When Substance Abuse Works*Understanding the importance of context in working with

individuals with addictions

Jason Reed, PsyD, LP

recoveryclinic.com kodiakrecovery.com

Learning Objectives

1. Contextual behavioral approaches

2. Contextual approach for addiction

3. Practical implications

Working Groups

Introduction

4

Introduction

Working Group Discussion

1. What percent of your clients fit the JellinekCurve?

2. What are the characteristics of the clients that fit this curve?

6

What if we viewed substance use disorders through a mental health lens?

Harm Reduction ModelContextual ModelMinnesota Model

Introduction

Introduction

Working Group Discussion

Where do the 92.5% of clients with co-occurring disorders end up?

Important Concepts

• Context: the circumstances that form the setting for an event, and in terms of which it can be fully understood and assessed

• Phenomenology: the central structure of an experience is its intentionality, its being directed toward something

Chair Exercise

Chair Exercise

Important Concepts

• “Successful working”: true or valid if it leads to effective action or achievement of some goal (in ACT, “workability”)

• “Truth Criterion”: for contextualists the truth and meaning of an idea lies in its function or utility

• Functional Contextualism: value analyses that allow both the prediction and influence of psychological events

• Acts-in-context (current and historical context): Behavior can only be interpreted and understood within the subjective world of a client.

Important Concepts

• Biological evolution (Darwin): contingencies of survival in a given environment select which genetic traits will persist in a species

• Behavioral evolution (Skinner, 1981): contingencies of reinforcement in a given context select which class of responses will persist (or be likely to occur)

• “Detailed inquire” (Sullivan, 1954): understanding roots and meaning of behavior

Quote

“Truth happens to an idea. It becomes true, is made true by events”

- William James (1907)

Quote

“Subjectivity is truth”

- Soren Kierkegaard

Working Group Discussion

1. What are some of the ways in which this client’s substance use is an attempt at a “failed solution”?

2. How would you apply the concept of “workability” to this client’s situation?

Quote

“Using substances or engaging in other compulsive behaviors is goal-oriented behavior,

not crazy or stupid or immoral”

- Beyond Addiction (Foote, et all, 2014)

Important Concepts

• Cognitive schema, information-processing mechanisms, brain activity, learning style, attitudes, expectations, emotions, thoughts, feelings, all can help predict events but are not very helpful in changing events

• Anything we can do to effect the performance of an individual, occurs in the environment of that individual, in the context of his or her behavior (Hayes & Brownstein, 1986)

Important Concepts

• Need to understand historical context of the behaviors and how they may have served the client in the past

• It is assumed that these behaviors have “worked” on some level for the client in the past

• Change will not take place unless new, more workable strategies are in place

Working Group Discussion

1. What is the historical context of this client’s substance use?

2. How has this client learned to use substances in a way that might have initially worked?

Client Examples• Attempts to cope with the eating disorder:

• “I use pot so I can eat during family dinners”• “Pot helps me eat and not purge after meals”• “Alcohol allows me to have a break from following the rules of the ED”

• Attempts to engage more in the eating disorder:• “I work out for hours and take pain meds to deal with the pain”• “Drinking makes me feel full and then it's easier not to eat”• “Drinking the night before helps me purge the next day”

• ED and CD get worse together (dysregulation model):• “When I drink alcohol, my awareness of food goes down and I tend to overeat”• “If I drink, I won't eat because it's too many calories”• “I binge eat really bad when I smoke pot”

Quote

“Repetitive coping behaviors are frequently misinterpreted as the source of the problem,

rather than being seen as attempts at solutions”

- Maia Szalavitz from Unbroken Brain

Important Concepts

• Learning Disorder (Maia Szalavitz, 2016):1. The behavior has a psychological purpose2. The specific learning pathways involved make it become nearly

automatic and compulsive3. It doesn’t stop when it is no longer adaptive

• “Overlearning” or reduced brain plasticity makes the behavior extremely resistant to change

• Unlike ordinary forms of learning, addiction involves interference with the brain processes that guide decision making and motivation. It alters the way the brain decides what it values

Research on ”third-wave” Behavior Therapy

Luoma et al, 2012: Targeting shame in SUDs via ACT• Shame = “self-stigma”• Two contexts for shame (and targets for intervention):

1. Cognitive fusion --> shame thoughts --> substance use --> reinforced beliefs2. Experiential avoidance = avoidance of difficult private experiences (beliefs)

• ACT approach encourages acceptance of shame vs. avoidance• Results:

– Higher treatment attendance, less substance use, and less shame at follow-up– Higher posttreatment levels of difficult thoughts/feelings = healthy

acceptance processes that were part of longer term gains

Quote

“Unhealthy suppression of shame may be involved in the treatment high sometimes seen in early recovery in which sobriety can lead to unrealistic treatment gains, only to be

followed by urges to use, relapse, or depression”

Luoma et al, 2012:

Research on ”third-wave” Behavior Therapy

Stotts & Northrup (2015): Contextual Approaches• ACT focuses on context and function, not content of thoughts• Negative consequences of substance abuse leads to experiential

avoidance, even when this is costly to the individual• Addiction causes impaired self-awareness; mindfulness creates a new

context to make decisions based on values instead of avoidance or control

• Goal of ACT is to create awareness of gap between pattern of avoidance and values, and enhance “Psychological Flexibility”

• DBT for SUDs: dialectical abstinence; targets emotion regulation

Quote

“Identifying values dignifies the inevitable suffering involved in abandoning a well-established behavior that served as an escape from distress and the consequences

of addiction”

Stotts & Northrup (2015):

Research on ”third-wave” Behavior Therapy

Lee et al, 2015: Meta-analysis of ACT for SUDs• ACT uses combination of acceptance, mindfulness, and values-

based therapy to enhance psychological flexibility• Clients learn more accepting and mindful ways of relating to

inner experiences rather than engaging in substance use (in response to cravings or escaping negative affect), while moving forward to build meaningful patterns of activity that are further inconsistent with substance use

• ACT produces lower drop out rates (33% vs 50%)• Positive effects of ACT increase over time and do not just

reduce substance use but improve quality of life

Contextual Variables in Addiction

• There are two main contexts:1. context of a specific behavior, or how the behavior has

served the client2. Context of what the client values in their life moving forward

• Behavior change will only take hold once the client understands the context or “function” of their behaviors, and then can see how more adaptive behaviors can lead them to the life they want.

Contextual Variables in Addiction

• Behavioral Choice Theory: The choice of one reinforcing behavior, such as substance use, depends on lack of effective access to alternative reinforcements. Key element of the social context is the alternative reinforcements provided by activities other than substance use

• Social Learning Theory: Substance use originates in the substance-specific attitudes and behaviors of the adults and peers who serve as an individual’s role models. Parental alcohol use predicts youth’s beliefs about positive effects of alcohol, which is associated with earlier initiation and misuse

• Stress and Coping Theory: Stressful life circumstances lead to distress and alienation and eventually to substance misuse. Life stressors may shake beliefs in predictability of events and relevance of conventional norms that lead to alienation and loosening of social bonds

Quote

“If the world is unpredictable and people are unreliable, an available reward now is more valuable than an uncertain gain later”

“Addictiveness seems like it should be a fundamental and invariable pharmacological property of a specific drug – but in fact, it is hugely affected by environmental factors”

“Addiction is, first and foremost, a relationship between a person and a substance, not an inevitable pharmacological reaction.”

- Maia Szalavitz from Unbroken Brain

Quote

“The real question is not ‘why the drugs’ but ‘why the pain’?”

- Gabor Mate

Implications for Treatment: Contextual Tools

• AAQ-SA• Valued Direction Worksheet• Payoff Matrix• Behavior Chain Analysis• Adaptive Function• Barriers to Values

AAQ-SA

Implications for Treatment: Contextual Tools1 2 3 4 5 6 7

Never true very seldom true seldom true sometimes true frequently truealmost always true

