Integrative Harm Reduction Psychotherapy - Andrew Tatarsky,Ph.D

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Intergative Harm Reduction Psychotherapy - Andrew Tatarsky, Ph.D

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Integrative Harm Reduction Psychotherapy A New Paradigm for Treating Risky and Addictive Behavior:

Integrative Harm Reduction Psychotherapy A New Paradigm for Treating Risky and Addictive Behavior Andrew Tatarsky, PhD

Workshop Objectives:

Workshop Objectives Introduction to harm reduction: principles and applications Discussion of challenges and diversity of people with risky and addictive behavior Overview of limitations in substance use treatment field “Abstinence-only” and the case for harm reduction Theoretical models have treatment implications From disease to psychobiosocial H arm reduction therapy reflects a new paradigm for understanding and treating substance misuse and addiction “extending the reach of traditional treatment” Domains of Integrative Harm Reduction Therapy Seven Therapeutic Tasks The Center for Optimal Living www.centerforoptimalliving.com

Challenges in Addictions Field:

Challenges in Addictions Field “One must not look hard to see that we are losing the battle against addiction” - Ed Khantzian, 2013 Harvard Psychiatrist The Center for Optimal Living www.centerforoptimalliving.com

Slide4:

Over 144 people die of drug overdose each day in the U.S. The Center for Optimal Living www.centerforoptimalliving.com

Our Challenge:

Our Challenge How can we make treatment more appealing, engaging and effective for this large group or people? The Center for Optimal Living www.centerforoptimalliving.com

Valerie:

Valerie 40-something, super mom, two young kids, president of PTA, husband high powered financial wizard Injecting Dilaudid 4-5x daily Hadn’t told anyone Very conflicted about using for fear of being discovered Hated the dependence and the hiding Loves using and does not want to stop Physical and verbal abuse by father as child Let to live alone in apartment by parents at 16 Sexual abuse by sibling Raped at 19 Early poly-drug use and IV heroin dependence Year in Daytop felt humiliating and further traumatizing The Center for Optimal Living www.centerforoptimalliving.com

Awad:

Awad 30 year old successful musician from Middle East Used heroin, methadone, meth, alcohol and marijuana to combat intense anxiety related to harsh inner critic so he could create Father was disappeared and tortured by the government several times when he was growing up Wanted to stop all drugs except marijuana and alcohol and Adderall prescribed since adolescence The Center for Optimal Living www.centerforoptimalliving.com

Private Practice Psychotherapist:

Private Practice Psychotherapist 24 year old man with several years of serious poly-drug use Social-worker girlfriend finally convinces him to see a therapist When he discussed his drug use during the first visit, the therapist said, “I would be glad to work with you if you stop using drugs”. Young man feels enraged and humiliated vows never to seek help again. The Center for Optimal Living www.centerforoptimalliving.com

Where do these people go for help?:

Where do these people go for help? 20 year old college student of professional parents Massive, frightening drug use: Injecting heroin and other opiates, using cocaine, ketamine, smoking marijuana, high dose Xanax Drug use began after near death illness two years prior In nine months of therapy with me, moved from refusing to admit any problem to agreeing to go into rehab After rehab, outpatient program refused to accept him because he agrees to stop all drugs but not MJ The Center for Optimal Living www.centerforoptimalliving.com

I’ve come to strongly believe:

I’ve come to strongly believe Harm reduction treatment can dramatically improve our ability to help the overwhelming majority of problematic substance users who are not being helped by traditional abstinence-only substance use treatment The Center for Optimal Living www.centerforoptimalliving.com

We Are in the Midst of a Scientific Revolution/Paradigm Shift:

We Are in the Midst of a Scientific Revolution/Paradigm Shift From simple to complex ideas and solutions From biological disease model (and moral and criminal) to psychobiosocial model From categorical (you have it or you don’t) to substance use disorders on a spectrum of severity Varying on multiple dimensions New view of substance users, substance use problems and addiction and appropriate treatment From abstinence-only to harm reduction therapy

My Story:

My Story My journey to embracing h arm r eduction as an essential part of effective helping

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Alan Marlatt , PhD : Trailblazer, Addiction/Controlled Drinking Researcher, Developed Relapse Prevention, First US book on Harm Reduction, Mindfulness-based Relapse Prevention, “Urge Surfing”, Mentor

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Edith Springer is widely recognized as an original driving force behind spreading the concept of harm reduction throughout the US. ED of New York Peer AIDS Coalition. “Sidewalk Psychotherapy”

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Keith Cylar , 1959-2004, ACT UP, Housing Works Co-Founder/ Co-ED , model for harm reduction housing proved formerly homeless people with AIDS could be successfully housed and their AIDS effectively treated without requiring they sto p using drugs. Keith was also an example.

Harm Reduction Coalition’s Definition:

Harm Reduction Coalition’s Definition A Philosophy and Set of Strategies “Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs. Harm reduction incorporates a spectrum of strategies from safer use, to managed use to abstinence to meet drug users “where they’re at,” addressing conditions of use along with the use itself .” The Center for Optimal Living www.centerforoptimalliving.com

What is Harm Reduction?:

What is Harm Reduction? “ Compassionate pragmatism ” ( Marlatt ) Shift from “abstinence-only” to any reduction of drug-related harm and related issues or to what is important to the other Safer use, reduced use, moderation and abstinence fall under the harm reduction umbrella “Any positive change” ~Chicago Recovery Alliance Acceptance and compassion First Do No Harm The Center for Optimal Living www.centerforoptimalliving.com

Harm Reduction Principle:

Harm Reduction Principle Start where the person is “ Come as you are” ~ Jeannie Little Drug users are unique individuals Drug use best understood as and address in the context of the whole person in their social environment Tailor the intervention to the person Lowers the threshold to treatment Curiosity, Respect and Acceptance The Center for Optimal Living www.centerforoptimalliving.com

Harm Reduction Principle:

Harm Reduction Principle Substance use is on a continuum of risk Goal is to move on continuum toward reduced risk Small incremental positive changes are successes and acceptable goals In substance use and related issues Affirmation Small Incremental Change The Center for Optimal Living www.centerforoptimalliving.com

Harm Reduction Principle:

Harm Reduction Principle Collaboration Drug users have strengths that can be mobilized Drug user are experts in their experience Improve self-efficacy “Therapeutic team” ~ Patt Denning Inherently Empowering The Center for Optimal Living www.centerforoptimalliving.com

Harm Reduction as Engagement Strategy:

Harm Reduction as Engagement Strategy We support people in beginning the process of positive change where ever they are ready, willing and able to begin We offer a positive, supportive and healing relationship with healthcare “We don’t need to know the destination to begin the journey” The Center for Optimal Living www.centerforoptimalliving.com

Public Health Harm Reduction:

Public Health Harm Reduction Honest Drug E ducation Medication Assisted Treatment/Recovery Methadone Buprenorphine Heroin Morphine Needle and syringe programs-NSPs Overdose prevention Naloxone Good Samaritan Law Supervised injection facilities The Center for Optimal Living www.centerforoptimalliving.com

Harm Reduction Texts:

Harm Reduction Texts The Center for Optimal Living www.centerforoptimalliving.com

Harm Reduction Psychotherapy:

Harm Reduction Psychotherapy Embraces core principles of harm reduction: Seeks to reduce harmful consequences without requiring abstinence Starts where the patient is Embraces small incremental change Collaboration, curiosity, empowerment, and compassion The Center for Optimal Living www.centerforoptimalliving.com

Harm Reduction Psychotherapy:

Harm Reduction Psychotherapy Brings a therapeutic orientation to harm reduction settings Brings a harm reduction orientation to treatment This links the entire continuum of care from syringe access to intensive addiction treatment The Center for Optimal Living www.centerforoptimalliving.com

Integrative Harm Reduction Psychotherapy Domains:

Integrative Harm Reduction Psychotherapy Domains Primacy of Therapeutic Alliance/Relationship “Harm Reduction Frame” Cognitive-Behavioral/Self-Management Psychodynamic/Exploratory Clarifies multiple personal and social meanings of substance use Body/Medical/Self-care Social/Community The Center for Optimal Living www.centerforoptimalliving.com

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The Center for Optimal Living www.centerforoptimalliving.com

Clinical Challenges:

Clinical Challenges “Based on 2008-2011 combined data, the most (often reported reason) for not receiving illicit drug or alcohol use treatment among persons aged 12 or older who needed and perceived a need for treatment but did not receive treatment at a specialty facility was( a) not ready to stop using (39.2 percent )” NSDUH, SAMHSA, 2012 The Center for Optimal Living www.centerforoptimalliving.com

Slide29:

Most problematic drug users who are concerned about their use are not ready, willing or able to commit to stopping at the point that they become concerned about their use Many problem users don’t want abstinence and avoid treatment Clinical Challenges

Scope of the Problem: USA:

Scope of the Problem: USA Majority of problem users, especially those with co-occurring disorders, are not being treated effectively (NSDUH, 2015) 66.7 million people (24.9 percent ) binged on alcohol in the past month (5 or more in one occasion) 17.3 million people (6.5 percent were heavy drinkers (5 or more 5 or more times in the last month) 20.8 million persons (7.8 percent) aged 12 or older were classified with substance dependence or abuse in the past year Only 2.3 million (10.8 percent) received treatment at a specialty facility The Center for Optimal Living www.centerforoptimalliving.com

Clinical Challenges:

Many people have multiple concurrent problem/addictive behaviors: e.g. alcohol, cocaine + sex; anorexia + medications d ifferent goals for different substances and behaviors: safer use, reduced use, moderation and abstaining/stopping Clinical Challenges The Center for Optimal Living www.centerforoptimalliving.com

Limitations in the US:

Limitations in the US 75-93% of drug and alcohol treatment only offers abstinence goal Very low rates of retention and abstinence in treatment as usual Kellogg, 2007, reviewed outcome studies showing 15%-35% retention at 12 weeks and 8% abstinent at 12 weeks The Center for Optimal Living www.centerforoptimalliving.com

Further Clinical Challenges :

Further Clinical Challenges Most problem/addictive behaviors need harm reduction because abstinence is not an option: i.e. eating, shopping, sex, internet, video games, love The Center for Optimal Living www.centerforoptimalliving.com

Major Challenges:

Major Challenges Most substance misusing people don’t go to treatment Most substance misusing people don’t want to stop or are engaging in problematic behaviors they can’t abstain from (e.g., food, sex, internet) Most who go to treatment don’t complete Most people who go to treatment don’t stop or switch additive issues Most people with substance use problems are not offered appropriate treatment and blamed for it The Center for Optimal Living www.centerforoptimalliving.com

Major Challenges for Women (Tuchman, 2010):

Major Challenges for Women (Tuchman, 2010) Women underrepresented in addiction tx . centers Experience higher levels of stigma, shame & guilt Do not respond well to punitive, confrontational, “powerlessness” approach originally designed for m en More likely to be impacted by trauma and interpersonal violence (affects 25-57% of women in SUD tx . programs) Lack of services for pregnant women and mothers Fear of losing custody, sexual harassment, child care needs May benefit from women-only groups The Center for Optimal Living www.centerforoptimalliving.com

Might the dominant addiction model be the problem?:

Might the dominant addiction model be the problem? Society is dominated by an anti-meaning one-size-fits-all abstinence-only reductive disease model addiction-recovery narrative Closely linked to moral and criminal models Informs an abstinence-only substance use treatment system Many mental health clinicians won’t treat active substance users Keeps people from seeking help The Center for Optimal Living www.centerforoptimalliving.com

Limitations of “Abstinence-only” Substance Use Treatment:

Limitations of “Abstinence-only” Substance Use Treatment Abstinence-only treatment fails to attract, engage and provide effective help for the overwhelming majority of people with substance use and other risky and addictive behavioral problems Abstinence-only treatment is irrelevant to people not ready, willing or able to stop using all substances The Center for Optimal Living www.centerforoptimalliving.com

The Tyranny of “Abstinence-Only”:

The Tyranny of “Abstinence-Only” Abstinence is only acceptable goal Commitment to abstain often a requirement of treatment Achieving abstinence quickly is often required Based on Jellinek’s Disease Model Pervades our culture Not supported by evidence The Center for Optimal Living www.centerforoptimalliving.com

The “Abstinence-only” Approach:

The “Abstinence -only” Approach Split between addiction treatment and mental health treatment Many addiction treatment providers won’t treat people who don’t want to stop using substanc es Many mental health and primary care practitioners won’t treat active substance users or those with addictive issues 70 %+ of public sector behavioral health patients in US diagnosed with co-occurring disorders The Center for Optimal Living www.centerforoptimalliving.com

We need a new model for understanding substance misuse to inform more effective treatment:

We need a new model for understanding substance misuse to inform more effective treatment Models/paradigms shape our perceptions and inform what we do Substance misuse/addiction m odels inform treatment approaches The Center for Optimal Living www.centerforoptimalliving.com

Polarizing Ideological Battles:

Polarizing Ideological Battles Addiction is a Choice!!! Disease!!! Habit!!! A stigmatizing word!!! A meaningful response to suffering!!! The Center for Optimal Living www.centerforoptimalliving.com

Do Addicts Exist?:

Do Addicts Exist? To many, “ a ddict” is a de-humanizing social construct: permanently diseased, incapable of rational thought, powerless, selfish, self-centered, liar, manipulator, thief, insane, dangerous “keep it simple stupid”, “addicts suffer from the disease of terminal uniqueness”, “take the cotton out of your ears and put it in your mouth” How much of the “addict’s” behavior is a self-fulfilling prophesy of the internalization of this construction? Yet some people love the “ addict ” identity and find it affirming…. The Center for Optimal Living www.centerforoptimalliving.com

What is Addiction?:

What is Addiction? Most agree: characterized by the experience of craving, compulsion, loss of control and inability to stop self-defeating/harming behavior. William White: “compulsive drug-seeking and drug-using in spite of persistent consequences to self and others and past efforts to decelerate or cease use .” Gabor Mate: “a. Craving, b . Short-term pleasure or relief, c. Long-term negative consequences, d . Inability to stop, desist, refrain from despite the negative consequences .” Bill Miller: ( 1) it is something done regularly, repeatedly, habitually; (2) there is a compulsive quality to it that seems at least partly beyond the individual's control; and (3) it does not necessarily involve a drug, although that is the most common association.  The Center for Optimal Living www.centerforoptimalliving.com

Learning/Behavioral:

Learning/Behavioral Coping mechanism “Overlearned habit” Stimulus ->response->reinforcement = “addictive urge” Biology, meaning and social context converge in the conditioned urge. The Urge is Axis of Change The Center for Optimal Living www.centerforoptimalliving.com

Disease:

Disease Physical illness or consequences of substance use D iseased or damaged self T oxic inner saboteur B iological illness, brain disease The Center for Optimal Living www.centerforoptimalliving.com

Spirituality:

Spirituality S piritual search for meaning Transcendence C onnectedness beyond the small self The Center for Optimal Living www.centerforoptimalliving.com

Social Determinants:

Social Determinants legal context A lcoholic beverage control laws, laws regarding driving under the influence, minimum purchase age laws, zoning reduce drinking Criminalization leads to guilt, shame, anxiety, hiding, lying Decriminalization of drugs in Portugal associated with 50% reduction in IDU economic context P ricing , tax rate, promotions on alcohol Restriction opiate prescribing increased the price and led to increased heroin use normative context S ocial attitudes and beliefs regarding substances Glamorizing of drugs increases interest Stigma increases shame, guilt, anxiety Abstinence-only ethos keeps some from seeking help physical aspects T he setting or context in which drinking and other drug-using behavior occurs A person’s associates, including their family cultural, friends, co-workers, and other peers Racism, sexism, homophobia Socio-economic variables: poverty, homelessness, unemployment The Center for Optimal Living www.centerforoptimalliving.com

Trauma:

Trauma The Center for Optimal Living www.centerforoptimalliving.com

Paradigm Shift: From “One Truth” Debates to Honoring Diversity:

