Managing Addictions. Flow of presentation Addiction? Addict? Addiction behavior? Theories? Treatments? Summary

Managing Addictions

Flow of presentation

• Addiction?• Addict?• Addiction behavior?• Theories?• Treatments?• Summary

Addiction/addiction behavior• Chronic relapsing disease• Addiction behavior applied in 2 wide range of behaviors:

– Traditional addictions: dependence on alcohol, opiates, cocaine & other stimulants (meth, mj, club drugs)

– Non-traditional addiction (non-chemical related behavior) [gambling, eating disoder, sexual behavior]

Addiction/addiction behavior

• Behavior that produce pleasure + escape from discomfort employed in a pattern characterized by:– Recurrent failure to control the behavior– Continuation of the behavior despite the negative consequences

(Goodman, 1990)– Compulsive use and or engagement in the behavior (Smith and

Seymour, 2004)


• All addictive behaviors attempt to meet one or more of 3 motives:• Psychic rewards (achieving a desired change in moods)• Recreational rewards (increasing sociability and having fun with

others)• Instrumental achievement rewards (enhance performance with

accompanying success in a sense of success, mastery and well-being)


• “(addiction is shown by) a demonstrated failure to refrain from a behaviour despite attempts to do so or a complaint by the person that the behaviour is out of his or her control.” (Heather,in press


• social construct which can be usefully defined as a reward-seeking behaviour that has become ‘out of control’ (West, 2006)

• It can involve a wide range of abnormalities in the system of forces that energise and direct our actions - the ‘motivational system’


• Addiction (Bishop, 2001)– 1) Behavioral pattern that changes the way client feels, thinks,

and behaves– 2) That he or she likes in the short-run– 3) But not in the medium-and-long run– 4) And that is very difficult to change


• This definition is designed to help clinicians help clients, but what really counts are the consequences for the client over time

• Definition does not specify who is to decide whether the medium-and-long term are negative and who is to say whether or not it is difficult behavior pattern to change


• The DSM4 devotes almost 100 pages to substance-related addictive behaviors…

Diagnostic criteria for addiction• APA states that addiction is a maladaptive pattern of AOD use, leading to clinically

significant impairment or distress, as manifested by three (or more) or the following occurring at anytime in the same 12 month period:

• 1. Tolerance, as defined by either of the following:– A. need for markedly increased amounts of the substance to achieve intoxication or

desired effect– Markedly diminished effect with continued use of the same amount of the

substance• 2. withdrawal, as manifested by either of the following:

– The characteristic withdrawal syndrome for the substance– The same (or a closely related) substance is taken to relieve or avoid withdrawal

symptoms• 3. The substance is often taken in larger amounts or over a longer period than was

intended

Diagnostic criteria for addiction• 4. There is a persistent desire or unsuccessful efforts to cut down or

control subtance use• 5. A great deal of time is spent in activities necessary to obtain the substance

(e.g. visiting multiple doctors or driving long distance), use the substance

(e.g. chain smoking), or recover from its efforts• 6. Important social, occupational, or recreational activities are given up

or reduced because of substance use• 7. The substance use is continued despite knowledge of having a persistent or

recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

• (e.g. current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

• Diagnostic and Statistical Manual of Mental Disorders, 4 th ed. APA, 1994

Continuum of Drug Use

AddictionCompulsive Drug Use

Intensive Drug Use

Casual Drug Use

Experimental Drug Use

Circumstantial Drug Use

Motivational Strength

Motivational Toxicity

From Bozarth (1990); terms described on the continuum were suggested by Jaffe (1975).

