Dr. Fred Rotgers Addresses NJ-ACT on New Directions in Treating ‘Addictive’ Behaviors

Part 2: Assessment & Treatment

By Lynn Mollick

Assessment

Begin with inoffensive questions: “Have you ever been a smoker?” “Have you quit?” “How did you do it?” Avoid implying substance use is a problem. Instead ask “When you use this substance, what happens?” Use a functional analysis to guide your assessment. “What are the triggers and effects of using?”

Always ask about alcohol use because it is the most common substance of abuse. One question will accurately identify 85% of abusers: “How many times in the past month have you consumed 5 (4 for women) or more drinks on one occasion?”

What’s a problem and what is not? Ask patients what they think. If you tell patients you disagree, you will activate resistance and perhaps cause patients to drop out. Work with the patient’s goals and see what can be achieved.

Facts to keep in mind: 14 or more drinks per week for men, 9 or more drinks per day for women, 4 or more on a single day for men, or 3 or more on a single day for women are deleterious to health. Male patients who consume more than 6 drinks per day and female patients who consume more than 5 drinks per day may require medical supervision during withdrawal.

Treatment

Dr. Rotgers urged workshop participants to treat addictions using standard CBT techniques: cognitive restructuring, mindfulness, contingency management (use of rewards), executive function training, behavioral couple treatment, development of alternative rewards.

Early in treatment: When patients deny abuse or are just beginning to consider change, use motivational interviewing, i.e. reflective, non-confrontational responses. Wait, and listen for statements indicating that patients want to change. Then ask what patients would like their habit to look like when treatment ends.

Asking patients to self-monitor incidents of abuse often helps them moderate.

Delayed discounting: Compared to non-abusers, patients who abuse are more influenced by the immediate positive effects of substance use than by the delayed negative consequences. Teaching patients who abuse to retain strings of digits in short term memory (as in the digit span subtest on the WAIS) eliminates this difference between abusers and non-abusers.

Support groups: 12-Step programs emphasize abstinence and reliance on a Higher Power. Some patients object to this spiritual emphasis. Other, secular options include:
Smart Recovery – professionally led, abstinence focused, and based on REBT. (SmartRecovery.org)
Moderation Management – led by lay people, seeks to diminish the harm caused by alcohol abuse. (Moderation.org)
LifeRing – attempts to empower the “Sober Self” by building on strengths substance abusers already have. Groups are led by lay people. (LifeRing.org)

Online support is available 24/7 through each of these programs and AA. Dr. Rotgers reported that all of the online programs are excellent.

When patients relapse or continue to abuse: Remember that there are two experts in the room: you and your patient. