination usually demonstrated with MRI.
It is now relabelled as Osmotic demyelination syndrome.
NON-PHARMACOLOGICAL MANAGEMENT:
PSYCHO-SOCIAL INTERVENTIONS
Principles for effective AUD
management
1. No single treatment effective for all individuals, so we need
to tailor it accordingly.

2. Readily available treatment.

3. Always pharmacological + psycho-social interventions better

than any single modality

4. Address patient’s post-treatment environment and a

continuum of care

5. Both voluntary and involuntary acceptance of treatment have

same outcome, depending on skills of therapist.
Challenges for AUD management

1. Poor-treatment retention/follow-up as majority of it

depends on the patient.

2. Efficacy of treatment linked to patient characteristics.

3. Personal characteristics of therapists affect the outcome:

strong IP skills like ‘empathy’ and ‘ability to forge a
therapeutic alliance’

4. Matching treatment experctations: Multidimensional

approach. Project MATCH (a large RCT) failed to proved
any single best effective method.
 Not considering
change in
problem
behaviour

Begin to
consider their
problem, costs
of changing

Sustained
change- Decide to take
abstinent action and
change
Begin to modify
problem
behaviour 97
 BRIEF INTERVENTION
1. Effectiveness comparable to extended counseling, specially for alcohol
and tobacco
2. Very effective in a country like India. Even for primary health
physicians.
Hester & Miller- 6 ingredients to induce change in problem
drinkers- “FRAMES” :

FEEDBACK on risks of substance use

RESPONSIBILITY for change- responsible for own decision
ADVICE – on modifying drug use
MENU of alternative options to choose from
EMPATHY- therapist- warm, empathic, non- judgemental
Client SELF-EFFICACY: absolute opposite to the philosophy of
powerlessness as advocated by fellowship groups like AA
99
MILLER
(William R. Miller)

&
ROLLNICK
(Stephen Rollnick)
Clinical Psychologists
Co- founders of Motivational Interviewing
100
Motivation Enhancement Therapy
 INTRODUCTION
⚫ was developed by William R. Miller
and Stephen Rollnick (1991)
⚫ based on principles of motivational
psychology
⚫ designed to produce rapid, internally
motivated change.
⚫ Acknowledging the presence of a drug related problem
would be the first step in building motivation. You need
to help your client take this first step.
 clients will best be able to achieve change when

motivation comes from within themselves, rather than

being imposed by the therapist.
 It is a trans theoretical model derived from a number

of sources, including stages of change

(Prochaska theory & DiClemente, 1984),
approaches. client-centered
 COURSE OF TREATMENT

Based on Motivational Psychology

To produce rapid, INTERNALLY MOTIVATED CHANGE
Mobilise CLIENT’S OWN RESOURCES
4 treatment sessions :

1st- week 1 - providing feedback, building motivation

2nd- week 2 – enforcing commitment
2 follow through sessions- week 6 , week 12- monitor
and encourage progress
Completed in 90 days
104
 CLINICAL CONSIDERATIONS
5 Basic motivational Principles – “ DARES”
1. EE= EXPRESS EMPATHY
NO superior/inferior relationship between therapist and client
supportive companion
LISTENING rather than TELLING
gentle, nonaggressive persuasion
change is up to the client

105
Client: “My parents are always behind my back; they
think I always do drugs.”
Judgement: “They are your parents and they could be
concerned. What’s wrong with that?”
Questioning: “Why do you think they do that?”
Reflection: “So your drug use has been getting you into
trouble with your parents. You seem to be annoyed with
their reaction?”

106
Client: “If I stop drinking, what am I supposed to do for
friends?”
Advice: “I guess you need to keep the company of non-
drinking friends.”
Suggestion: “You can tell them that you have quit
alcohol but still wish to see them.”
Reflection: “It’s hard for you to imagine living without
alcohol.”

107
2. DD= DEVELOP DISCREPANCY
discrepancy between WHERE THEY ARE and WHERE THEY
WANT TO BE
raising client's awareness of the adverse personal
consequences of his drug use
regain emotional equilibrium

108
This can be done by open ended questioning. You can
use one of the following:

“What brings you here; how can I help you?”

“I assume that since you have come here, that you are
concerned about your drinking; can we talk about your
concerns?”
“How has your drug use changed over time? Tell me
what you have noticed, has it been bothering you in any
way?”
“What do people around you say about your drinking?
What do you think are their concerns?”

109
The 5 Rs can also be used to develop discrepancy an enable the
client contemplate change. The 5 Rs represent the following:

Relevance: What is the personal relevance of quitting substance

for the client?
Risks: What are the potential negative consequences of using
substance for the client?
Rewards: What are the potential benefits of stopping the
substance for the client?
Roadblocks: What are the barriers in quitting the substance and
elements in treatment that may help in handling the barriers.
Repetition: The motivational intervention should be repeated
every time the unmotivated client visits you.

111
….”DARES”
3. AA = AVOID ARGUMENTATION
evokes resistance
ASSIST client to see consequences of drug use
it is the client and not the therapist who voices arguments for
change

112
Reframing is a strategy by which therapists invite clients to
examine their perceptions in a new light or a reorganized form

Drinking as a reward - You may have the need to reward yourself

on the weekends for successfully handling a stressful and difficult
job during the week.......
Your drinking can be viewed as a means of avoiding tension or
conflict in your marriage. It tends to keep things as they are. It
seems like you have been drinking to keep your marriage intact.
Yet both of you are uncomfortable with this arrangement

113
4. RR = ROLL WITH RESISTANCE
do not meet resistance HEAD-ON,
"ROLL WITH" the momentum, shifting client perceptions in
the process

Solutions- evoked from client rather than provided by

therapist

114
Client: “I am not addicted to alcohol.
Therapist: So as far as you are concerned you have
not had any problems with alcohol”.
C: “Well I cannot say that exactly”.
T: “So you think that alcohol is a problem but you
don’t want to be called an addict”.

115
C: “I can’t quit because I will offend my boss if I say no”.
T: “You can’t imagine how you could not drink, and at the
sametime be working for your boss”.
C: “I just can’t stop, as all my friends are using”.
T: “You are thinking too far ahead, lets first work on things we
have at hand. You can think of stopping and what you can
do about it later”.

116
5. SS = SUPPORT SELF-EFFICACY
belief that one can perform a particular behavior/
accomplish a particular task

118
He/She stops resisting and raising objections
Asks fewer questions.
Appears more settled, unburdened, resolved and
peaceful.
Client makes self-motivational statements indicating an
openness to change.
Begins imagining how life might be after change.

119
 Differences from Other Treatment Approaches

1. MET vs CONFRONTATIONAL STRATEGIES

MET- emphasizes client's personal choice regarding
future drug use
Confrontational strategies- describe drug abuse as a
disease beyond the individual's control

The ME therapist does not:

argue with client
impose a diagnostic label on client
tell the client what he "must“ do
"break down" denial by direct confrontation
imply a client's "powerlessness“
120
2. MET vs CBT
CBT – assumes client is motivated
teaches specific coping skills
MET- No direct skill training
client's own natural change processes & resources
Instead of telling HOW TO CHANGE, elicits IDEAS FROM
THE CLIENT AS TO HOW CHANGE MIGHT OCCUR.

3. MET vs NONDIRECTIVE APPROACHES

therapist does not direct treatment,
but follows client's direction wherever it leads
MET - systematic strategies toward specific goals

121
Phase 1: Building Motivation for Change

1. ELICITING SELF-MOTIVATIONAL STATEMENTS

Phenomenon of COGNITIVE DISSONANCE- discomfort due to
contradictory beliefs

SELF-PERCEPTION THEORY-
“as I hear myself talk, I learn what I believe”
words coming from a person's mouth can persuade him better than
words spoken by another

Open- ended questions :

“Tell me about your drinking. What is positive about drinking for u?
What are your worries about drinking?”
122
….BUILDING MOTIVATION
2. LISTENING WITH EMPATHY
empathy - "FEELING WITH" a person/ having an immediate
understanding of their situation by having experienced it

therapist listens to client --REFLECTS it back in a modified form

selective reflection CAN BACKFIRE:

client who is ambivalent, reflection of one side of the dilemma ("So you
can see that drugs are causing u problems.") may evoke the other side
from the client ("Well, I don't think I have a problem really.")