Paradigm Shift: From “One Truth” Debates to Honoring Diversity Multiple Paths to Addiction Trauma Self-regulation deficits Co-occurring psychiatric disorders Meaninglessness, spiritual vacuum Learning/overlearned habit Poor health/aging Genetics Biological impact of drug use Challenging social circumstances: poverty, homelessness, etc. Stigma Criminalization of drug use Dislocation from social support

From “One Truth” Debates to Honoring Diversity :

From “One Truth” Debates to Honoring Diversity Varying on Multiple Dimensions Use : pattern, frequency, chronicity, etc . Problems: On a continuum of severity, embraced by DSM 5 SUD Physical adaptation: tolerance, physiological dependence Behavioral Dependence: only coping strategy Cognitive impairment Medical harm Motivation for change From Miller and Munoz, 2011, Chapter Two, What is Addiction? Co-occurring psychiatric issues including trauma Benefits /positive functions Multiple personal and social meanings Awareness/ dissociation Social circumstances The Center for Optimal Living www.centerforoptimalliving.com

From “One Truth” Debates to Honoring Diversity Within Addicted Population:

From “One Truth” Debates to Honoring Diversity Within Addicted Population Varying on multiple pathways to healing, growth and positive change/Recovery Spontaneous/natural recovery 12-Step Programs MAT-Medication A ssisted Therapy Psychedelic Assisted Therapy Ibogaine Therapy Comprehensive Psychotherapy Medical detoxification Abstinence-oriented in- and outpatient rehabs

Clinical Rationale:

Clinical Rationale Psychobiosocial process model of misuse and addiction Multiple meanings and adaptive value of substances Transtheoretical Stages of Change Model Focus on therapeutic relationship and development of self-management skills

Psychobiosocial Process Model of Addiction:

Psychobiosocial Process Model of Addiction Mis -use and addiction are the result of an interaction of psychological, biological and social vulnerabilities unique to each person that renders substances and other potentially risky behavior desirable The psychobiosocial consequences of chronic use contribute to increased desire and escalation in use The Center for Optimal Living www.centerforoptimalliving.com

Treatment Implications:

Treatment Implications Vulnerabilities and consequences may need to be identified or resolved before behavior can be addressed directly Addressing any relevant issue changes the system This changes one’s relationship to the behavior and motivation to change Even if risk behavior is not the primary focus of treatment The Center for Optimal Living www.centerforoptimalliving.com

Multiple Meanings Model:

Multiple Meanings Model An experience near way of thinking about the meaning of substance use Meanings are on a spectrum of awareness Problem behavior may be the language people speak-acting rather than feeling and speaking Alexithymia - desymbolization -dissociation (Krystal) The Center for Optimal Living www.centerforoptimalliving.com

Multiple Meanings Model:

Multiple Meanings Model Substance use often carries, expresses or reflects multiple meanings , simultaneously Meanings reside inside of meanings The Center for Optimal Living www.centerforoptimalliving.com

Multiple Meanings Model:

Multiple Meanings Model Addictive relationship both expresses and disguises dissociated meaning and aspects of the self Multiplicity Self-states Good Me, Bad Me, Not Me Problem behavior can be the entry point for the process of rediscovering and integrating disowned aspects of self expressed by substance use The user’s meaning-metaphor is most effective way to engage the exploration The Center for Optimal Living www.centerforoptimalliving.com

When Simple Isn’t the Solution I want to overwhelm you with the complexity!!!:

When Simple Isn’t the Solution I want to overwhelm you with the complexity !!! Self-medication of suffering (Khantzian) Attempt to repair self-regulation problems: feelings, self-esteem, relationships Regulation Disorder- (Khantzian) Expresses dissociated parts Identity Group membership Interpersonal expression Relational meaning Rebellion against inner critic Identity integrator Self-destructiveness/guilt Habit/conditioning Body needs: pain, fatigue, disease, inadequacy

The Case of Mary:

