PSY389 Lecture 6/7 - Recovering from Alcohol and Other Drug Dependencies

Changing a behaviour - How do substance dependent individuals break their addiction?

1. What motivates or prevents an individual from considering quitting?

2. What moves them to actually quit?

3. What procedures do they use to quit?

4. Why is quitting so difficult to maintain, with many attempts end in relapse?

5. Finally, how do they achieve success in the long-term?

Models of decision making (Bennett, 1986)

asked 135 opioid users: why and how they started using opioid?

• Start with non-opioid drugs (e.g., cannabis, amphetamine)

• Introduced to first opioid by friends/acquaintances (i.e., free from pressure)

• Made a conscious/deliberate decision to use before actual use due to curiosity, follow friends, integrate with group, share experience with friends, or desire to involve in addict lifestyle (i.e., use has meanings and purposes)

• Took between 1 and 3 years to progress from first use to daily use with gaps of non-use or occasional uses in between (i.e., use is intentional and control, not compulsive use)

• Desire to feel high, to perform in social situations, to treat psychological issues (e.g., depression) (i.e., drug use is functional)

Continuation (What caused them to continue to use?)

• ‘I like them’

• I want to follow friends

• It makes me feel secure and confident

• Self-medicate

• Drug use is functional

Cessation (What caused them to stop use?)

• 50% foresaw a lifetime addiction (life is better on opioid) and have no plan to give up (self-determined)

• 50% considered abstinence conditionally (e.g., entering into a stable relationship, social groups move out of the area, pregnancies) or unconditionally (self-determined, responsible and control)

Thus, Bennett (1986) argued that addiction is best understood through rational choice paradigm

• Individual is self determined & responsible

• Behaviour is purposeful, intentional & limiting (not out of control)

• This view is consistent with drug use being functional, purposeful & not pathological (an assumption of the social learning theory pertaining substance use)

BUT:

• The opioid users in Bennett study were self-motivated to use drugs

• Motivation: a desire to engage in a behaviour (e.g., use drugs) involves a decision-making process - likened to weighing the pros & cons

• Being emotional human beings, we do not always accurately weigh up the relevant options, the pros, and the cons

• Emotions are important in decisions

• We do not always think rationally and are clouded by emotions •

• Thus, do we always make the ‘right’ decision?

Janis & Mann Decisional Balance Sheet of Incentives

Provides a framework for understanding cognitive, emotional and motivational elements of decision

Gains of behaviour contrasted with costs of that behaviour, and costs and gains of NOT doing

When making decision people consider gains and losses:

• Gains and losses for self-personal goals

• Gain and losses for significant others (family goals)

• Self-approval and self-disapproval

• Approval and disapproval by significant others

There are some defective coping behaviours which affect quality of decisions

Janis & Mann- Defective Coping Behaviours

1. Unconflicted inertia- carry on as usual without considering other alternatives;

2. Unconflicted change- chose an alternative option without considering other alternatives;

3. Defense avoidance- adopt an inappropriate course of action because alternatives are not considered favourable (e.g., fearful of them);

4. Hypervigilance- respond immediately without considering consequences.

– Hypervigilance and defense avoidance coping mechanisms are common in drug use.

• Encouraged rational vigilant decisions by using a balance sheet of pros and cons, and their likely consequences.

• Individuals who make vigilant decisions suffer less stress and more content with it afterwards.

Example of decisional balance sheet for alcohol problems

What influences motivation or decision to change or not?

• Expectancy (what will happen, the expected good or bad consequences of change)

• Self-efficacy (if I try will I succeed?)

• Importance of consequences of changing or not changing

• In the balance sheet, the pain of staying the same must outweigh the pain of change

What do people say about changing AOD use ?

• Ageing, money, new relationships, work, guilt, social pressure and new information/knowledge.

• Major life events

• Lifestyle changes

• Treatment is only helpful when coincided with significant life event(s)

• Reasons for giving up can appear trivial

CRITICAL FACTORS FOR COMMITMENT TO CHANGE

• Being aware of negative impacts of drug use (functioning, thinking, & feeling)

• Having strong positive view of different possibilities available (new lifestyles and self concept)

• Being optimistic about one’s capacity to change (self-efficacy)

• Having support (personal and/or professional)

• Psychologists can:

• help people assess costs and benefits

• help people develop vision of abstinence

• help build self-efficacy

• support people

Stages of change (Prochaska et al., 1994)

• Prochaska et al. (1994) viewed quitting as a process involving different stages.

• Progress through stages is not without reversals

• Setbacks to an earlier stage occur

• Thus, the model involves a spiral rather than linear patterns over time

Stage 1 –Pre-Contemplation (Not Ready for change)

• Denial of problem, no intention to change in near future, unaware of the need to change, underestimating the pros to changing and focus on cons

Therapist Goals: explore costs & benefits, build self-efficacy, explore vision/goal & how decisions fit in, minimise harm(s)

• Help the person develop reason for changing

• "Does anything about the issue actually cause you problems or lessen your quality of life?” “If things stay exactly the same where do you see yourself in 5 years?”

Validate experience

• "I can understand why you feel that way”

Encourage further self exploration

• "From what you have been telling me it sounds like you are managing, but I wonder what it would be like if you didn’t have the problem, could it be better?”

Leave the door open for future conversations

• "I don’t want to preach to you; I know that you’re an adult and you will be the one to decide if and when you are ready to give up”

• "I hear you saying that you are nowhere near ready to deal with the problem right now.

Stage 2 – Contemplation (Getting ready for change)

• Aware that a problem exists, thinking about changing, but makes no commitment (sitting on a fence)

• More aware of pros of changing, but pros are equal to cons

• Ambivalence can cause them to put off taking action

Therapist’s goals: use motivational interviewing exploring costs, benefits, fears of change, create sense of discrepancy between life without change & how one wants life to be, self-efficacy.

• Validate the person’s experience:

• "I’m hearing that you are thinking about dealing with the problem but you’re definitely not ready to take action right now.”

• Acknowledge person’s control of the decision:

• "I don’t want to preach to you; I know that you’re an adult and you will be the one to decide if and when you are ready to deal with the problem.”

Clarify person’s perceptions of the pros and cons of attempted change:

• ”What are some of the downsides of changing? And the upsides?”

Encourage further self-exploration:

• "These questions are very important to beginning a successful change to occur. Would you be willing to talk to me about it at our next visit?”

Leave the door open for moving to preparation:

• "After talking about this, and doing the exercise, if you feel you would like to make some changes, the next step won’t be jumping into action - we can begin with some preparation work

Stage 3 – Preparation (Ready to change)

• Is ready to change and start taking action

• Takes small steps toward changing behaviour

• Starts making plans – the better prepared the individuals are, the more likely to succeed

Therapist’s goal: goal setting, action plan support

1. Praise the decision to change behaviour:

• "It’s great that you feel good about dealing with your problem; you are doing something important to improve the quality of your life and those around you.”

2. Prioritise behaviour change opportunities:

• "Looking at the negative aspects of what is happening, what do you think it would be the first thing you would like to see change or improve in her behaviour?

3. Identify and assist in problem solving (e.g., obstacles):

• "Have you ever attempted to deal with the problem? What was helpful? What kinds of problems would you expect in making those changes now? How do you think you could deal with them?”

4. Encourage small, initial steps:

• "So, the initial goal is try to do this instead of that X number of times this week.”

5. Assist in identifying social support:

• "Which family members or friends could support you as you make this change? How could they support you? Is there anything else I can do to help?"

Stage 4 - Action

• Modify behaviour or environment in order to overcome problems.