DOUBLE-SIDED REFLECTIONS
“You don't think drugs are harming you seriously now, BUT you are
concerned that they might go out of hand later” 123
….BUILDING MOTIVATION

3. QUESTIONING
purposeful questioning
Rather than TELLING THE CLIENT how he should feel, or what to do,
therapist ASKS THE CLIENT about his own feelings, and plans

CLIENT: I guess I do use too much sometimes, but I don't think I have a
problem with drugs.

CONFRONTATION: Yes you do! How can you sit there and tell me you
don't have a problem when . . .
QUESTION: Why do you think you don't have a problem?
REFLECTION: So on one hand you see reasons for concern, and you
really don't want to be labelled as "having a problem."
124
…..BUILDING MOTIVATION
4. PRESENTING PERSONAL FEEDBACK
give the client the PERSONAL FEEDBACK REPORT (PFR)- a written
report of their results , explain each information,
point out client's score, compare with normal ranges
Observe client as you provide feedback.
Allow time for client to respond verbally.

5. AFFIRMING THE CLIENT = encouraging

affirm, compliment, and reinforce the client
“You've taken a big step today, and I really respect you for that”

125
126
….BUILDING MOTIVATION
6. HANDLING RESISTANCE
Interrupting - cutting off /talking over the therapist
Arguing - challenging the therapist, disagreeing, hostility
Sidetracking - changing the subject, not responding, not paying
attention
Defensiveness - minimizing the problem, excusing own behavior,
blaming others

CLIENT RESISTANCE IS A THERAPIST PROBLEM

NEVER MEET RESISTANCE HEAD ON
Simple reflection, Reflection with amplification, Double-Sided
Reflection,
Shifting Focus, Rolling With Resistance

127
7. REFRAMING
New meaning is given to what has been said
current problems in a more positive , optimistic frame

8. SUMMARIZING
Towards end of a session
client hears his own self-motivational statements a third
time, after the initial statement and your reflection of it

128
Phase 2: Strengthening Commitment

RECOGNIZING CHANGE READINESS

once sufficient motivation is present
stage of DETERMINATION (PREPARATION), client is ready for action
not irreversible

Client stops resisting, asks fewer questions, appears more peaceful,

1. missed previous sessions?

2. hesitancy about scheduling future sessions?
3. Is the treatment being offered different from what he has
experienced in the past?
5. Guarded during sessions or resistant to suggestions?
6. Perceive treatment to be a degrading experience?
129
….PHASE 2
DISCUSSING A PLAN
REASONS to change IDEAS a PLAN for change

CONSEQUENCES OF ACTION AND INACTION

written list of:
positive and negative aspects of continuing to use drugs
benefits and costs of making a change

INFORMATION AND ADVICE – from therapist

provide your own views giving them permission to disagree

EMPHASIZING ABSTINENCE
Not all clients choose to abstain totally- give a rationale for abstinence
A reduction in frequency and quantity of use represents progress
permanent “COLD TURKEY” cessation
Some "WARM TURKEY" options : a trial period of abstinence , gradual
tapering of use, a trial period of reduced use 130
….PHASE 2
HANDLING RESISTANCE
THE CHANGE PLAN WORKSHEET
The changes I want to make
The reasons why I want to make these changes
The steps I plan to take
The ways other people can help me

RECAPITULATING = Summarising
client's self-motivational statements, plans for change,
consequences of changing and not changing.
Use Change Plan Worksheet as a guide

ASKING FOR COMMITMENT

If the client is willing to make a commitment, ask him to sign the
Change Plan Worksheet and give him the signed original
If hesitant, defer the decision until a later time 131
Involving a Significant Other in MET
SPOUSE/ FAMILY MEMBER/ FRIEND – in first two MET sessions
Client and SO can work collaboratively on drinking problem
MET DOES NOT INCLUDE INTENSIVE MARITAL/FAMILY THERAPY

SO in Phase 1
Establish rapport, identify issues
negative experiences - stress, family disorganization, job difficulties-discussed
as common in families with drug problems
Negative information by both SO and therapist - client feels "ganged up on"
results in treatment drop-out
focus on client's responses to what CSO has offered

SO in Phase 2
comment favorably on positive steps by the client

SO could become an OBSTACLE in MET, for damage control:

132
Limit the involvement of CSO in sessions, in decision making
PHASE 3: FOLLOW-THROUGH
STRATEGIES
REVIEWING PROGRESS
begin with a review of what has happened since last session

RENEWING MOTIVATION
asking clients what they remember as the most important
reasons for changing

REDOING COMMITMENT
problems in initial plan- reevaluation, moving toward a new plan
and commitment

need for further treatment or referral is assessed in phase 3 133

STRUCTURE OF MET SESSIONS
INITIAL SESSION
Preparation
importance of bringing a SO,
should be sober- breath test, if alcohol detected- rescheduling
Presenting Rationale and Limits of Treatment
introduction, structuring, CSO's role
“The only person who can decide whether and how you change is you.”

Ending 1st Session

Summarise, speed of session -depends on client's stage of motivation
Follow-up Note- personalized message in your own handwriting

Missed appointments
respond immediately- telephone, Clarify reasons, encourage to
continue, reschedule
134
…..STRUCTURE OF MET SESSIONS

FOLLOW-THROUGH SESSIONS

2nd SESSION
1 to 2 weeks after Session 1
Pick up where you left off
Proceed with Phase II strategies and commitment to change
Closing summary
Thank the SO
Never assume that ambivalence has been resolved and
commitment is firm

135
 …..STRUCTURE OF MET SESSIONS
SESSIONS 3 AND 4
Weeks 6 and 12 respectively
“BOOSTER SESSIONS”- to reinforce motivation
Do not involve SO unless not attended earlier sessions
DRINKING SITUATIONS
Remain empathic, non-judgemental, elicit self-
motivational statements
NON-DRINKING SITUATIONS
Praise clients even for small steps
Review situations in which they were tempted to
drink, but did not 136
Preventing Relapse
⚫ lapse refers to the initial episode of alcohol or other
substance use following a period of abstinence
⚫ relapse refers to failure to maintain behavior change
(substancefree state) over time. It is a state in which an
individual returns to a continuous pattern of taking a
substance,after a period of abstinence.
⚫ Common Relapse Precipitants

⚫ MOOD STATES:Positive mood (excessive

happiness),Negative mood (sadness, frustration)
⚫ BEHAVIORAL:Impulsivity,Poor coping skills
⚫ COGNITIVE:Overconfidence (self-perception of ability to
cope with high-risk situations)
⚫ ENVIRONMENTAL:Peer pressure,Loneliness / no
engagement,Lack of social support/ constant criticism by
family
⚫ PHYSIOLOGICAL:CravingLong lasting withdrawal
symptoms (sleep disturbance after stopping alcohol,
Chronic physical pain
⚫ PSYCHIATRIC CONDITIONS: Anxiety disorder,Mood
disorder , Psychoses Unrecognized depression/anxiety
disorders .
Interventions to Reduce Relapse
⚫ Once the detoxification is over, the main focus should be on this aspect
of management
⚫ A. Identifying and Handling High Risk Situations
⚫ Common Situations where a Person can Develop Craving
⚫ The sight of a bar, especially the one the person used to frequent
before,Meeting friends with whom one was using drugs, passing by usual
hangouts,Peer pressure,Parties.
⚫ Saturday nights/ weekends,Some environmental cues like eating
non-
vegetarian food.
⚫ Being home alone,Family conflicts, Job stress, other stresses, fatigue,
Having a lot of unscheduled time,Negative emotions like frustration,
sadness, depression, Positive emotions such as happiness, excitement, a
feeling of accomplishment (desire to celebrate).
⚫ Making the client aware of those situations which trigger craving is very
important to prevent relapse.
 B. Handling Craving

⚫ Postponement (Urge Surfing):

