It Takes a Village to Resolve an Addiction…

And Certain Kinds of Villagers

Barbara S. McCrady

Center on Alcoholism, Substance Abuse, and AddictionsUniversity of New Mexico

Presented at the Addiction Summit “A Climate for Change”Melbourne, Australia

10 July 2008

Work Family of Origin

Nuclear Family>Spouse>Children

Friends

CommunityOrganizations:>Religious>Social>Service

SexAgeRaceEthnicityReligionSexual orientationFamily HistoryGeneticsTemperamentPersonalityPsychopathology

Individuals Live in Complex Social Environments

Work Family of Origin

Nuclear Family>Spouse>Children

Friends

CommunityOrganizations:>Religious>Social>Service

SexAgeRaceEthnicityReligionSexual orientationFamily HistoryGeneticsTemperamentPersonalityPsychopathology

Individuals Live in Complex Social Environments

Purpose of Talk

To briefly review what we know about social support and alcohol/drug use disorders

To discuss selected findings from outside our field that might help us think more broadly about how social support works

To pose some questions To present some modest propositions

Positive Social Support

“It takes a village to hold a world.” Photograph courtesy of Diane Walker

Harry Harlow’s Monkeys

Wire Milk Mother Cloth Mother

Social Support and Health“Social bonding and soothing behaviors mitigate the destructiveeffects of negative environmental events and promote enhancedhealth and well-being (Berscheid, 2003). Indeed, social isolationis now considered a major health risk (House, Landis, &Umberson, 1988). Moreover, married people tend on average tobe happier and healthier than unmarried people (Wood, Rhodes,& Whelan, 1989), and among married individuals, highermarital quality is associated with decreased risk of infection,faster recovery from injury, and a lower rate of mortality followinga diagnosis of life-threatening illness.”

Coan et al., 2006

Alcohol/Drug Use and Positive Social Support

Monkeys and Drinking

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NurseryReared

MotherReared

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Davenport, Maxey, Daunals, & Friedman, 2008

Social Support and the Resolution of SUDs

Having more social support is associated with better drinking outcomes Support from the most important person Number of supportive persons

Having more nondrinking friends is associated with better outcomes

Both alcohol specific and general support are important

Quality of Relationships is Associated with SUD Outcomes

Family adjustment Family cohesion Active, recreational orientation Low conflict Quality of marriage Specific marital support

When Social Support Goes Awry

The Four Horsemen of the Apocalypse

Criticism Defensiveness Stonewalling Contempt

When Social Support Goes Awry for Alcohol and Drug Users

Negative Family Functioning

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Low ExpressedEmotionHigh ExpressedEmotion

Days Since Entering Behavioral Couples Therapy

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port

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O'Farrell et al. (1998)

Negative Social Environmental Predictors of Outcome

Support for drinking predicts negative outcomes

Having more drinking friends is associated with poorer outcomes

Certain partner behaviors predict a negative response to treatment withdrawing from the drinker avoiding dealing with drinking tolerating drinking

Social Support and Treatment

Social Support and Treatment

Involving a concerned significant other in treatment improves outcomes For persons who have not sought treatment

themselves For men and women with alcohol or drug use

disorders For teens

Influencing Problem Recognition and Help-Seeking

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Al-Anonfacilitation

Unilateral(CRAFT)

JohnsonIntervention

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Unilateral Family Therapies

Miller et al., 1999

Engaging Families in Treatment - Alcohol Behavioral Couples Therapy

Focus on primary intimate relationship Based on cognitive-behavioral approaches to:

Alcohol use disorders Distressed relationships

Three major treatment elements Teach abstinence skills Teach partner behaviors to cope with drinking and

support change Improve intimate relationship

Alcohol Behavioral Couples Therapy and Abstinence

Treatment Follow-up

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ABIT ABCT

McCrady, Epstein, Cook, Jensen, & Hildebrandt, 2008

Alcohol Behavioral Couples Therapy and Heavy Drinking

Treatment Follow-up

Months

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ABIT ABCT

McCrady, Epstein, Cook, Jensen, & Hildebrandt, 2008

Social Support in Detoxification

A simple meeting with the person in a detoxification program and a concerned other to recommend continuing care resulted in: 92% entering continuing care

vs 62% who received treatment as usual

O’Farrell, Murphy, Alter, & Fals-Stewart, 2008

A Pause

The first half of the talk:

We have a fundamental drive to connect and be connected

Positive social support plays a powerful role in change in addictions

Social influences also play a powerful role in perturbing the process of change

Treatments that involve significant others lead to better outcomes

What’s to come:

Three questions to contemplate: How does social support actually change a

person’s behavior? How do people elicit or repel social support? How do people effectively provide social

support?