Addiction as aMotivational Problem

• Addiction is best understood by considering the drug’s impact on the individual’s motivation

• Experimental psychology and behavioral neuroscience provide the methods for analysis

Dynamic Feature of theMotivational Hierarchy

0

10

20

30

40

50

Choice Behavior and the Notion of “Self-Control”

Response Selection Behavior

food sex social drug

Motivational Toxicity

• Motivational toxicity describes a disruption of the motivational hierarchy. This is manifest as– increased motivational efficacy of the drug

– decreased motivational efficacy of natural rewards

• Motivational toxicity produces the intense motivational focusing characteristic of addiction and the apparent “enslavement” inherent in the etymology of this term

Addiction Cycle

• Initiation• Use/abuse• Lapse/Relapse

What Causes Addiction? (Zinberg, 1984)

THEDRUG

THEPERSON

THEENVIRONMENT

Addiction Theories

• Addiction-like Behavior (Newton, de la Garza, et,al, 2009): – Negative Reinforcement-NR (“Pain Avoidance”)

– Positive Reinforcement-PR (“Pleasure Seeking”)

– Incentive Salience-IS (“Craving”)

– Stimulus Response Learning-SRL (“Habits”) and

– Inhibitory Control Dysfunction-IIC (“Impulsivity”)

Addiction Theories (Pre-clinical)

• Negative Reinforcement-NR (“Pain Avoidance”)• Premise = drug use reduces withdrawal dysphoria• Example of this model highlights the cumulative

negative effects produced by repeated cycles of intoxication and withdrawal,4–6 and falls under the rubric of the opponent process theory of emotional regulation


• Positive Reinforcement-PR (“Pleasure Seeking”)• Based on classical learning theory• is probably the most familiar preclinical model of

addiction• states that users will say they take drugs because they

enjoy using them

Addiction Theories

• Incentive Salience-IS (“Craving”)• posits links between sensitization of particular brain

systems and motivation, which is distilled into the concept of drug craving

• the attribution of incentive salience to drug-related stimuli is increased by exposure to abused drugs

• drug use is attributable to craving

Addiction Theories• Stimulus Response Learning-SRL (“Habits”)

• stimulus response learning model identifies habit learning as the key to understanding addiction

• classical learning theory = stimuli and responses are associated with outcomes, and the outcome determines the likelihood that the response will follow the stimulus in the future

• stimulus response learning = the outcome is less important, and the stimulus itself elicits a habitual response

• Conditioned reinforcement and impulsivity are key features of this theory

Addiction Theories

• Stimulus Response Learning-SRL (“Habits”) • model predicts that users will describe drug taking as

habitual or compulsive

Addiction Theories

• Inhibitory Control Dysfunction-IIC (“Impulsivity”)• Implicates impulsivity as the factor that underlies addiction• Impulsivity has been linked to appetitive approach systems

as well as drug-related impairments in new learning and to perseveration

• Thus, models involving inhibitory control deficits predict that users will attribute drug use to impulsivity or perseveration.


• Preclinical research on these theories examines behavior, or neural activity underlying behavior

• By contrast, clinical research often involves the surveying of participants in order to understand the motivation(s) that underlie their behavior.

• While it is true that clinical studies often lack the experimental control that is typically observed in preclinical studies, clinical studies are not solely reliant on inference in order to determine the motivations of the study participants.


• Examples of questions include: • “Do you use drugs mostly to make bad feelings like

boredom, loneliness, or apathy go away?”,• “Do you use drugs mostly because you want to get

high?”• “Do you use drugs mostly because of cravings?”• “Do you find yourself getting ready to take drugs

without thinking about it?”• “Do you impulsively take drugs?”

Addiction Treatments

Treatment modality Goals Methods Settings

Therapeutic community

Effect change in negative pattern of behavior Social and vocational rehabilitation

Peer counselling Confrontational group therapy

in-patient

Self-help groups Maintaining sobrietyChanging negative traits

Following the 12 steps

Out-patient program


Treatment modality Goals Methods Settings

Aftercare/half-way homes

Prevent relapsesReinforce new patterns of sober livingEstablish support systemsVocational rehab

PsychotherapyTherapy for familyVocational training

In-patient

Behavioral Therapies

Effects behavior change from initiation to relapse prevention

CBT/REBT, Behavior Change, etc

In-patient;out-patient


• TC is a residential program that can emphasize self-help and rely heavily on ex-addicts as peer counsellors, administrators and role models.

