Integrative Addiction Psychotherapy
Diana Calvario
Scott Kellogg, PhD
Foundational Concepts
Harm Reduction Psychotherapy
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People use substances in problematic ways for a
range of reasons
 Reasons that need to be respected
In many cases, they will need to be addressed
directly
 Sometimes before the person is ready to
decrease or cease their use of substances
 (Tatarsky)
Schema Mode Therapy
Multiplicity of Self
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In this model, the internal world of patients is
conceived of as containing different parts,
selves, modes, or identities –
Many of which may not only play a role in a
patient’s suffering and drug use,
But also in his or her healing and recovery.
(Kellogg)
Mechanisms of Change
Leonardo Da Vinci
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Components of Treatment
Wide Rothko (2008) by Joao Vasco Paiva
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Therapeutic Relationship
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Therapeutic Alliance
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A central factor in successful recovery
Therapists demonstrate:
 Love
 Empathic Listening
 Authenticity and Optimism
 Courage and Determination
Within the Context of their Personal Style
Motivation and Complexity
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Patient Voices
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Patient Voices
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“I’ve always felt like I wanted to die since I was
a little kid. I don’t know why…
I want to see a therapist or psychiatrist about it
but I don’t go ‘cause I’m afraid to tell them I still
do dope.
I still just really love to get high.” (Welch, 2011)
Patient Voices
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Addicted Woman: “People are, like, crackheads
and alcoholics and whatever because they’re
covering up [stuff], you know what I mean?
And, if they don’t deal with that… they’re not
going to get anywhere.
Interviewer: Are you going to have to deal with
some personal [stuff]?
Patient Voices
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Addicted Woman: Oh yeah. But …. I’m scared.
…. I stay up for days, you know, because I don’t
want to sleep, cause I get nightmares.
Interviewer: …What’s scary about going to sleep?
What gave you the nightmares?
Addicted Woman: … I’ve been like sexually
abused….and raped, you know.” (Wild, 2002)
Substance Use Domains
Self-Stimulation Domain
Drug Use to Feel Alive,
Experience Pleasure;
Access Creative and
Spiritual Aspects of Self
Self-Soothing Domain
Drug Use to Treat Inner
Anguish, Pain, and
Psychopathology
Somatic Domain
Drug Use to Address
Brain Changes, Withdrawal,
Mood Dysregulation, Cravings, and
Medical Illness
Social Identity Domain
Drug Addiction Lifestyle;
Addict Identity
Social Justice Domain
Social Oppression: Sexism,
Racism, Homophobia,
Disenfranchisement; Poverty
Motivations to Change
Family/Parental/
Relational Threats
Job Loss/
Economic Damage/
Prestige Threats
Existential/Spiritual
Concerns
Health Concerns
Legal Problems
Role Strain/
Role Conflict
Decisional Balance
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Decisional Balance
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The heart of Addiction Psychotherapy
Assesses the many forces supporting the drug
use
And the forces favoring change and/or recovery
Decisional Balance
Positives of Drug Use
Positives of Change
Immediate physical pleasure
(10)
Escape/Feeling more “there”
(10)
Feels more emotion (10)
Reduces social anxiety (6)
Shuts out critic (7)
People will know “real” self (7)
Feel a greater sense self
discipline (9)
Would be more productive (10)
Help him be more comfortable
with self (8)
Greater confidence (6)
Negatives of Drug Use
Negatives of Change
Feels guilty (7)
Others are concerned (6)
Not as productive (10)
Feels like it a crutch (10)
Feels bad (7)
Health Problems (7)
Would not enjoy life as much (9)
Would be ignoring a part of
himself (10)
Breaking up with something he
loves – a hard breakup (9)
Multiplicity of Self
Dancing of the Selves
By Brenda Clews
Positive Goals;
Desire for Something
Better
Violates Personal
Moral Standards
Provides Great Pleasure;
Feels Alive;
Hedonic Experience
Reduces Inner Pain;
Depression and Anxiety
Improve Relationships
With Significant Others
Concerns About Health
And Wellbeing
Facilitates Social Interaction
Goal Setting and
Problem List Development
http://ideaswar.com/wp-content/uploads/2012/05/Goals.jpg
Therapeutic Strategy
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Work with Drug Use First?
Work with Underlying Problem/
Psychopathology First and Monitor the Drug
Use?
Do Both Simultaneously?
Drug Use Goals:
 Harm Reduction, Moderation,
“Nonaddictive” Use, or Cessation?
Institutional Goals
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Embrace them
Ally with Patient Against Them and Use Harm
Reduction Strategies (Wallace)
Vertical and Horizontal
Interventions
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Interventions
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Vertical Interventions
 Those that are used to address and treat the
underlying issues and co-occurring
psychopathology
Horizontal Interventions
 Those focused on controlling and/or
discontinuing drug use
Vertical Interventions
Relational
Cognitive
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Behavioral
Dr. B. F. Skinner
Experiential
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Existential
http://www.jerseyshoremindfulness.com/wp-content/uploads/2012/08/Viktor-Frankl-quote.png
Meditative/Self-Soothing
http://cmhc.utexas.edu/stressrecess/images/progessive_muscle_relaxation.jpg ; http://img.ehowcdn.com/article-new/ehow/images/a04/t2/nb/guided-imagery-technique-800x800.jpg ; http://www.emergingrnleader.com/wp-content/uploads/2012/05/Mindfulness11.jpg
Horizontal Interventions
Substance-Use Management
http://www.drcnet.org/links/
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Substance Use Management
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Helping people use drugs in ways that are safer
Including
 Reducing the amount consumed
 Changing methods of use
 Reducing the time of involvement
 Changing the context of use
 Drug substitution (Dan Bigg, 2008)
 Overdose Prevention/Naloxone
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Relapse Prevention
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Relapse Prevention
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Involves working with patients to:
 Understand triggers and cues
 Identify high-risk situations
 Develop such coping skills as:
 Cognitive Restructuring, Relaxation Therapy,
Distraction, Social Support
 Assertiveness – Drink and Drug Refusal
 Awareness/Mindfulness/Urge Surfing
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Ideal Use Plan
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“If you were to use drugs or alcohol in such a
way as to maximize the pleasure and benefit you
gain from them while minimizing the pain and
danger involved, what would that look like?”
Can they implement this?
What interferes or stops this from happening?
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(Tatarsky & Kellogg, 2010)
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Contingency Management
Contingency Management in the
Treatment of Addictive Disorders
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Uses positive reinforcement principles to:
 Improve retention
 Decrease substance use
 Increase group attendance
 Improve medical compliance
 Encourage harm-reducing and recoveryrelated behaviors
Positive Reinforcement and Retention
Standard
Incentives
% Retained
100
80
60
40
20
0
2
4
6
8
Weeks
Petry et al., 2000
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Treatment of Cocaine Use in Methadone Patients
Retained Through
Study
>=8 Weeks of Cocaine
Abstinence
100
100
75
75
% 50
% 50
25
25
0
0
Incentives
Standard
Incentives
Standard
Silverman et al., 1996
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Identity Theory
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http://onderdiemaanensterre.files.wordpress.com/2009/03/vintage_romantic_couple_stock5_by_l.jpg
Identity Theory
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Addresses the questions:
 Why do people change?
 How do they change?
 How do they maintain long-term abstinence,
sobriety, or moderation?
Identity Theory
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Recovery Capital
Identity Theory
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Identity processes are a core component of
psychosocial treatments
People have Multiple Identities
Organized into a Hierarchy of Importance
Identity and Recovery
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The core idea:
 Drug use will decrease and eventually cease
or moderate as:
 Nonaddict identities become more
central, reinforcing, and important to
individuals
 And as they compete with and replace the
Addict Identity
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(Anderson, 1998; Biernacki, 1986; Granfield & Cloud, 1996; Kellogg, 1993)
The Case of N
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"Agape" by Jane Korins
Identity Restructuring
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Long-term recovery can be seen as involving
identity creation and restructuring
Treatment programs may specifically seek to
create a Recovery Identity
 “My name is Bob and I am an Alcoholic.”
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Individual Psychotherapy
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Individual Psychotherapy can involve:
 Transforming the drug-using self
 Creating or empowering competing identities
The Addict Identity can dialogue with the
 Work
 Family
 Religious/Spiritual
 Athletic
 And other past, present, or future selves/identities
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Identity Dialogues
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Identity and Harm Reduction
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Harm reduction organizations have the potential
to provide users with
 New identities
 New roles
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A needle exchange program that is run by active
drug users
Their involvement in this process also led to
positive identity changes
“Not only are user-run programs the most viable
and effective way to reach active drug users,
The users become activists through their work.
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Since becoming active in our organization,
Many council members have been able to move
away from ‘unmanageable’ drug use towards the
stability that maintenance brings”
(Zibbell, 2005)
The War on Drugs interferes with Identity Creation;
Therefore the War on Drugs interferes with
Healing and Recovery
Recovery Culture
http://goodmenproject.com/ethics-values/come-out-come-out-wherever-you-are/
Strengths
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Seeks to create a broader culture of recovery
A culture that would supplant that based on
drug use and addiction
Create networks of support
Provide identity materials and niches
Help addicted individuals claim
 A Recovery Identity
 Other Identities
Countertransference
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Countertransference
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Working with drug-using patients in this manner can
evoke strong emotions including:
 Love
 Admiration
 Fear
 Anger
 Grief
It is important to have to have places where it is safe
to process these feelings
Diana Calvario
Scott Kellogg, PhD
scott.kellogg@nyu.edu
http://gradualismandaddiction.org/