The Case of Mary Mary was a 25 year old Mid-Western ambitious, well put-together graduate student who sought therapy for daily heavy drinking from the time she can home from work until she passed out. She was very motivated to cut back due negative effects on her physical and emotional health and productivity at work. During our fourth session I asked her if she could tell me what part of her felt such urgency to drink when she got home. She stopped for a moment, then looked startled and said, “Why, it ’ s the four year old little girl who was kicked down the stairs whenever my dad came home in a bad mood. I would hide in my bedroom closet hoping he wouldn’t find me and now that’s what I do to deal with the anxiety I feel when I come home.” The Center for Optimal Living www.centerforoptimalliving.com

Motivational Stages of Change Prochaska and DiClemente:

Motivational Stages of Change Prochaska and DiClemente The Center for Optimal Living www.centerforoptimalliving.com

The Major Challenge...:

The Major Challenge... How do we offer treatment that is Appealing? Relevant to people’s needs? Engaging? Effective? Honors this diversity? The Center for Optimal Living www.centerforoptimalliving.com

Propositions:

Propositions Treatment must be more appealing than problem behavior or why come to treatment? Treatment must not require abstinence to be more appealing and accessible Integrative Harm Reduction Psychotherapy (IHRP) is my name for this approach IHRP is essential for attracting, engaging and supporting the majority of problem substance users in making positive change The Center for Optimal Living www.centerforoptimalliving.com

Times are Changing:

Times are Changing Increased recognition of need to: View substance use as a health and human right issue T reat addictive behavior issues in context of co-occurring issues From criminal justice to public health approach Treatment rather than incarceration The Center for Optimal Living www.centerforoptimalliving.com

Integrative Harm Reduction Psychotherapy Domains:

Integrative Harm Reduction Psychotherapy Domains Primacy of Therapeutic Alliance/Relationship “Harm Reduction Frame” Cognitive-Behavioral/Self-Management Psychodynamic/Exploratory Clarifies multiple personal and social meanings of substance use Body/Medical/Self-care Social/Community The Center for Optimal Living www.centerforoptimalliving.com

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The Center for Optimal Living www.centerforoptimalliving.com

Task 1 Managing the Therapeutic Alliance?:

Task 1 Managing the Therapeutic Alliance? Defined as “the ability to work purposefully together” Sets the therapeutic stage Anchors the patient in therapy The Center for Optimal Living

Primacy of Therapeutic Alliance:

Primacy of Therapeutic Alliance Over 50 years of research show it is the best predictor of therapeutic success A key contributor to positive outcomes in substance abuse research Strength of alliance is based in agreement about goals, tasks and quality of bond ( Safran and Moran, 2001) Supported by goal choice research The Center for Optimal Living

Engagement Skills:

Engagement Skills Active listening-empathic mode ( Fosshage ) “Start where the patient is” Try to put aside your presumptions Listen with no agenda except to be helpful Face not knowing Empathic resonance for client´s experience Imagine and feel client’s experience Manage your reactions (countertransference) The Center for Optimal Living

Engagement Skills :

Engagement Skills Collaborative I nquiry Collaborate with the aware self-state, witness, adult mode Keeps client and clinician on the same side Focus on clarification Open-ended questions The Center for Optimal Living

Engagement Skills:

Engagement Skills Empathic Reflection Checking in- “did I hear you right?” Client’s process informs focus Client chooses goals ― this motivates them Therapist must be attuned and flexible The Center for Optimal Living

Task 2 The Therapeutic Relationship Heals:

Task 2 The Therapeutic Relationship Heals Enhances self-regulation of feelings, self-esteem, relationships Creates a safe space for identifying harm, setting goals and working toward change Supports client in finding lost aspects of herself Relationship allows reworking of interpersonal issues that have been expressed through problem behavior The Center for Optimal Living

Task 3 Enhancing Self-Regulation Skills :

Task 3 Enhancing Self- Regulation Skills “Self-regulation difficulties are often at the heart of substance misuse” -Khantzian and Henry Krystal Certain self-regulation skills are necessary for changing one’s behavior It may be necessary to help the client strengthen these skills as prerequisite to change Implicitly Explicitly Support the “adult self”, “witness”, “conductor” The Center for Optimal Living

