WCSAD | 6 Evidence-Based Behavioral Therapies for SUD Treatment

Regardless of the level of care in which patients are placed, practitioners should be using evidence-based practices whenever possible to achieve the best outcomes, James A. Peck, PsyD, UCLA Integrated Substance Abuse Programs, told West Coast Symposium on Addictive Disorders attendees in a session presented on Wednesday.

“For a while, there has been a misconception in the practitioner community that evidence-based practices are these manualized treatments developed by researchers that are being foisted on practitioners and we’re expecting them to put them into practice,” Dr Peck said. “We’re clarifying here that we want to integrate the best available evidence with practitioner expertise.”

Behavioral therapies teach or improve patients’ coping skills, target key “mechanisms of change,” facilitate self-efficacy, improve social support, and reinforce positive behaviors. He walked attendees through 6 evidence-based behavioral therapy practices in his presentation.

Motivational Interviewing

Motivational interviewing helps patients explore their ambivalence about their substance use and begin to make positive behavioral and psychological changes. Originally designed as a method for transitioning adults into drug and alcohol treatment, motivational interviewing has since been applied to multiple behaviors/conditions, such as adolescent substance use, eating disorders, smoking cessation, among others, Dr Peck said.

Motivation is a state, not a patient trait, Dr Peck explained, and can be influenced and modified by the clinician’s style of interacting with the patient.

“What we term ‘lack of motivation’ is a challenge for the clinician’s therapeutic skills, not a fault for which to blame our clients or patients,” Dr Peck stated. “That’s not saying we’re taking on complete responsibility for a patient’s level of motivation. We’re not solely responsible for their motivation. However, it is saying when we are getting resistant responses, we must step back and say what is it about how I’m being with this person that is eliciting this response, and is there a different approach that could elicit a different response?”

Motivational interviewing includes 4 processes:

• Engaging: Forming the relationship and therapeutic alliance with the client.
• Focusing: Determining treatment goals.
• Evoking: Identifying patients’ goals and reasons for change.
• Planning: Breaking down the process of recovery into small steps to implement daily.

“Constructive behavior change comes from connecting with something valued, cherished, and important,” Dr Peck said. “Motivation within comes from an accepting, empowering, safe atmosphere where the painful present can be faced by the client.”

When engaging in motivational interviewing, Dr Peck reminded providers to be nonjudgmental, gently persuasive, more supportive than argumentative, listening more than telling, and respectful of clients’ feelings. Match your intervention strategy to the stage of change the client is in.

CBT and Relapse Prevention

Cognitive behavioral therapy is a cost-effective, counseling-teaching approach that is well-suited to the resource capabilities of most clinical programs, and it is compatible with a range of other treatments, including pharmacotherapy, Dr Peck said. It is a collaborative, structured, goal-oriented approach that focuses on the immediate problems of individuals with substance use disorder (SUD) as they enter treatment.

There are several ways to conceptualize behavior: classical conditioning, operant conditioning, and social learning theory. With classical conditioning, repeated pairings of certain events or cues with substance use can produce impulses to engage in destructive behaviors, Dr Peck elaborated. It’s vital for clients to understand classical conditioning takes place at an unconscious level, and therefore they have no control over whether it takes place. Careful strategies are required to extinguish the conditioned behavior, such as planning time to engage in nondrug-related behavior or avoiding drug-use situations.

CBT helps patients and clients by:

• Using a planned schedule of low-risk activities
• Recognizing high-risk situations and avoiding them
• Coping with a range of problems and behaviors associated with using

CBT provides skills that both assist individuals with achieving initial drug abstinence, as well as maintaining long-term abstinence.

Contingency Management

The use of contingency management in treatment assumes that drug and alcohol use behavior can be modified by using operant reinforcement procedures, or rewards for desired behaviors. An example in SUD treatment is patients earning vouchers or prizes for submitting drug-free urine samples or maintaining good attendance for therapy sessions. It has demonstrated efficacy for every type of substance to which it has been applied and has been particularly effective in treating cocaine use.

“We can modify behavior through rewards or through punishments,” Dr Peck said. “It’s the contingency that matters. If there’s some sort of behavior followed by a reward or punishment, learning occurs best when the behavior is followed immediately by the consequence.”

Clinicians should frequently monitor target behaviors, provide incentive when target behaviors occur, and remove such incentives when behaviors don’t.

Family and Couples Counseling

There are multiple evidence-based family and couples treatment interventions for SUD. Although the intensity and specific techniques vary, there is one overarching finding: Treatment programs that engage significant others or family members into the treatment process result in better retention rates and outcomes for the individual, Dr Peck explained.

12-Step Facilitation Therapy

Several studies have demonstrated that 12-Step facilitation therapy (educating patients about the 12-Step program and promoting program involvement) does increase involvement and program participation. There is an expanding body of research that documents the benefits of 12-Step program participation, including findings from Stanford University that show 12-Step program participants have better outcomes than those who don’t participate.

Matrix Intensive Outpatient Model

The matrix intensive outpatient model synthesizes motivational interviewing, CBT, and contingency management. Its components include individual sessions, early recovery group, relapse prevention group, family education group, 12-Step meetings, social support group, relapse analysis, and urine drug testing.

Dr Peck concluded his presentation by sharing strategies for matrix outpatient treatment:

• Create an explicit structure and expectations
• Establish positive, collaborative relationship with client
• Educate on important recovery issues
• Positively reinforce desired behavior change
• Provide corrective feedback as needed using a motivational interviewing style
• Educate family members on alcohol and drug abuse recovery
• Encourage self-help participation
• Use drug testing to monitor use

Reference

Peck J. Best behavioral practices in substance use disorder treatment. Presented at: West Coast Symposium on Addictive Disorders; September 29-October 3, 2021; Virtual.