• Provide a highly structure milieu with programme stages through which members must progress and this advancement is noted with special tasks and ceremonies

• The stages progressively demand more responsibility and provide more freedom


• Group encounter sessions often are confrontational, focusing on openness and honesty

• Social and vocational skills also are taught• Family involvement is essential in the recovery process

Therapeutic community• TC concepts includes:• An addict can change• Involvement in groups foster change• To change, an individual has to take responsibility for his

action• Structure helps in measuring the change


• How they help:• Developing a drug-free lifestyle• Changing negative patterns of behaviour, thinking and

feeling that predispose drug use


• Twelve step facilitation (TSF)/AA-NA Model• What are the 12 Steps?• According to AA, "The heart of the suggested program of

personal recovery is contained in the 12 Steps describing the experience of the earliest members of the Society"

• In other words, they are the 12 steps to be executed one by one as a suggested path to recovery from the abuse of drugs, alcohol or other behavioral disorders.


• Twelve step facilitation (TSF)/AA-NA Model• Explicit within the literature of AA is that people new to

the meetings or the program are under no obligation to accept or follow the 12 Steps "in their entirety if they feel unwilling or unable to do so." However, three things are asked of newcomers:

• • » To maintain an open mind • • » To attend the meetings • • » To read the AA literature


• There are also some expectations of AA members. They will usually:

• • » describe their personal experiences in achieving sobriety

• • » emphasize to newcomers that only problem drinkers themselves, individually, can determine whether or not they are in fact alcoholics


• They will also point out that:• • » all available medical testimony indicates that

alcoholism is a progressive illness • • » it cannot be cured in the ordinary sense of the

term • • » it can be arrested through total abstinence from

alcohol in any form


• The Twelve Steps• Step 1 • We admitted we were powerless over alcohol—that our lives

had become unmanageable. • Step 2 • Came to believe that a Power greater than ourselves could

restore us to sanity. • Step 3 • Made a decision to turn our will and our lives over to the care

of God as we understood Him.


• The Twelve Steps• Step 4 • Made a searching and fearless moral inventory of ourselves. • Step 5 • Admitted to God, to ourselves, and to another human being

the exact nature of our wrongs. • Step 6 • Were entirely ready to have God remove all these defects of

character.


• The Twelve Steps• Step 7 • Humbly asked Him to remove our shortcomings. • Step 8 • Made a list of all persons we had harmed, and became willing

to make amends to them all. • Step 9 • Made direct amends to such people wherever possible, except

when to do so would injure them or others.


• The Twelve Steps• Step 10 • Continued to take personal inventory and when we were wrong

promptly admitted it. • Step 11 • Sought through prayer and meditation to improve our conscious

contact with God as we understood Him, praying only for knowledge of His Will for us and the power to carry that out.

• Step 12 • Having had a spiritual awakening as the result of these steps, we

tried to carry this message to alcoholics, and to practice these principles in all our affairs.

MI

• “… a collaborative person-centered form of guiding to elicit and strengthen motivation for change.” (2009 definition)

• A central concept of MI is the identification, examination, and resolution of ambivalence about changing behavior..

• Ambivalence, feeling two ways about behavior change, is seen as a natural part of the change process

• The skillful MI practitioner is attuned to client ambivalence and “readiness for change” and thoughtfully utilizes techniques and strategies thatare responsive to the client.

MI

• Motivational interviewing is a form of collaborative conversation for strengthening a person's own motivation and commitment to change.

• It is a person-centered counseling style for addressing the common problem of ambivalence about change by paying particular attention to the language of change.

• It is designed to strengthen an individual's motivation for and movement toward a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.