⚫ Craving is like a wave and episodes of craving are time- limited.
Rather than increasing steadily until they become unbearable,
they usually peak after a few minutes, and then die down like
a wave.
⚫ TRY the 4 Ds :
⚫ Delay, Destract, Drink water, Deep breathing
⚫ One advice that works very well in clinical situations is
that of HALT. If one avoids these situations, the likelihood
of craving decreases.
⚫ Hunger, Anger ,Loneliness, Tiredness
 ⚫C. Drink Refusal Skills and Assertiveness
⚫ One of the common situations of relapse is peer pressure during
different occasions and situations. One should be aware of pressure
tactics, usually from friends.
Bewareof Pressure Tactics
⚫ Pleading: “Please give me company just for a few minutes.”
⚫ Reassuring: “It’s ok, I’ll talk to your family so they won’t be angry with
you.”
⚫ Anger: “Look, I’m drinking, but nothing has happened to me.” “
So you mean to say I’m bad and you are a reformed person.”
“So you want to avoid me.”
⚫ Ridicule: “Are you planning to build an estate with all the money you
have saved.”
⚫ Challenging: “Are you a slave to your wife?”
“Aren’t you the earning member? Don’t you have the right to spend
your own money the way you want to?”
⚫ Threatening: “So you don’t want our friendship.”
“We will expel you from our group if you don’t drink with us
anymore.”
⚫ Refusal skills are a specific set of skills which are related
to dealing with social pressure. Hence it needs a strong
body language and confident tone of voice from the
person while refusing to drink/use a drug.
⚫ Some Common Drink Refusal Statements
⚫ “No thanks, I have stopped drinking.”
⚫ “Let us have tea of coffee instead.”
⚫ “I am taking medicine and I can’t drink on it.”
⚫ “I have an important engagement.”
⚫ “I have to get up early.”
⚫ “I have to work a double shift tomorrow.”
⚫ “I have a headache.”
⚫ “I was just leaving.”
⚫ One of other ways to learn and master it is through role play.
Individual role play between substance user and therapist is one of
the best ways to enhance drink refusal skills.
⚫ Another important component is learning to be "Assertive."
Assertiveness is the ability to insist and stand up for one's own
rights, without hurting others or violating their rights.
⚫D. Dealing with faulty cognitions like
overconfidence, helplessness, etc.
⚫ A person’s faulty thought very often becomes a problem for
him/her and leads to a relapse. A simpleexample is:
“ I can stay away from alcohol. Nothing can tempt me.”
⚫ The consequence is - going to parties where alcohol may be
available, telling myself “I will go, but I’ll not drink.”
⚫ The person needs to recognize that this thought is a red flag
or a
dangerous thought and consciously needs to tackle it.
⚫ Similarly another example very often one comes across is
that:
⚫ “My life has no meaning, it is so bad that I need a break.”
Recognize it’s a Red-flag Thought
⚫ Challenge these thoughts:
⚫ “Even if my life is bad, will reusing drugs really give me the
break I need?” “Or will my life become more ‘bad’ than
before?”
⚫ “What happened before when I was using drugs?”
⚫ “Even if I succeed in forgetting my troubles for a while, how
long can I forget? For a few hours,until the effect lasts.”
⚫ “Think of other ways in which I can take a break: go home
immediately, share with my family, just relax by reading a
book, or resting for a while?”
⚫ Similarly there are other thinking errors like catastrophizing
[e.g. “After all these months of abstinence, I used the drug
again, so there’s no use. I can not recover again” ], jumping to
the conclusion that “I am a useless person because of my
alcohol addiction” etc.
⚫ Very often it is better to practice how to handle these in a
work sheet (written down).
⚫ The basics are what are described as above i.e. Listing
relapse related thoughts, stating what is wrong with it and
challenging and creating new statements.
 ⚫ E. Handling Negative Mood States
⚫ Negative mood states like anger, anxiety, fear, depression,
guilt, getting upset or bored easily, irritability,tiredness,
restlessness, etc. are associated with relapse.
⚫ Some people suggest that addicts frequently relapse as a
result
of joylessness in their lives. A few ways to handle this are:
⚫ The first step is to be aware of one’s self-defeating
thoughts and depressed mood.
⚫ Realizing the adverse consequences of these negative
thoughts.
⚫ Creating opposite (positive) thoughts, challenge negative
thoughts.
⚫ Ignoring negative thoughts, not responding to them.
⚫ Accepting oneself as one really is, with strengths as
well as limitations.
⚫ Having realistic self-expectations.
 ⚫ F. Assess for coexisting Psychiatric Disorders
⚫ Very often the person needs to be assessed for an
independent psychiatric disorder.
⚫ These can have an influence on a person’s judgment,
motivation and functioning with regard to substance use.
⚫ Common comorbid disorders are Depression (Mood
disorders) , Anxiety disorders (Panic Disorder, Generalized
AnxietyDisorders ), Schizophrenia, Somatoform disorders or
Insomnias.
⚫ It is important to get these details and treat these conditions
effectively. That in turn will help immensely for controlling
substance problems.
⚫ These conditions mostly need pharmacotherapy and one
should not hesitate to treat them effectively.
 G. Having a Balanced Life Style

⚫ Attitude is the key – be positive!

