Motivational Interviewing (MI) is a brief treatment developed by Bill Miller and Stephen Rollnick, initially as an approach for helping clients work with alcohol problems. Clinicians now use MI to help people deal with a variety of issues, as research has shown it to be broadly effective. Aside from specific strategies and techniques of this therapeutic approach, at its heart MI is a way of working with clients in a collaborative, respectful, and empathic manner. MI values clients’ autonomy to make wise choices, and helps clients deal with their natural ambivalence about making changes. The “spirit” of the motivational approach runs throughout our work at CMC.
You can read more about Motivational Interviewing here.
The Community Reinforcement Approach (CRA) has established a track record of success with individuals and their families. CRA takes each person’s life circumstances into account as an active part of change. Clients come to understand their behavior in the context of their entire lives, including their social support network, triggers to use, motivations for changing, and need for a life that is rewarding—rewarding enough to make giving up old behaviors worthwhile.
The motivational and cognitive-behavioral bases of CRA together serve as the basis for all treatment at CMC. In this way, CRA is not a separate track at CMC, rather a part of all the work that we do.
Using the core strategies in CRA (Community Reinforcement Approach) Drs. Robert J. Meyers
and Jane Ellen Smith
of the University of New Mexico developed a program that teaches families how to positively impact a loved one who is struggling with a substance use problem. The CRAFT program avoids both detachment and confrontation, the respective strategies of Al-Anon ( a Twelve Step-based self-help approach), and traditional (Johnson Institute-style) interventions. While all three approaches have been found to improve family members’ functioning and relationship satisfaction, CRAFT has proven to be significantly more effective in engaging loved ones in comparison to the Johnson Institute Intervention or Al-Anon/Nar-Anon facilitation therapy.
Community Reinforcement and Family Training (CRAFT) teaches family and friends effective strategies for helping their loved one to change and for feeling better themselves. CRAFT works to affect the loved one’s behavior by changing the way the family interacts with him or her. It is designed to accomplish three goals:
- When a loved one is abusing substances and refusing to get help, CRAFT helps families move their loved one toward treatment.
- On its own, CRAFT helps reduce the loved one’s alcohol and drug use, whether or not the loved one has engaged in treatment yet.
- CRAFT improves the lives of the concerned family and friends.
CRAFT is a skills-based program that impacts families in multiple areas of their lives, including self-care, pleasurable activities, problem solving, and goal setting. At the same time, CRAFT addresses their loved one’s resistance to change. CRAFT teaches families behavioral and motivational strategies for interacting with their loved one. Participants learn, for example, the power of positive reinforcement for positive behavior (and of withdrawing it for unwanted behavior), and how to use positive communication skills to improve interactions and maximize their influence.
Specifically, CRAFT teaches several skills, including:
- Understanding a loved one’s triggers to use substances
- Positive communication strategies
- Positive reinforcement strategies – rewarding non-using behavior
- Domestic violence precautions
- Getting a loved one to accept help
In multiple studies, across a range of substances and settings, CRAFT engaged on average 7 out of 10 reluctant loved ones into treatment.
Dialectical Behavior Theray (DBT) is a well- established evidence based treatment that is a combination of cognitive-behavioral therapies and mindfulness training that helps clients learn to modulate behavior and regulate emotion. Specifically, DBT targets behaviors that contribute to emotional pain and interpersonal difficulties and teaches skills to manage these problems without resorting to self-defeating behaviors.
DBT skills training encompasses four areas: distress tolerance, emotion regulation, interpersonal effectiveness, and mindfulness.
Prolonged Exposure (PE) is a time-limited, evidenced based treatment that aims to reduce your anxiety and improve your life. Treatment consists of approximately 8-15, 90 minute sessions, involving psychoeduation, breathing re-training, ongoing out of session practice, and in vivo and imaginal exposure. PE will helps clients to stop avoiding trauma reminders and will help you to approach the things that scare you. This is done in two ways
- In vivo exposure will help you to gain experience confronting situations and memories you have previously worked to avoid, outside of sessions. You can learn that you can actually tolerate the situations and the feelings you experience, and nothing bad actually happens to you. In fact, the more you confront these situations, your anxiety will decrease, a process called habituation. Further, you will gain a new sense of competence and confidence in your life and experience new learning and a shift in perspective related to situations which were previously considered unsafe due to trauma reminders.