MI

• Central goal – to help client articulate their reasons for changing and , in so doing, strengthen their intention to change

MI Elements

MI

MOTIVATIONAL INTERVIEWINGMOTIVATIONAL INTERVIEWINGPrinciplesPrinciples

• Express empathy (seeing the world through the client's eyes)

• Develop discrepancy (make them aware how current behaviors may lead them away from, rather than toward their important goals)

• Avoid argumentation/ Roll with resistance (“dancing” rather than “wrestling” with the client; avoid the “righting reflex”)

• Support self-efficacy (focusing on previous successes and highlighting skills and strengths that client already has)


• R= Resist the righting flex• U = understand your client’s

motivation• L = Listen to your client• E = Empower your client


• R= Resist the righting flex – (consider the possibility of ambivalence; don’t’ view change as

necessary or possible)• U = understand your client’s motivation

– (motivation comes from within)• L = Listen to your client

– (safely explore conflicts and face difficult realities; being emphatic and communicating it)

– Fundamental and defining characteristic of MI• E = Empower your client

– (outcomes are better when clients are engaged)– All change is ultimately self-change (Di Clemente, 2003)– Self-efficacy targeted perception of one’s ability to achieve desired

results (can do attitude)

MOTIVATIONAL INTERVIEWINGMOTIVATIONAL INTERVIEWINGTechniquesTechniques

• Foundational Skills (Counselling): Reflective Listening

• Open-ended questions (help client explore the reasons for and possibility of change)

• Affirmation (statements that recognize client strengths)

• Reflective listening (guide client in resolving ambivalence)• Summary Statements (recaps what occurred in the session;

call attention to important elements)

• Personal feedback• Decision balance• Eliciting self-motivational statement• Develop alternatives and options


• Thomas Gordon’s 12 Roadblocks1. Ordering, directing, commanding- a direction is given

with the force of authority behind it. Authority can be actual or implied

2. Warning or threatening – similar to directing but carries an implication of consequences, if not followed. This implication can be a threat or a prediction of a bad outcome

3. Giving advice, making suggestions, providing solutions- the therapist uses expertise and experience to recommend a course of action


• Thomas Gordon’s 12 Roadblocks4. Persuading with logic, arguing, lecturing – the

practitioner believes that the client has not adequately reasoned through the problem and needs help in doing so

5. moralizing, preaching, telling clients their duty- the implicit message is that the person needs instruction in proper morals

6. judging, criticizing, disagreeing, blaming – the common elements among these four is an implication that there is something wrong with the person or with what has been said. Simple disagreement is included in this group


• Thomas Gordon’s 12 Roadblocks7. agreeing, approving, praising – this message gives the

sanction or approval to what is being said. This stops the communication process and may imply an uneven relationship between speakers and listener

8. shaming, ridiculing, name calling – the disapproval may be overt or covert. Typically, it’s directed at correcting a problematic behavior or attitude

9. interpreting, analyzing – this is a very common and tempting activity for counselors; to seek out the real problem or hidden meaning and give and interpretation


• Thomas Gordon’s 12 Roadblocks10. reassuring, symphatizing, consoling- the intent here is

to make the person feel better. Like approval, this is a roadblock that interferes with the spontaneous flow of communication

11. Questioning or probing – questions can be mistaken for good listening, the intent is to probe further, to find out more. A hidden communication is the implication that if enough questions are asked, the questioner will find the solution. Questions can also interfere with the spontaneous flow of communication, directing it in the interests of the questioner but not necessarily the speaker


• Thomas Gordon’s 12 Roadblocks12. withdrawing, distracting, humoring, changing the

subject- these divert communication and may also imply that what the person is saying is not important or should not be pursued


• CHANGE TALK• Eliciting specific kinds of speech from

client• Evoke and reinforce this kind of language

when it occurs• Based on the idea that clients will be more

likely to do what have genuinely spoken in favor of during a session = predicts commitment which in turn predicts behavior


• CHANGE TALK• Having your client make the arguments

for particular change is most important when the client is ambivalent

• Client ambivalence creates a special dilemma: whatever the practitioner argues for, the client may argue against = counsellors move in the direction of useful change (righting reflex) only to be met with “ yes, but…” response = clients talking themselves out of changing