⚫ Begin and end your day with prayer and/or reflection.
⚫ Believe in yourself
⚫ Cultivate a best friend whom you can really trust.
⚫ Stay away from negative people who constantly criticize.
Minimize peer influence that is adverse. Spend time with family
and children.
⚫ Take a healthy balanced diet rich in fruits etc. Follow a regular
fitness regimen. Get sufficient sleep.
⚫ Plan your time effectively.
⚫ Pursue a hobby
⚫ Read a humorous book. Exchange jokes with a friend. Watch a
funny movie. Remember, laughter is truly the best medicine!
⚫ Practice Relaxation Technique (deep breathing).Be regular
to job or work.
⚫ Use of Pharmacological Agents as an Adjunct to
Psychosocial Treatment
⚫ It has been well know that a combination of
pharmacological and psychosocial treatment work
better than any one modality.
⚫ Role of Family in Relapse Prevention
⚫ Realize that alcohol/ drug dependence is a disease,
and not a moral weakness or a lack of willpower.
⚫ Do not argue, quarrel, justify his/her use of substance
⚫ Do not suspect.
⚫ Pay extra attention to his needs –
nutrition, medications, health.
⚫ Do not discuss his previous drinking/drug use
problems with others.
⚫ Arranging Follow ups
⚫ Relapse prevention as described at the beginning is a
process and is ongoing.
⚫ If abstinent:“What were the high-risk situations /
warning signs you faced since your discharge/last
session, and what did you do to deal with them
⚫ If lapsed:Where?How?What were you thinking
and feeling?
⚫ Follow-up needs to be frequent in the first three to six
months as the chance of relapse is very high. The other
aim of the whole process is to enable the person to
identify the relapse events and strengthen the person’s
ability to handle such situations effectively.
 RELAPSE MANAGEMENT
Misconceptions about relapse… We must
understand it is a natural course of De-
Addiction Process:
1. NOT A SIGN of poor motivation.

2. DOES NOT SIGNAL FAILURE of treatment.

3. DOES NOT INDICATE that there is no hope of

recovery.

4. Clients need not hit rock-bottom once again to ask

for help.
 • 4 components of Relapse Management
1. Stabilization: Medical Management for withdrawals.

2. Insight and Relapse Pattern:

A) Identify relapse triggers: stress, I-P conflicts, mood

states, peer-pressure.
B) Recognize warning signs: Irrational thoughts,
umanageable feelings, self-defeating nehavior
patterns.
C) Understand the relapse process.