- Through imaginal exposure, (repeatedly revisiting the traumatic memory) in session, you will come to realize that your trauma was a specific event occurring in a specific time and place. This realization will help change any beliefs that you have that the entire world is a dangerous place and that you are incompetent to deal with it. In addition, you will learn that you can tolerate the anxiety you experience when remembering the traumatic memory and that this anxiety, with repetition, will decrease. You will also gain new perspective on the memory and learn that although the memories can be very scary, the memories are not dangerous.
Skills Training in Affect Regulation (STAIR) is an evidence based, time limited treatment, which also addresses PTSD and complex trauma. STAIR focuses on teaching people skills, which a traumatized individual might not have learned due to early traumatic experiences, or skills which may have diminished due to prolonged, or chronic trauma in later life, (Cloitre).
STAIR is a two part treatment, each phase consisting of approximately 8 sessions. The first phase of treatment focuses on learning skills for handling negative feelings and managing distress and developing emotional awareness. Phase 1 also prepares you to work effectively in the more emotionally intense Phase II, which involves discussion and analysis of painful memories of childhood trauma.
The goal of Phase II, or Narrative Story Telling (NST), is to organize your memories of trauma and resolve your feelings about them, so that you control the memories rather than the memories’ controlling you. In addition, the process of describing your past is a means by which you will be able to identify beliefs about yourself and patterns of relating that might have been adaptive in abuse circumstances, but no longer are adaptive and need to be changed.
The skills training from Phase I will help you leave behind old patterns of functioning and develop interpersonal behaviors and emotion management strategies that are consistent with your current life goals. We offer both group and individual STAIR services.
Approximately thirty percent of Americans experience some symptoms of insomnia, including difficulty falling asleep or staying asleep. Difficulty being able to fall asleep or stay asleep is often a cause of (or a reason to maintain) substance abuse in the first place. When compared to patients without insomnia, patients with insomnia have more difficulty maintaining sleep, are more likely to report frequently using alcohol in order to sleep, and have more severe alcohol dependence and depression. While insomnia often has a role in substance use problems, Cognitive Behavioral Treatment for Insomnia (CBT-I) is for anyone who suffers from insomnia. The benefits of better sleep include decreased anxiety, increased mood, and increased energy.
The most common treatment for insomnia is sleep medication, such as Ambien and Lunesta. These medications do help to initiate sleep and often result in people sleeping through the night, but can have side effects such as feeling “hung over” in the morning, sleep walking, sleep driving, and sleep eating. Furthermore, sleep medications are often abused and are therefore not appropriate for patients with a substance abuse history.
CBT-I is an empirically supported, sleep-medication-free treatment. It has repeatedly proven to be the most effective treatment for chronic insomnia, equal to sleep medications in the short term and more effective in the long term. Combining the techniques of sleep restriction, stimulus control, cognitive corrections, and relaxation training, CBT-I’s six-to-twelve-week protocol works to change sleep habits and correct common misconceptions about sleep that help to maintain the insomnia.
- Sleep restriction is a technique for matching up sleep ability with sleep opportunity. Clients collect sleep data and, with their CBT-I therapist, determine a bedtime, wake-time, and rules around sleep that increase the pressure to sleep and decrease time spent awake in bed.
- Stimulus control is used to change sleep-destructing behaviors that have developed from insomnia, behaviors like watching TV in bed, using a computer in bed, and otherwise creating a whole world in the bedroom, naturally, since spending so much time awake in bed. Stimulus control means to break those habits and make the bedroom a place that stimulates sleep.
- There are many unhelpful myths about sleep. For example, a person who believes he must get eight hours of sleep each night may worry about getting less, which worrying makes it harder for him to sleep. Correcting such cognitive distortions and replacing them with facts (many people function very well on less than eight hours of sleep) reduces anxiety and stress that prevent sleep.
- Relaxation training helps to quiet the body and mind. It is particularly helpful for people who have a lower threshold for anxiety and worry and find themselves unable to stop racing thoughts at night. Relaxation training includes progressive muscle relaxation and breathing and mindfulness techniques.
Medications can be a useful part of treatment for some people with substance use or compulsive behavior issues. As with all other aspects of treatment, the degree of usefulness, if any, depends on the particular person. Considerations would include:
- Are there other emotional/psychiatric issues (such as depression, anxiety, mood swings, ADHD) that could be well-managed with medication?
- Are there “addiction” medications (those developed specifically for help with certain substances of abuse) that could be useful, such as disulfiram (Antabuse) or naltrexone for alcohol issues, or buprenorphine (Suboxone) for opiate use issues?
It is not helpful to ignore these adjuncts to treatment. It can, in fact, be harmful. When appropriate, CMC refers clients to outside psychiatrists who specialize in addiction issues for evaluation.