• CHANGE TALK• Preparatory change talk• Desire (I want to change)• Ability (I can change)• Reason (It’s important to change)• Need (I would change)


• CHANGE TALK• Implementing change talk• Commitment (I will make changes)• Activation(I am ready, prepared, willing

to change)• Taking steps ( I am taking specific actions

to change)

Specific StrategiesSpecific Strategies• Ask Evocative Questions• Explore Decisional Balance• Good Things/Not- ‐So- ‐Good Things• Ask for Elaboration/Examples• Look Back• Look Forward• Query extremes• Use change rulers• Explore goals and values• Come alongside

MOTIVATIONAL INTERVIEWINGMOTIVATIONAL INTERVIEWINGSpiritSpirit

• Use of microskills, the application of other interventions and techniques, and the elicitation of change talk

• Metaphor of song (lyrics might be the OARS and other strategies + change talk-the content of the MI session; structure of the song-refrain, key changes are the principles; melody is the MI spirit = determines the mood and underscores the lyrics)


• 3 components:• Collaboration• Evocation• Autonomy


• Collaboration = practitioner working in partnership with the client; avoids prescriptive and proscriptive advice (vs confrontation)

• Evocation = drawing out ideas and solutions from the client; MI practitioners as guides, offers info about the paths to change (vs Imposition/Prescription)

• Autonomy = in decision making is left to the client; cannot force clients to change; they, rather, than we, argue why change is required (vs authority)


•1. MI is a particular kind of conversation about change (counseling, therapy, consultation, method of communication)•2. MI is collaborative (person- ‐centered, partnership, honors autonomy, not expert- ‐ recipient)•3. MI is evocative (seeks to call forth the person’s own motivation and commitment)

Cognitive, Emotive and Behavioral Techniques

• Integrated treatment model (cognitive behavioral therapy, stages of change, motivational enhancement therapy, rational emotive behavior therapy, relapse prevention, harm reduction + self-help groups to pharmacotherapy)

Our life is shaped by our mind;we become what we thinkOur life is shaped by our mind;we become what we think – The buddha – The buddha

Stage 1 Precontemplation You don’t think about it. You are either : -ignorant (you don’t realize that you have a problem) demoralized (you’ve given up)

Stage 2 Contemplation You start thinking about it, but you’re ambivalent

Stage 3 Preparation You prepare to change, although you still may feel ambivalent

Stage 4 Action You start to change. Ambivalence may continue to be a problem

Stage 5 Maintenance You try to maintain your change through relapse prevention techniques such as review and rehearsal

Stage 6 Termination At some point, you may consider yourself recovered

Prochaska and DiClemente;s Model of Change

3 types of clients

• Type 1 clients are in stage 1– Sent to therapy rather than come on their own– Do not admit to having a problem

• Type 2 are in stages 2 and 3– Usually ambivalent: have a problem but not sure what to do about it– Therapy is to explore their options

• Type 3 clients are in stage 4 or 5– Know they want to change; not ambivalent– Want help in maintaining the progress they so far made or in starting

again

Basic ABC Model

• Basic theory underlying all cognitive behavioral theories of psychological behavior expressed in Ellis’s ABC format (Ellis 1962, 1995)

• A = activating event or adversity, perhaps a potential “trigger”• B = beliefs or thoughts a person has about A• C = consequences – what a person feels, thinks or does as a result of the

A and the B’s

Basic ABC Model

• CBT/REBT assert that • A’s do not cause C’s • [humans with their beliefs, stand between the A and the C, thinking

about, interpreting, and evaluating what is happening, has happened or might happen. It is these thoughts, the B’s –made up of interpretations and evaluations- and not the A’s that cause the C’s]

• It is what the addict thinks about and how he evaluates his behavior that determines how he feels and what he does

• Problem resides in his pattern of thinking or core beliefs [idea shared by Epicureans and Stoics, by Buddha and Krisnamurti]

