How The Two Pillars of Recovery
Promote Patient Responsibility
Geoff Kane, MD, MPH
HUB Teleconference
April 14, 2014
Themes
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Vulnerability
Empathy
Responsibility
Accountability
Honesty
Feelings / Emotions
Authenticity
Spirituality
Outline
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Recidivism
Laws of Nature – Neurobiology
Two Pillars of Recovery
Motivation
Eliciting Story
Discussion
RELAPSE RATE OVER
TIME
10
0
Heroin
Smoking
Abstainers (%)
90
Alcohol
80
70
60
50
40
30
20
0
1
10
2 Weeks
0
2
3
4
5
6
7
Time (Months)
8
9
10
11
12
Abstinence results from
Skill Power
not Will Power
Kane, MD 2013
Recidivism happens
• Two universal mistakes
• Two Pillars of Recovery
Relapse – The Usual Mistakes
• Individuals take insufficient
responsibility for:
The
details of recovery
management
Honest self-disclosure
Nature: Cause and Effect
You either take responsibility
or take nature’s consequences.
“Addiction is like gravity; it
is governed by the laws of
nature and never takes
time off.”
Laws of Nature –
Neurobiology
• Behavior
• Addiction
• Recovery
There is more to who we
are and more to why we
do the things we do than
what meets our own
minds.
Lower centers of the
Central Nervous System
can, and routinely do, act
independently of higher
centers.
“New research shows that
emotions have a separate system
of nerve pathways, through the
limbic system to the cortex,
allowing emotional signals to
avoid conscious control.”
-Robert Ornstein, 1991
“…unconscious decisions for action
go on constantly inside the head.”
-Robert Ornstein
“We’re worse off than Freud thought,
because many actions proceed
without our knowing anything about
them.”
-Robert Ornstein
Addictive chemical
substances change the
brain and change behavior.
Addiction
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Positive reinforcement
Negative reinforcement
Conditioning
Altered motivational hierarchies
“…the essence of addiction:
uncontrollable, compulsive
drug seeking and use, even in
the face of negative health and
social consequences.”
- Alan Leshner, PhD
Addiction
• Subjective: Powerlessness (loss
of control)
• Objective: Persistent use
despite adverse consequences
neurobiology of behavior
plus
neurobiology of addiction
equals
neurobiology of powerlessness
“I have a passion for
alcohol.”
- 25 year old female
“Any addict knows, you’ll do
anything to get it.”
- 23 year old male
Pillar of Recovery
It is the nature of addiction that
you can’t trust yourself, so
Keep Your Distance!
Positive interpersonal
relationships change the
brain and change behavior.
27
“Neural repatterning comes
as we enter into and sustain
new types of relationships
that allow us to reregulate
our sense impressions
slowly and over time.”
- Tian Dayton, PhD
“Interpersonal experience shapes the
mind as it continues to develop
throughout the lifespan…
Interactions with the environment,
especially relationships with other
people, directly shape the development
of the brain’s structure and function.”
- Daniel J. Siegel, MD
“ …the amygdala, along with related
areas…, plays a crucial role in
coordinating perceptions with memory
and behavior. These regions are
especially sensitive to social interactions.”
- Daniel J. Siegel, MD
“Our limbic system sets the mind’s
emotional tone and stores our
highly charged emotional
memories.”
- Tian Dayton, PhD
RELAPSE RATE OVER
TIME
10
0
Heroin
Smoking
Abstainers (%)
90
Alcohol
80
70
60
50
40
30
20
0
1
10
2 Weeks
0
2
3
4
5
6
7
Time (Months)
8
9
10
11
12
Kane, MD 2013
“The treatment of
addiction is [still]
people.”
Suggestions Made in Addiction
Treatment
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90 meetings in 90 days
Obtain and use sponsor
Do some Step work
Participate in an aftercare
group
• Participate in counseling/
psychotherapy
Some Recovery Skills/Tips
• Be honest
• Embrace your pain
• Mistrust yourself
• Keep your distance
• Seek people, not
chemicals
• Pay attention!
Pillar of Recovery
It is the nature of recovery that
you can’t do it alone, so
Ask for Help!
Messages for Patients
• The only way out of
embarrassment and shame is
through it.
• Honesty is more important than
image.
• Replace “What can I take?” with
“Who can I talk to?”
The Two Pillars of
Addiction Recovery
• Keep your distance!
(avoid the negatives)
• Ask for help!
