EMPIRICALLY-SUPPORTED TREATMENTS FOR

STIMULANT DEPENDENCE

RICHARD A. RAWSON, Ph.D.RICHARD A. RAWSON, Ph.D.UCLA INTEGRATED SUBSTANCE ABUSE UCLA INTEGRATED SUBSTANCE ABUSE

PROGRAMS (ISAP)PROGRAMS (ISAP)

October 9, 2004October 9, 2004

Behavioral/Cognitive Behavioral Treatments

Cognitive/Behavioral Therapy-CBTCognitive/Behavioral Therapy-CBT Motivational Interviewing-MIMotivational Interviewing-MI Contingency Management-CMContingency Management-CM Community Reinforcement Approach-CRACommunity Reinforcement Approach-CRA Matrix Model of Outpatient TreatmentMatrix Model of Outpatient Treatment

Cognitive Behavioral Therapy

Based upon Social Learning Theory (Bandura Based upon Social Learning Theory (Bandura and others)and others)

Also referred to as Relapse Prevention TherapyAlso referred to as Relapse Prevention Therapy Applied to treatment of alcoholism, cocaine Applied to treatment of alcoholism, cocaine

dependence, dependence, nicotinenicotine dependence and dependence and marijuana abuse.marijuana abuse.

Cognitive Behavioral Therapy Key ConceptsKey Concepts

Encouraging and reinforcing behavior change Encouraging and reinforcing behavior change Recognizing and avoiding high risk settingsRecognizing and avoiding high risk settings Behavioral planning (scheduling)Behavioral planning (scheduling) Coping skillsCoping skills Conditioned “triggers”Conditioned “triggers” Understanding and dealing with cravingUnderstanding and dealing with craving Abstinence violation effectAbstinence violation effect Understanding basic psychopharmacology principlesUnderstanding basic psychopharmacology principles Self-efficacySelf-efficacy

Cognitive Behavioral Therapy

ResourcesResources Marlatt and Gordon 1985Marlatt and Gordon 1985 NIDA CB ManualNIDA CB Manual NIAAA Project Match CB Manual NIAAA Project Match CB Manual Gorski PublicationsGorski Publications Washton PublicationsWashton Publications

Motivational Interviewing

Based upon Prochaska and DiClemente Stages Based upon Prochaska and DiClemente Stages of Change Theoretical Modelof Change Theoretical Model

Also referred to as Motivational Enhancement Also referred to as Motivational Enhancement TherapyTherapy

Applied with many substances, data primarily Applied with many substances, data primarily with alcoholicswith alcoholics

Major Publications/Studies: Miller and Major Publications/Studies: Miller and Rollnick, 1991; Project MATCH Rollnick, 1991; Project MATCH

Motivational Interviewing Basic AssumptionsBasic Assumptions

People change their thinking and behavior according to a series People change their thinking and behavior according to a series of stagesof stages

Individuals may enter treatment at different “stages of change”Individuals may enter treatment at different “stages of change” It is possible to influence the natural change process with MI It is possible to influence the natural change process with MI

techniquestechniques MI can be used to engage individuals in longer term treatment MI can be used to engage individuals in longer term treatment

and to promote specific behavior changesand to promote specific behavior changes Confrontation of “denial” can be counterproductive and or Confrontation of “denial” can be counterproductive and or

harmful to some individualsharmful to some individuals

Motivational Interviewing

Key ConceptsKey Concepts Empathy and therapeutic allianceEmpathy and therapeutic alliance Give feedback and reframe Give feedback and reframe Create dissonanceCreate dissonance Focus of discrepancy of expected and actualFocus of discrepancy of expected and actual Reinforce changeReinforce change Roll with resistanceRoll with resistance

Motivational Interviewing

ResourcesResources Miller and Rollnick 1991Miller and Rollnick 1991 NIAAA Project MATCH manualNIAAA Project MATCH manual CSAT TIP on Motivational TechniquesCSAT TIP on Motivational Techniques NIDA Tool BoxNIDA Tool Box

Community Reinforcement Approach

Basic assumptionsBasic assumptions Drug and alcohol use are positively reinforced Drug and alcohol use are positively reinforced

behaviors. They can be reduced/eliminated by behaviors. They can be reduced/eliminated by proper application of behavioral techniques.proper application of behavioral techniques.

To successfully build an effective intervention, some To successfully build an effective intervention, some techniques should focus on reducing drug and techniques should focus on reducing drug and alcohol use and others should focus on acquisition of alcohol use and others should focus on acquisition of new incompatible behaviors.new incompatible behaviors.

Community Reinforcement Approach

Key conceptsKey concepts Behavioral analysis and teach conditioning informationBehavioral analysis and teach conditioning information Positive reinforcement with vouchers for drug free Positive reinforcement with vouchers for drug free

urine samplesurine samples Behavioral marriage counselingBehavioral marriage counseling Shape and reinforce new behavioral repertoireShape and reinforce new behavioral repertoire Coping skill/Drug refusal skill trainingCoping skill/Drug refusal skill training Vocational CounselingVocational Counseling Frequent urine testingFrequent urine testing

Community Reinforcement Approach

ResourcesResources Meyers and Smith 1995Meyers and Smith 1995 NIDA CRA ManualNIDA CRA Manual Higgins and Silverman 2000Higgins and Silverman 2000

Contingency Management

Basic AssumptionsBasic Assumptions Drug and alcohol use behavior can be controlled Drug and alcohol use behavior can be controlled

using operant reinforcement proceduresusing operant reinforcement procedures Vouchers can be used as proxy’s for money or goodsVouchers can be used as proxy’s for money or goods Vouchers should be redeemed for items incompatible Vouchers should be redeemed for items incompatible

with drug usewith drug use Escalating the value of the voucher for consecutive Escalating the value of the voucher for consecutive

weeks of abstinence promotes better performanceweeks of abstinence promotes better performance Counseling/therapy may or may not be required in Counseling/therapy may or may not be required in

conjunction with CM procedure conjunction with CM procedure

Contingency Management

Key conceptsKey concepts Behavior to be modified must be objectively measuredBehavior to be modified must be objectively measured Behavior to be modified (e.g. urine test results) must Behavior to be modified (e.g. urine test results) must

be monitored frequentlybe monitored frequently Reinforcement must be immediateReinforcement must be immediate Penalties for unsuccessful behavior (e.g. positive UA) Penalties for unsuccessful behavior (e.g. positive UA)

can reduce voucher amountcan reduce voucher amount Vouchers may be applied to a wide range of pro-social Vouchers may be applied to a wide range of pro-social

alternative behaviors alternative behaviors

Matrix ModelAn Integrated, Empirically-based, Manualized

Treatment Program

Relapse Prevention Family and Group Therapy

Motivational Interviewing

12- Step Involvement

Psychoeducation Social Support

Matrix Model of Outpatient Treatment

Organizing Principles of Matrix Treatment

•Create explicit structure and expectations

•Establish positive, collaborative relationship with patient

•Teach information and cognitive-behavioral concepts

•Positively reinforce positive behavior change

Matrix Model of Outpatient Treatment

Organizing Principles of Matrix Treatment(cont.)

•Provide corrective feedback when necessary

•Educate family regarding stimulant abuse recovery

•Introduce and encourage self-help participation

•Use urinalysis to monitor drug use

Elements of the Matrix Model

Engagement/RetentionEngagement/Retention StructureStructure InformationInformation Relapse PreventionRelapse Prevention Family InvolvementFamily Involvement Self Help InvolvementSelf Help Involvement Urinalysis/Breath Urinalysis/Breath

TestingTesting

The Matrix Model

MondayMonday WednesdayWednesday FridayFriday

Early Recovery Early Recovery Skills Skills

Weeks1-4Weeks1-4

Family/educationFamily/education

Weeks 1-12Weeks 1-12

Early Recovery Early Recovery Skills Skills

Weeks1-4Weeks1-4

Relapse Prevention Relapse Prevention

Weeks 1-16Weeks 1-16

Social SupportSocial Support

Weeks 13-16Weeks 13-16

Relapse Prevention Relapse Prevention

Weeks 1-16Weeks 1-16

Urine or breath alcohol tests once per week, weeks 1-16

Matrix Model: Resources

Matrix Treatment Manual (Matrix Institute, Matrix Treatment Manual (Matrix Institute, www.matrixinstitute.orgwww.matrixinstitute.org

CSAT TIP 33CSAT TIP 33 CSAT TAP Matrix ManualCSAT TAP Matrix Manual