Basic ABC Model

• Thinking is sometimes rational and sometimes irrational [ Ellis]• Irrational means that something does not make sense given the context

and a person’s goals and values [ cf as unhelpful, self-destructive, dysfunctional]

• Client’s goals and values have a central role in determining if their beliefs are rational or irrational

• Part of the therapist’s job is to help clients uncover the hidden, irrational parts or to give voice to thoughts that they are not aware of or may have never been expressed in words

Doing a generic ABC(DE)

• Step 1• Start at C (the consequences). The therapist asks his client:• “What do you want to work on?” [therapy primarily for working on and

managing problems]• “What would you like to talk about?”[gentler approach]• “How are things going?”[gentler approach]• “How are you feeling?”• “Bring me up to date. What has been happening?”


• Step 2• Explore the A’s (the activating events)• “How did you convince yourself to drink?• You also seem angry. Why are you feeling angry? What happened?”

• Step 3• Uncover the B’s (the Beliefs) –therapist tries to help client uncover what

aspects of thinking, feeling, and behavior contributed to the consequences [from belief that A’s as causing the B’s to helping begin to see the role of B’s, in what happened]


• Step 3• Uncover the B’s (the Beliefs) –therapist tries to help client uncover what

aspects of thinking, feeling, and behavior contributed to the consequences [from belief that A’s as causing the B’s to helping begin to see the role of B’s, in what happened]

• When you were driving home and just before you downed the bottle of wine, what were you thinking? [or what were you telling yourself- common CBT/REBT phraseology]

• How did you convince yourself that drinking was an okay solution?• Was there any debate?• Did you consider doing anything else?


• REBT-ers usually use the term ‘irrational beliefs’ for thoughts that contribute to addictive behaviors = destructive beliefs, stinking thinking, unhealthy thoughts, dysfunctional thoughts, unhelpful thoughts

• Cognitive therapists use cognitive distortions and automatic thoughts• Therapist may use other terms: healthy beliefs, sensible beliefs, helpful thoughts,

helpful beliefs)– I want a drink = rational– I have to have what I want = irrational– “ I want a drink and I have to have what I want” = clients think rationally at the same

time that they are thinking irrationally• Therapist’s job to help client uncover and discover the irrational or automatic beliefs

lurking underneath benign thoughts


• Step 4• After identifying some of the beliefs that may be contributing to the

client’s emotional disturbances and addictive behaviors….• it is time to examine, question, challenge, and/or Dispute (hence the D in

expanded ABCDE model) • the validity, helpfulness, rationality and the reasonableness of the

various beliefs/feelings/behaviors that contributed to the C’s

• Step 5• Look for new, more Effective ways of thinking, feeling and behaving for

the future


• 4 kinds of disputing• 1. Functional disputing = practical disputing=focuses on the practical

consequences of continuing to hold onto an irrational belief – “Given your goals and values, how does thinking that way help?”

• 2. Philosophical =focuses on the worst case scenarios– “If not getting a promotion means that you should look for another

job, is that really the end of the world?”


• 4 kinds of disputing• 3. Empirical = focuses on the evidence

– “Is there evidence that not getting promoted means you should look for another job? What is the evidence that you are ready for promotion?”

– Socratic disputing/didactic disputing (more like teaching: gentle rather than confrontative)

– Research does not support the old style of confrontation in the treatment of addictions (Miller, 1995)

• 4. Thug therapy – beat clients over the head disputing their irrational beliefs– If clients cannot see the crookedness in their thinking, the therapists will

show them


• RBT/REBT are supplanting Freudian and Rogerian psychotherapy– F and R helped people change, but they were often very inefficient, especially with

addictive behaviors [ a combination of warmth and firmness; supportive and directive therapists are the best ones]

– Mechanical and thug therapy is not only arrogant; it dishonors the complexity of a client’s problem and his capabilities to learn to solve these problems himself

• Apart from disputing, role-playing, analysis of the positive and negative effects of various behaviours, rational emotive imagery and deep diaphragmatic breathing may be equally helpful