(chase the positives)
Motivation
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A state – not a trait
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You are a brain treatment
Professionals Influence
Client Motivation
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Expectations influence outcomes
Differences in drop-out rates
Differences in outcome rates
Simple actions decrease drop out
Empathic professionals have
better outcomes
-Obert and Farentino
Determinants of Client “Change”
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Client factors
Relationship factors
Expectancy & Hope
Model/technique
40%
30%
15%
15%
- Michael Clark, MSW
Counseling Tips
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Be Empathic, Nonconfrontational
Offer Choices
Emphasize Patient’s Responsibility
Convey Confidence In Patient’s
Ability To Change
“…people will forget what
you said, people will forget
what you did, but people
will never forget how you
made them feel.”
- Maya Angelou
Motivational Interviewing
• Elicits Behavior Change
• Respects Autonomy
• Tolerates Patient Ambivalence
• Explores Consequences
- Obert and Farentino
Four Principles of
Motivational Interviewing
• Express empathy
• Develop discrepancy
• Avoid argumentation
• Support self-efficacy
What Motivational Interviewing
is not:
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Giving information
Giving advice
Using logic to persuade
Warning
Confronting
Agreeing
Theresa Moyers, PhD
Style
• Accepting
• Patient• Non-judgmental elicited
• Collaborative
• Empowering
• Ambivalence
• Supportive
normal
• Understanding
• Facilitative
-Obert and Farentino
Building Motivation
• Open-ended questioning
• Affirming
• Reflective listening
• Summarizing
- Obert and Farentino
Reflective Listening: Key-Concepts
• Listen to what patient says and to
what patient means
• Check out assumptions
• Create an environment of empathy
(non judgmental)
• Patient and change agent do not
have to agree
• Be aware of intonation (statement,
not question)
- Obert and Farentino
Providers help ensure recovery
success when they promote
continuity of:
• Healthcare
• Caring
• Accountability
Influences on Cognitive and
Emotional Responses to Pain
Pain
Relevant factors
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• Current context
• Meaning
• Past experiences/
expectations
• Fatigue
• Depression/anxiety
• Distraction
• “Stress”
• Coping techniques
• Addiction
Intensity
Character
Location
Duration
Precipitants
Treatments/
pharmacology
- Adapted from Compton et al. 2009
Contributors to Increased Opioid
Dependence
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Availability
Decreased price/Increased purity
Removal of the injection barrier
Speed of physical dependence
“Truth”
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Unreliability of memory
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Vagaries of psychopathology
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What is historically untrue may
be emotionally true
Conflicts of interest create
distortions
“Turning the Tables”
When the only treatment
that has ever provided a patient relief
happens to be a controlled substance;
much more often than not, the patient’s
complaint is motivated by addiction.
Consider telling the patient that
the more they push for that treatment,
the more concerned you must be
about addiction.
- Adapted from Ted Parran, MD 1997
If you are convinced the only
treatment that can help you
is an addictive medication:
worry and ask for help because
that’s a sign of addiction.
If You Have an Addictive Illness:
Avoid These Medications
• Benzodiazepines
• Opioids
• Barbiturates (esp.
Butalbital)
• Stimulants
• Meprobamate (including
carisoprodol or Soma)
• Alcohol
And Be Cautious Taking Any of
These:
• Antihistamines
• Muscle relaxants
• Sedating medications
(psychiatric and other)
Your Responsibilities With
Prescribers
• Look for alternatives before accepting an
addictive medication
• Tell them you have an addictive disorder even
if the problem was a long time ago
• It’s best to tell them this before you are sick
• Remember you have “no brakes” when it
comes to addictive substances
• Ask the prescriber to set a time limit
• Have someone else control the supply of
medication
Biomedical Ethics:
Basic Principles
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Respect for Autonomy
Nonmaleficence
Beneficence
Justice
Spirituality
Involves Relationships With:
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Self
Other Human Beings
Nature
Creator, God, Higher Power
Patients help ensure recovery
success when they embrace:
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Abstinence
Mental and emotional changes
Spiritual changes
Daily spiritual practice
A Model for Recovery
• Emotional Arousal
• Sense of Hope
• Sense of Mastery
• Love and Humor
- Modified from Jerome Frank, MD
Additional Information
• addictiontreatmentbareessentials.
com
• The Two Pillars of Recovery
• Keep Your Distance!
• Ask for Help!
• Adverse Childhood Experiences
• “Can I have just one?”
• Sedative-hypnotics