The Urge is the Axis of Change:

The Urge is the Axis of Change Biology, meaning, habit, social context meet in the urge Urge-Surfing, bringing mindful, accepting awareness and breath to the urge: inhibits the “addictive” habit i mproves affect tolerance facilitates reflection enables the discovery of what aspects of self live there This discovery can lead to new choices about how to respond, alternative ways to care for oneself more effectively Working in these alternatives is the recovery process The Center for Optimal Living www.centerforoptimalliving.com

Skills for Change:

Skills for Change Curiosity motivates self-inquiry “Alliance around compassionate curiosity” - Donnel Stern Mindfulness -Awareness with acceptance; self - monitoring, observing ego enables the patient to identify events, thoughts and feelings relate d to substance use Affect Tolerance - breath, self-talk, self-soothing The Center for Optimal Living

What is Mindfulness?:

What is Mindfulness? “Receptive attention to and awareness of present events and experiences” (Brown & Ryan, 2003) “Mindfulness means paying attention in a particular way: On purpose, in the present moment, & non-judgmentally” ( Kabat -Zinn, 1990) “The stance of mindfulness is one of welcoming and allowing . Its invitational . ( Segal, Williams, & Teasdale, 2002 ) It encourages ‘ opening ’ to the difficult and adopting an attitude of gentleness to all experience… a friendly awareness ” (Segal, Williams, & Teasdale, 2002) The Center for Optimal Living www.centerforoptimalliving.com

Inquiry Process:

Inquiry Process The Center for Optimal Living www.centerforoptimalliving.com Cultivate and model curiosity, awareness, slowing down, non-attaching to the content

Mindfulness Practices :

Mindfulness Practices Mindfulness of the body Sensations Breath Posture In movement Daily activities Mindfulness of Feelings Mindfulness of Thoughts Mindfulness of the what hinders our happiness and satisfaction Desire Aversion Sloth Restlessness and Worry Doubt The Center for Optimal Living www.centerforoptimalliving.com

SOBER Breathing Space (Bowen, Chawla, & Marlatt, 2011):

SOBER Breathing Space (Bowen , Chawla , & Marlatt , 2011) Stop : Slow down, pause for a moment and consider what’s happening Observe : Observe what you are sensing, feeling, thinking, and what events led to the situation. Breathe : Gather your attention and take a few deep breaths Expand your awareness to include the rest of your body, your experience, and the situation Respond (vs. react) mindfully : Respond with awareness of what is truly needed and how you can best take care of yourself. You have a choice in how you respond The Center for Optimal Living www.centerforoptimalliving.com

Urge Surfing Exercise (Bowen, Chawla, & Marlatt, 2011):

Urge Surfing Exercise (Bowen, Chawla , & Marlatt , 2011) Guided practice that includes imaginal exposure to cravings and introduces mindful acceptance of cravings/urges Observing, witnessing the craving without reacting to it Noting body sensations, feelings, emotions, thoughts, reactions to the experience (e.g., “this feels intolerable”) Gentle, kind, compassionate awareness How to find ease in the discomfort Image of using the breath as surfboard that helps you ride out the wave of the craving Increasing the capacity to “stay with” and be present with the urge without automatically responding to it in a habitual way The Center for Optimal Living www.centerforoptimalliving.com

Task 4 Assessment as Treatment:

Task 4 Assessment as Treatment Initial basis for therapeutic alliance and treatment plan Ongoing therapeutic activity As problems are clarified, goals can be set The Center for Optimal Living

Assessment as Treatment:

Assessment as Treatment Our assessment facilitates patient’s self assessment: Substance use severity Dependence, withdrawal, protracted withdrawal Medical status Relationship to psychobiosocial variables Multiple meanings Stage of change Other important issues Hierarchy of needs, order of importance The Center for Optimal Living

Microanalysis:

Microanalysis Microanalysis of current use pattern: Describe your pattern of using in a typical episode, week or month How does substance use fit in with other aspects of life? What did you want from drug and how did it work out? Problem severity: negative consequences What might you like to change about use? Chart the above between meetings The Center for Optimal Living