• REBT focuses on 4 types of irrational thinking• 1. Is the client engaging in catasthropizing or awfulizing, thinking and

evaluating activating events in an exaggerated, negative manner?– Things are too awful to stand without some kind of chemical or

activity to alter the way they are feeling (and thinking and behaving)• 2.Is the client making things worse by sneaking in the thought, “I can’t

stand it?”– Chronic bouts of discomfort (anxiety, rebelliousness, frustration,

anger and depression) due to low frustration tolerance (LFT)– Has a drink or took drugs to withstand the discomfort

• ”


• REBT focuses on 4 types of irrational thinking• 3. Is the client engaging in demandingness?

– Fanning the fires of upsetness by demanding thoughts “I should’nt have been argumentative, I should’nt have lost my temper.” “Life shouldn’t be so hard. It’s not fair”

– Substituting must for should may help the client see the demanding nature of her thought: “Life must be fair” sounds irrational; “I must not lose my temper”, “I must be able to drink like other people”


• REBT focuses on 4 types of irrational thinking• 4. Is the client engaging in some form of global self-downing

– Cannot accept self as a typical human being with problems– Repeatedly condemns self without compassion for repeated errors

“How could I be so stupid?” I’s such a jerk?– Fails to realize that the works of Buddha, over 2500 years old and the

Bible, all clearly indicate the trials and tribulations of life and our consistent ability to “sin” and make mistakes

Vicious Circle

• This is really bad

• I cant stand it• This is too hard• I’ll feel too

uncomfortable if this keeps up

• The world should be different• You should be different• I should be different• I have to do something to change it• I want a drink, and I have to have

what Iwant

• I’m such a loser• I’ll never change

Trying to change behaviors?7 points to keep in mind

• 1. Goals• 2. Motivation• 3. Connections• 4. Know-how and practice• 5. Failures• 6. Successes• 7. Re-evaluate your progress


• 1. Goals– Pick a goal. Make it specific and achievable. It may not be your final

goal. Later, you may decide it is not the right goal for you. But you may have to start somewhere.

• 2. Motivation– What will be the positive and negative effects for you over time?– Is there a way you can “ sweeten the carrot?”– Can you make the stick more threatening?– Would that help or hurt?– Do you need to better balance your conflicting wants?


• 3. Connections– Are you connected with other people who can help you out?– Do other people know your goal?

• 4. Know-how and practice– Do you know what to do?– Do you know how to do it?– Can you accept the discomfort that goes along with practice?– What are you going to do? When? Be as concrete and specific as

possible (day/ time?place?how much?how many?)


• 5. Failures– What do you do when you fail? Beat yourself up? Call yourself names?Convince

yourself that practicing is too hard? Convince yourself that the goal is not worth it? • 6. Successes

– Savor your successes. Feel pleased that you did what you set out to do. Reward yourself if you think that will help

• 7. Re-evaluate your progress– Should you adjust goal?– How can you increase your motivation?– Would you more connections help?– How are you stopping yourself from practicing?– Are you learning from your failures?

Strategy for the 1st session – 10key questions

• What stage of change is the client in?• What are his goals? What is he interested in doing?• How serious is the client’s problem?• What does the client already know? Past attempts? Sucesses? Failures?

– What happens when he drinks? Uses?overeats? How does it occur?– What is stopping him from changing? How is he derailing himself?

• Internal resources? External resources?• Can the therapist treat this client?• What is the greatest risk?• What might be the most effective interventions? Cognitive? Emotive? Behavioral?• What does the client seem willing to do this week?• Home work?

Summary• What can we learn from all these:• That everybody is an addict• That addiction is a social construct/product (disease,

disorder, social problem, moral problem, legal problem etc.)

• That addiction like any other behavior could be “treated” or “managed”

• That there are various ways of treating and managing it• That management could be done at the personal and

professional levels

• Thanks for listening

Documents

Managing Addictions. Flow of presentation Addiction? Addict? Addiction behavior? Theories? Treatments? Summary