always true

1. I can do things that are important to me even when I’m feeling urges to use substances. 1 2 3 4 5 6 7

1. My urges and cravings to use get in the way of my success. 1 2 3 4 5 6 7

1. If I have urges to use substances, then I am a substance abuser 1 2 3 4 5 6 7

1. I try to achieve my sobriety goals, even if I am uncertain that I can. 1 2 3 4 5 6 7

1. I work towards things I value, even though at times I feel cravings to use substances. 1 2 3 4 5 6 7

1. I am not very aware of what occurs around me when I am thinking of using substances. 1 2 3 4 5 6 7

1. I can set a course in my life and stick to it, even if I have doubts about my sobriety. 1 2 3 4 5 6 7

1. Memories of my substance use history make it difficult for me to live a life that I would value. 1 2 3 4 5 6 7

1. If I get bored working toward my recovery, I can still take the steps necessary to succeed. 1 2 3 4 5 6 7

1. If I feel uncertain about my recovery, I can still make a choice and take action. 1 2 3 4 5 6 7

1. If I promised to do something, I’ll do it, even if I later don’t feel like it. 1 2 3 4 5 6 7

1. Having some worries about substance use will not prevent me from living a fulfilling life. 1 2 3 4 5 6 7

1. I would rather achieve my goals than avoid thoughts and feelings about substances. 1 2 3 4 5 6 7

1. Urges and cravings cause problems in my life. 1 2 3 4 5 6 7

1. I’m afraid of my positive feelings about a substance I’ve abused. 1 2 3 4 5 6 7

1. When I think of substance use my mind is often on “automatic pilot”, not fully involved in what I am doing in the moment.

1 2 3 4 5 6 7

1. I worry about not being able to control my urges and cravings. 1 2 3 4 5 6 7

1. Feeling sad or anxious makes me want to use substances. 1 2 3 4 5 6 7

Valued Direction WorksheetStep 1: Make Your Importance RatingsStart by rating the importance of each area by circling a number on the Importance Scale (0, 1, or 2). It’s okay if you don’t value all areas, or you don’t rate them as being equally important.Ex: Work, Relationships, Parenting, Education, Social life, Health, Family, Spirituality, Community, recreation

Step 2: Rate Your SatisfactionGo back and focus on areas that you rated as moderately (1) or very important (2). Pause and reflect on those areas. Then, using the Satisfaction Scale, rate how satisfied you are (0, 1, or 2) with the quality and depth of your life in each important area.

Step 3: Write Your IntentionsAfter completing your ratings, go back to each value you rated as either moderately important (1) or very important (2) and write down your intentions. An intention is a statement that reflects the direction you want to move in for the foreseeable future. It’s simply a statement of how you’d like to live your life. It should capture what’s most important to you in that area.

Implications for Treatment: Contextual Tools

Payoff Matrix

Implications for Treatment: Contextual Tools

Advantages of Use Disadvantages of Use

Advantages of Stopping Disadvantages of Stopping

Behavior Chain Analysis• Prompting Event• Problem Thoughts• Problem Emotions• Target Behavior• Short Term Relief• Long Term Consequencers

Implications for Treatment: Contextual Tools

Ask questions of the behavior:

• What problem does it solve?• How does it alter the environment in a

positive way?• What mood state does it manage or

change?• How does it punish the negative self?

“Adaptive Function” (Amy Baker-Dennis)

Barriers to ValuesEx: Work/CareerValue Statement:Barriers:

Implications for Treatment: Contextual Tools

Introduction

“The proper question is not, ‘Why isn’t this person motivated’ but rather ‘For what is this person

motivated’”

- Miller and Rollnick (2002)

Introduction

“He who has a why to live for can bear almost any how”

- Friedrich Nietzsche

Working Group Discussion

1. What might be this client’s “why” for recovering?

2. How would you help her get there?

Resources

References

• contextualscience.org/ACT_Randomized_Controlled_Trials (250 RCTs for ACT)• Unbroken Brain (Maia Szalavitz, 2016)• In the Realm of Hungry Ghosts (Gabor Mate, 2010)• Pleasure Unwoven and Memo to Self (Kevin McCauley, 2009, 2016)• The Wisdom to Know the Difference (Kelly Wilson, 2012)• Slow and steady wins the race: A randomized clinical trial of ACT targeting shame in

substance use disorders (Luoma, et al, 2012)• The promise of third-wave behavioral therapies in the treatment of substance use

disorders (Stotts & Northrup, 2015)• An initial meta-analysis of ACT for treating substance use disorders (Lee et al., 2015)• Mental Health Systems ACT Training – Nov 8th and 9th (www.mhs-dbt.com)• Contact Info: Jason@recoveryclinic.com

Questions and Discussion