• Maintain altered behaviour for a period of one day to 6 months

• Successfully altering behaviour means reaching a criterion

Therapist goals:

• Help to develop problem solving and goal setting skills to cope with the changes

• Help to develop better lifestyles

• Help develop relapse prevention skills, recognising triggers to deal with high risks situations

• Help coping with pressures to use to prevent relapse

• Encourage the use of achievable alternatives to drug use

• Reinforce change

• Praise change

Goals:

• Long term goal (6-12 mths)

• In the first week I will…. In the second week I will…. In the third week I will… In the fourth week I will…

Stage 5 - Maintenance

• Work to maintain abstinence and prevent relapse

• Being free of addictive behaviour and being able to consistently engage in new incompatible behaviour for more than 6 months

• Need to practice a less harmful lifestyle until it becomes automatic (6 months or more)

• Consolidate gains attained

• Reinforce the decision to change and the positives that are happening

• Emphasise the need for external support from family and friends

But in reality... Relapse (recycle) often occurs…

Stage 6 - Relapse

• Stages of change are not linear (Spiral model)

• Relapse can happen at any time and go back to any stage

• Relapse essentially means return to the old behavior.

• When working with clients, therapists try and highlight the difference between lapses and relapse.

• Look at relapse in terms of degree

• Slips and setbacks are part of learning

• Client can feel shame and self-loathing

Stages of Change model - Pros

• has large support

• popular with clinicians & researchers

• appeals to all models- disease or social learning

• Has face validity

• Generates enthusiasm

• not judgemental

Stages of Change model - Criticisms/cons

• Time periods/stages are arbitrary

• Lack of longitudinal research

• Stages may not reflect under lying process.

• Does not consider nature, aetiology and development of dependence

• Lacked empirical definition of terms and rules

• Is difficult to falsify

Stages of Change model - Implications for treatment

Wrong to assume:

• Someone wants to change

• There is a right time to change

• Therapists can make people change

• “Tough love” is best

• “I am expert, follow me”

Right to assume:

• Different interventions for each stage

• People must be ready for change

• Therapists can help ‘moving’ them along

Methods of Recovery

Natural recovery

Informal self-help

• Alcoholics Anonymous, Cocaine Anonynous, Narcotics Anonymous, Women for Sobriety

Formal professional treatment

• Pharmacotherapy

• Individual or group psychotherapy

• Motivational Interviewing

• Cognitive Behavioural Therapy

Self-help for Substance Dependence

How Might Self-Help Work?

• Changing the person–substance relationship

• Trigger-→Craving/Urge-→Coping Strategy→Alternate behaviour→Reward/self-control

Key psychological mechanisms:

• Self-monitoring – tracking substance use and triggers

• Motivation – identifying reasons for change

• Self-efficacy – "I can manage this craving"

• Coping skills – responding differently to urges

• Stimulus control – reducing exposure to triggers

• Alternative reinforcement – finding other rewarding activities

• Relapse prevention – preparing for high-risk situations

Craving does not have to lead to substance use.

McNally and Palfai (2001)- link between readiness to change and expectancies

Aim

• Examined whether alcohol outcome expectancies are related to a person's readiness to change (RTC) their drinking.

• Specifically compared:

  • Positive expectancies → expected positive effects of alcohol.

  • Negative expectancies → expected negative effects of alcohol.

• Researchers predicted that negative, but not positive, alcohol expectancies would be associated with greater readiness to change among binge-drinking university students.

McNally and Palfai (2001)- link between readiness to change and expectancies

Background

Alcohol expectancies

• Alcohol expectancies = beliefs about what will happen when someone drinks alcohol.

• Positive expectancies include:

  • increased sociability;

  • having fun;

  • sexual enhancement;

  • tension reduction.

• Negative expectancies include:

  • social problems;

  • negative emotions;

  • physical consequences;

  • impaired thinking/performance.

Why negative expectancies might matter

Previous research had mostly focused on positive expectancies, which are associated with people's motivation to drink.

However, the Revised Expectancy Motivation hypothesis (REMh) proposes:

• Positive expectancies → motivation to drink.