3. Develop a Recovery plan to Safeguard Sobriety

4. Strengthening social support

Cognitive Behaviour Therapy (CBT)
⚫ CBT primarily focuses on individuals’ thoughts and
behaviours.
⚫ This therapy is based on three theories of substance
use namely relapse prevention, cognitive therapy and
behavioural learning theory.
⚫ CBT is a structured, directive, focal time-limited
approach (12 to 24 sessions) and has strong empirical
support for use in the treatment of substance use
disorder.
⚫ General Principles in CBT
⚫ 1) An emphasis on functional analysis of drug
use within the context of its antecedents and
consequences.
⚫ 2) Skills training, through which the individual
learns to recognize the situation or states in which
he or she is most vulnerable to substance use, avoid
those high- risk situations whenever possible, and
use a range of cognitive and behavioral strategies to
cope effectively with those situations if they cannot
be avoided.
Cognitive Behavior Therapy
1. Case Conceptualization-
⚫ Case conceptualization involves the assessment of
patients’ backgrounds,presentingproblems,psychiatric
diagnoses, developmental profiles,and cognitive-
behavioural profile.
⚫ It should also look into factors leading to
initiation and continuance of substance use.
⚫ However, it is also important to consider
motivation to change before determining the
timing and technique of CBT.
⚫ Functional Anaylsis of Substance use
Behaviour
⚫ 2. Collaboration-However, for substance abuse it should be
highly collaborative, supportive, and empathetic.
⚫ They are also encouraged to use the technique of active
listening and role playing rather than lecturing patients.
⚫ Discussion of appropriate non-substance related
problems by patients are encouraged.
⚫ 3. Psycho-education-Therapists offer opportunity for
patients to learn more by means of brief lectures, written
materials, videotapes, or workbooks on a variety of topics.
Long lectures are inappropriate.
⚫ 4. Structure- This includes setting the agenda, checking
the patient's mood, bridging from the last visit (including a
review of substance use, urges, cravings, and
upcomingtriggers),discussion of problems (including
potential coping strategies and skill building activities),
frequent summaries, the assignment and review of
homework, and feedback from the patient about the
session.
⚫ 5. Attention to the multiple needs of patients- CBTs for
substance abuse emphasizes the need for addressing
serious life problems of patients' which include health,
legal, employment,family and housing problems by
referring the patient to appropriate services, for example,
⚫ providing basic information and referrals to self-help
groups for patients needing them.
⚫ Thus, the therapist must be familiar with community
resources, including legal services,detoxification centres,
HIV testing sites, and self-help groups.
⚫ 6. Monitoring substance use- asking patients about
substance use at each session is an essential component of
CBT and the accuracy of self-report is enhanced when
confidentiality is assured.
Specific Techniques of CBT
⚫ CBT approaches for substance use, there are several strategies
common to most of them which includes functional analysis
of substance use and coping skills management.
⚫ Functional analysis of substance use-
⚫ Functional analysis (or chain analysis), is defined as "the
identification of important, controllable, causal functional
relationships applicable to a specified set of target behaviours for
an individual patient".
⚫ The initial step is to help the patient recognize the triggers and
reinforcers of substance use and skills needed to intervene in this
process.
⚫ The method used is usually through open-ended exploration
of patients' substance use history (e.g., determinants of
substance use, patterns of use, common thoughts and feelings
associated with urges to use, reasons for using substances).
⚫ Coping skills for managing the antecedents of substance use-
⚫ Once the functional analysis is complete, patients are taught
coping skills either to prevent substance use or prevent relapse
to substance use.
⚫ There may be different types of antecedents present in
individual patient which includes social, environmental,
emotional, cognitive, and physical factors.
⚫ Social Antecedents
⚫ These include attending social events such as parties or
festivals where people use substances, peer influence through
pressure or conditional association with substance use.
⚫ For such antecedents, the coping strategies taught to the
patient are lifestyle changes, enhancing social support and
refusal skills.
⚫ Environmental Antecedents
⚫ These include external substance-related cues (e.g.,
advertisements for alcohol, the smell of alcohol) and
general cues that have come to be associated with
substance use through classical conditioning (e.g.,money,
times of day).
⚫ For such antecedents, patients are taught cue
exposure treatment (CET) and decision making skills.
⚫ CET involves repeated exposure to the environmental
cues associated with substance use (e.g., photographs of
high- risk locations),with the goal of decreasing
responsivity (e.g., cravings, substance-related thoughts) to
these stimuli
⚫ Strategies include identifying examples of poor decisions
(e.g., keeping substances in the house), recognizing
associations between decisions and exposure to high-risk
situations, challenging cognitive distortions that encourage
risky decisions,and practising safe decision-making.
⚫ Emotional Antecedents
⚫ These include change strategies and acceptance
strategies. Change strategies include challenging
distorted thoughts that fuel negative affect,
completing daily thought records, and using
positive coping statements (e.g., “I can handle these
feelings without using”).
⚫ Behavioral strategies include activities to decrease
the intensity of negative affects such as distraction,
engaging in pleasurable activities, self-soothing,