How Does Social Support Change a Person?

Coan, Schaefer, & Davidson, 2006

Social Support Affects Brain Function

Responses measured in fMRI when• Husband hand-holding• Research assistant hand-holding• No hand-holding

Social Support Affects Brain Function

The unpleasantness of the threat was lower when anyone held the woman’s hand

Neural activation to the threat was lower when her husband held her hand than when no one held her hand in:

Right dorsolateral prefrontal cortex, left caudate–nucleus accumbens, and superior colliculus

Neural activation to threat was lower when anyone held her hand in:

Ventral anterior cingulate cortex, posterior cingulate, right postcentral gyrus, and left supramarginal gyrus

Coan et al., 2006

fMRI Results

How Does Social Support Change a Person with an Alcohol/Drug Problem? Does it impact psychological functioning?

Motivation? Self-efficacy? Outcome expectancies? Coping skills? Affect regulation?

Does it damp down craving responses to alcohol cues?

Does it impact neural function?

Social Support Affects Motivation

Unpublished research from McCrady graduate student, Dorian Hunter-Reel:

Used structural equation modeling to test the impact of pretreatment social support on 3-month motivation

Then tested the impact of 3-month motivation on 9-month drinking outcomes in a sample of women with alcohol use disorders

Pretreatment support for drinking was a negative predictor of 3-month motivation

Motivation partially mediated the relationship between support for drinking and 9-month drinking outcomes

AAExposure

AbstinenceSelf-

Efficacy

PositiveOutcome

Social Support Affects Self-Efficacy

.30 (SD = .05)

Reduced to = .21 (SD = .06)

.21 (SD = .08) * .33 (SD = .11) *

Forcehimes & Tonigan, in press

Does Social Support Affect Neurocognitive Function?

A study in progress: Exposure to alcohol cues for persons with

alcohol use disorders in an fMRI Present these alcohol cues with and without

intimate other present and holding the drinker’s hand

Examine changes in brain function in regions associated with reward

Ladd, McCrady, Hutchison, & Tonigan, in progress

How do People Elicit or Repel Social Support?

What does a Person do to Have Good Social Supports?

How does a drinker/drug user find social networks that will support nonproblem alcohol or drug use?

How does a drinker/drug user engage others to provide support?

We don’t have answers to these questions

What Does a Person Do that Makes it Hard to Obtain Social Support?

Can a drinker or drug user drive others away through alienating behaviors (other than those associated with the substance use)?

Alienating Interpersonal Behaviors

Variable B SE B Beta Adjusted R2 Change

Step 1: Baseline 0.39 0.08 0.43 0.13**Percent Drinking Days

Step 2: Tx Condition 5.77 4.76 0.11 0.01

Step 3: Baseline 1.06 0.36 0.03 0.07**Alienating InterpersonalBehaviors

** p < .01Hunter Reel, McCrady, & Epstein, 2007

What Do Other Persons do to Provide Effective Social Support?

Providing Effective Social Support

Having a sponsor is one of the strongest predictors of success in AA But, we know nothing about effective and

ineffective sponsoring We know that having a supportive family

enhances outcomes, but we have not isolated effective family behaviors

Implications for Change

Some Modest Propositions We should consider the universality of the need

for bonding, attachment, and love in thinking about the change process

Treatment should create an environment of bonding and attachment

Treatment should help individuals learn to elicit support from others

We should help individuals in the social support system learn to delicate balance between “enabling” and effecting change

We should find more ways to bring treatment to people in their existing social environments

Some Research Needs

Study the psychological interface between the social environment and the individual – what happens at a psychological level?

Study the brain functions that underpin positive social support to learn to enhance the impact and understand more about how it goes awry

Study people who are particularly effective at eliciting positive social support

Study people who are particularly effective at providing positive social support, even in the face of negative behavior

It Takes a Village to Resolve an Addiction…And Certain Kinds of Villagers