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SAN FRANCISCO – Recent studies show that direct behavioral incentives are effective in treating substance abuse that is comorbid with psychiatric disorders. But contingency management can be difficult to implement in real-world settings, Dr. Steven L. Batki said at the annual meeting of the American Academy of Clinical Psychiatrists.
Motivational enhancement therapy, which is based on the Prochaska and DiClemente stages of change model (J. Consulting Clin. Psychol. 1983;51:390–5), may be a better fit to everyday clinical practice, said Dr. Batki, professor of psychiatry and behavioral sciences at the State University of New York, Syracuse.
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“Many of us are old enough to remember the old token economy in schizophrenia, where you give direct behavioral incentives for behaviors,” Dr. Batki said. “This stuff works.” The problem is that in most institutional settings, it is difficult to bring the powers that be around to the notion of paying people not to use drugs.
Furthermore, contingency management works only if the target behavior is monitored frequently, with breath tests for alcohol or urine tests for drugs, for instance.
The “fishbowl” system, a type of contingency management, has actually demonstrated its effectiveness in substance abuse disorders, and it has the added advantage of being relatively inexpensive for the institution to implement. In this system, patients get the privilege of drawing a random card from a fishbowl when they have a negative urine test or have attended a 12-step meeting, for example.
Half the cards are winners. Patients have a 50% chance of winning a $1 prize, 1 chance in 16 of winning a $20 prize, and 1 chance in 500 of winning a $100 prize. Studies of the fishbowl system in alcohol abusers show a significant increase in time to the first heavy drinking episode, and studies with cocaine abusers show a significantly longer duration of cocaine abstinence than when control treatments are used.
In an outpatient setting, however, motivational enhancement therapy is more practical. It's based on several assumptions: that substance use disorders are common, that change often takes a long time, that the pace of change is variable, that knowledge is usually not sufficient to motivate change, and that relapse is the norm.
The therapy and the motivational interviewing that forms its basic technique require the therapist to recognize what stage the patient is in, in terms of readiness to change. If the patient is in the “precontemplation” stage, where he or she isn't even considering changing his drug or alcohol use, it's pointless for the therapist to encourage the patient to develop specific plans to change. Instead, the therapist's objectives are to help the patient identify his or her goals, provide information about the substance use, and bolster the patient's self-efficacy.
“The bottom line is if you have somebody come into your office who has no intention of stopping drug use, it's probably a waste of time to refer [him or her] to a residential treatment program,” Dr. Batki said. “Just talk about, 'Hey, what are you getting out of drugs? Are you concerned by the negatives? What are the positives for you? How do you balance those?'”
If the patient has reached the “contemplation” stage, where he or she is considering change but remains ambivalent, the therapist's objective is to help the patient recognize the discrepancy between goals and behavior and to elicit self-motivational statements.
When the patient reaches the “determination” stage, where he or she is committed to change, the therapist should strengthen that commitment and help the patient plan specific strategies.
Then, when the patient has reached the “action” stage, where he or she is actively involved in implementing these plans, the therapist's job is to identify and manage new barriers that may arise and to keep alert for relapse or impending relapse.
The next stage is “maintenance,” where the patient has made the change, and the therapist's objective is to ensure the stability of the change and to foster the patient's personal development. If the patient enters the “relapse” stage, where undesirable behaviors have returned, the therapist must identify the relapse when it occurs, reestablish self-efficacy and commitment, and help the patient develop behavioral strategies.
Finally, if the patient's change is very stable, he or she is said to have entered the “termination” stage, and the therapist should assure the patient of the stability of that change.
Throughout all of this, the therapist should give advice only when the patient is receptive and should target that advice to the patient's state of change. The therapist should also recognize that it's up to the individual whether to change and how to change. The therapist should also help individuals decrease the desirability of the substance abuse and help them identify other behaviors to replace the positive aspects of the substance abuse.
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SERIES INFO
Genre : Comedy Drama
Stars : Elaine Cassidy, Alexandra Roach, Colin Salmon, Will Mellor, Paul Ritter, Joanna Scanlan, Ste Johnston, Tom Varey, Saira Choudhry, Neet Mohan
Series Plot : No Offence follows the tough but big-hearted bobbies who go above and beyond to bring down the criminal rabble in a crumbling cop-shop. Keeping these streets clean is a Herculean task, enough to demoralize even the keenest rookie - but there's a reason why this hotchpotch of committed cops are on this force, on this side of town. Drug labs, arsonists, neo-Nazis and notorious murderers are all in a day's work for this close-knit team, led by the dizzyingly capable but unquestionably unhinged DI Vivienne Deering. Flanked by her right-hand women - the compassionate but impulsive DC Dinah Kowalska and DS Joy Freers - Deering and her team must crack this case by whatever unconventional means possible.
EPISODE INFO
Title : Episode 4
Airdate : 2018-10-04
Episode plot : Paul Abbott's award-winning drama returns for a third series and sees DI Viv Deering and the Friday Street team face off against their most formidable antagonist yet: the far-right.
MEDIAINFO
Container = Matroska (mkv)
Duration = 00:45:41.712
Filesize = 842 MiB
--ViDEO
Codec info = AVC [email protected] VMPEG4/ISO/AVC
Resolution = 1280x720
Display AR = 1.778 16:9
Bitrate = 2 332 kb/s
Framerate = CFR 25.000
Color space = YUV
Chroma subsampling = 4:2:0
Encoder = x264 - core 155 r2901 7d0ff22
--AUDiO
Codec info = MPEG Audio Layer 2 AMPEG/L2
Channels = 2
Bitrate = CBR 192 kb/s
Samplerate = 48.0 kHz
Language = English
SCREENSHOTS
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