• Negative expectancies → motivation to restrain/change drinking.

Therefore, thinking about the negative consequences of alcohol may increase someone's motivation to change their behaviour.

McNally and Palfai (2001)- link between readiness to change and expectancies

Participants

• 152 undergraduate students from a private university in the northeastern USA.

• Ages 17–23 years; average age = 18.74 years.

• 49.3% women.

• Most were first-year university students.

• To participate, students had to report at least one binge-drinking episode in the previous month.

• Binge drinking was defined as consuming 5+ drinks in one sitting.

McNally and Palfai (2001)- link between readiness to change and expectancies

Measures

Participants completed several self-report questionnaires.

Alcohol consumption

• Assessed how much and how frequently participants drank.

• Examined drinking over the previous 30 days and year.

YAAPST

Young Adult Alcohol Problems Screening Test

• 27 items measuring negative drinking consequences.

• Included:

  • drink driving;

  • missing classes;

  • other alcohol-related problems.

Readiness to Change Questionnaire (RTCQ)

Measured participants' motivation/readiness to change their drinking.

Based on three stages:

• Precontemplation

• Contemplation

• Action

Researchers combined these to produce a continuous total readiness-to-change score:

Higher score = greater motivation to change drinking behaviour.

Alcohol Outcome Expectancies Scale (AOES)

Measured participants' expectations about drinking.

Positive expectancies:

• Social

• Fun

• Sexual

• Tension reduction

Negative expectancies:

• Social

• Emotional

• Physical

• Cognitive/performance

McNally and Palfai (2001)- link between readiness to change and expectancies

Procedure

• Participants completed questionnaires in groups of 10–20 students.

• One session lasting approximately 1 hour.

• Questionnaires assessed:

  • alcohol consumption;

  • alcohol-related problems;

  • readiness to change;

  • alcohol expectancies;

  • demographics.

McNally and Palfai (2001)- link between readiness to change and expectancies

Main results

Positive vs negative expectancies

A key finding was:

Positive alcohol expectancies did NOT significantly predict readiness to change.

However:

Negative alcohol expectancies DID significantly predict readiness to change.

Importantly, this remained significant even after researchers controlled for:

• age;

• gender;

• amount/frequency of drinking;

• drinking-related problems.

Which negative expectancy mattered most?

Of the four types of negative expectancies:

• ❌ Negative social

• ❌ Negative physical

• ❌ Negative cognitive/performance

• ✅ Negative emotional

Only negative emotional expectancies significantly predicted readiness to change in the regression analysis.

Negative emotional expectancies included anticipating feeling:

• guilty

• ashamed

• depressed

after drinking.

McNally and Palfai (2001)- link between readiness to change and expectancies

What do the results mean?

The findings support the Revised Expectancy Motivation hypothesis:

Positive expectations about alcohol → may motivate drinking

whereas

Negative expectations about alcohol → may motivate people to change/restrain their drinking.

More specifically, anticipated negative emotions appear particularly important for motivating change.

Cognitive dissonance explanation

The authors connect this finding to cognitive dissonance.

• People experience psychological discomfort when their behaviour conflicts with their goals or beliefs.

• For example, a student might realise:

"My drinking behaviour doesn't match the person I want to be."

• Anticipating guilt, shame or depression after drinking may create this discomfort.

• The person may then become more motivated to change their drinking to reduce the discrepancy.

McNally and Palfai (2001)- link between readiness to change and expectancies

Clinical implications

The findings suggest interventions for heavy-drinking university students could:

• Increase awareness of the negative emotional consequences associated with drinking.

• Help students recognise discrepancies between their current drinking and personal goals.

• Potentially use motivational interviewing to explore these discrepancies.

• Combine this with approaches that reduce positive alcohol expectancies.

However, the authors do not recommend confrontational approaches designed to deliberately induce guilt/shame.

Instead, they suggest an empathetic motivational approach involving gentle reflection and exploration.