acting opposite of emotions and relaxation strategies.
Cognitive Antecedents
⚫ These include drug-related beliefs (e.g., “Using drugs improves my
mood”), automatic thoughts (e.g.,“Drink”!), and facilitating beliefs
(e.g., “I can handle one peg”) that increase the risk of lapse and
relapse.
⚫ These cognitions often derive from core beliefs about self (e.g., “I’m
vulnerable”) and resulting rules that a person has developed for
survival (e.g., “If I let myself feel my emotions, I’ll fall apart”).
⚫ The strategies include modifying automatic thoughts and drug-
related beliefs and modifying conditional assumptions and core
beliefs.
⚫ The initial step in modifying automatic thoughts is to help patients
identify their automatic thoughts and drug-related beliefs and to
recognize that they may not be completely accurate.
⚫ Patients are taught to identify logical errors in their
thinking that may trigger substance use (e.g.,
ignoring evidence that substance use is becoming
problematic, exaggerating their ability to quit,
overemphasizing the positive aspects of substance
use, devaluing non- substance-using friends and
activities, and believing that life without substance
use is boring).
⚫ A variety of cognitive restructuring techniques can
be used to modify distorted automatic thoughts and
drug-related beliefs, including examining the
evidence, considering the alternatives, keepingdaily
thought records, using a cognitive continuum and
surveying others.
⚫ In addition, patients can create cards on which
they can write their common automatic thoughts
and effective challenges to them.
⚫ Patients can refer to these when confronted with
high- risk situations that trigger these cognition.
⚫ Techniques available for identifying core beliefs
include looking for central themes in patients’
automatic thoughts, recognizing core beliefs that are
expressed as automatic thoughts, Socratic
questioning, and the what-if method.
⚫ Once patient’s core beliefs have been identified,
strategies for modifying these beliefs include
examining advantages and disadvantages, historical
tests, keeping a daily log of evidence that supports
and contradicts the core belief, and conducting
behavioral experiments to test the conditional
assumptions associated with core beliefs.
⚫ Physical Antecedents
⚫ These include substance use to control cravings,
withdrawal symptoms and non-specific
conditions such as headache. Techniques include
distraction, urge surfing and focus on
consequences.
⚫ Distraction techniques include physical exercise,
talking with someone, snapping a rubber band on
their wrist, relaxation strategies and thought
stopping.
⚫ Urge surfing is done by focusing attention on the
experience of craving and describing the
associated physical sensations, feelings and
thoughts in an objective way.
⚫ This helps in increasing acceptance of craving as
a time-limited normal experience that patients
can manage without using substances.
⚫ Focusing on consequences, an analysis of
advantages- disadvantages is helpful in identifying
the pros and cons of abstinence and continued drug
use.
⚫ Another strategy involves recalling the negative
consequences of past substance use in order to make
disadvantages of giving in to the craving more
salient.
Alcoholics Anonymous
(A.A.)
⚫ Clinicians must recognize the potential importance of
“12 – Step-based “ self-help groups such as AA.
⚫ Members of AA have help available 24 hours a day, the
meeting promote developing a sober peer group, and
participants learn that it is possible to participate in
social functions without drinking.
⚫ While also being presented with a model of recovery
by observing the accomplishments of sober members
of group.
⚫ Learning about AA often begins during inpatient or
outpatient rehabilitation
⚫ The clinician can play an important role by encouraging
AA attendance while helping patients select a group most
appropriate for them.
⚫ Some meetings are comprised only of men or women and
others are mixed, some are mostly attended by blue –collar
men and women where as others are mostly for
professionals, some groups place great on
religion
emphasisand others are more eclectic
⚫ The patients with co-existing psychiatric disorders
may
lead some education about AA
⚫ The clinician should remind them that some members
of AA may not understand their special need for
education and should arm the patient with ways of
coping if anyone inappropriately suggests that the
required medication be stopped.
AA Twelve Steps
⚫ We admitted we were powerless over alcohol that our
lives had become un-manageable.
⚫ Come to believe that a Power greater than
ourselves could restore us to sanity.
⚫ Made a decision to turn our will and our lives over
to the care of God as we under stood him.
⚫ Made a searching and fearless moral inventory
of ourselves.
⚫ Admitted to God to ourselves and to other
human beings the exact nature of our wrongs.
⚫ Were entirely readily to have god remove all
these defects of character.
⚫ Humbly asked him to remove our shortcomings.
⚫ Made a list of all persons we had harmed, and became
willing to make amends to them all.
⚫ Made direct amends to such people wherever possible
except when to do so would injure them or others.
⚫ Continued to take personal inventory and then we
were wr0ng promptly admitted it
⚫ To try to discover, through prayer and mediated to
improve our conscious contact with God, as we under
stood him, praying only for knowledge of his will for
us and the power to carry that out.
⚫ Having had a spiritual awakening as the result of these
steps, we try to carry these message to alcoholics and
to practice those principals in all our affairs
REFERENCES
⚫ Psychosocial interventions for persons with
substance abuse theory and practice guide in
NIMHS and neuro sciences de addiction center
developed under WHO – GOL collaborative
programme 2006-2007.
⚫ CTP ninth edition.