Unwrapping the Urge:

Unwrapping the Urge The Intersection of Psychodynamic, Cognitive-Behavioral, and Mindfulness Approaches Surf the urge Dialogue with the urge: What happened just before? What does it want? What does it want to change or escape from? If it could speak, what might it say? Is there a story it has to tell? What part is speaking through the urge? The Center for Optimal Living

Task 5 Embracing Ambivalence:

Task 5 Embracing Ambivalence Contemplation and preparation phase Ambivalence vs. denial There is always ambivalence about changing Splitting ambivalence may explain addictive flight The Center for Optimal Living

Slide86:

Motivational Intervention Helping client to experience ambivalence allows consideration of new goals Bring the ambivalence into the room “Standing in the Spaces” (Bromberg) Experience of integration in the presence of an other, a new definition of recovery? The Center for Optimal Living Embracing Ambivalence

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Techniques Empathize with both sides of conflict Voice Dialogue ~ Stone and Winkleman Transformational Chairwork ~ Kellogg Motivational Interviewing “Decisional balance ” The Center for Optimal Living Embracing Ambivalence

The Decisional Balance:

The Decisional Balance The Center for Optimal Living

Task 6 Harm Reduction Goal Setting:

Task 6 Harm Reduction Goal Setting Contemplation and preparation/decision stages Supports client choice, agency and motivation The question of goals promotes curiosity about what is wrong Goals motivate change Goal choice increases retention and outcomes The Center for Optimal Living

Harm Reduction Goal Setting:

Harm Reduction Goal Setting Empowers patient to consider what is wrong and what changes they want to make Goals change as issues are clarified or resolved “Any positive change”- Small changes begin the process of change, build “self-efficacy” and are typically how change occurs The Center for Optimal Living

Task 7 Strategizing for Change: Ideal Use Plan:

Task 7 Strategizing for Change: Ideal Use Plan Create a hypothetical plan with the patient “If you were to create a plan for using your substances of choice that would provide the greatest amount of benefit with the lowest level of risk, what might it look like?” The Center for Optimal Living

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Goals and strategies for achieving them. How much? How often? With whom? What practices? What other changes would you need to make to support it? The Center for Optimal Living Ideal Use Plan

:

The ideal use plan is like driving to a destination Destination: Where do I want to go? (goal setting) Route: How do I get there? (strategizing ) Skills: What are good defensive driving skills ? (self-management skills) Important skills include c uriosity mindfulness/awareness a ffect tolerance Self-talk The Center for Optimal Living www.centerforoptimalliving.com Driving as Metaphor for Self-managing Change

Strategizing for Positive Change :

Strategizing for Positive Change Biological Interventions Medical examination/treatment Psychiatric assessment/treatment A variety of medications useful for detox , reducing desire Nutritional assessment/diet Fitness assessment/exercise Yoga Bodywork The Center for Optimal Living

Strategizing for Positive Change :

Strategizing for Positive Change Psychological/Cognitive Interventions Education about harm reduction, psychobiosocial model, multiple meanings and stages of change Creating an attitude conducive to change: acceptance, awareness, curiosity, experimental “Play” with the habit rather than enforcing change Mindfulness/Self-monitoring in the moment Stop technique: hold breath and slow it down www.andrewtatarsky.com The Center for Optimal Living

Strategizing for Positive Change :

Strategizing for Positive Change Psychological/Behavioral Interventions Charting and journaling urges: ABCs, pre/urge/post Manage or resolve triggers in new ways (goals) Avoidance strategies Refusal skills Alternatives: less harmful self-caring behaviors to address triggers? (Keep a list of at least 18 Alternatives in pocket) Ideal Use Plan: positive change goals Game plan substance use with specific goals and strategies for each using situation The Center for Optimal Living

Strategizing for Positive Change :

Strategizing for Positive Change Social/Interpersonal Interventions Group therapy Couple/family therapy Mutual help groups Lifestyle modification ( Marlatt ) The Center for Optimal Living

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Thank you! The Center for Optimal Living www.centerforoptimalliving.com

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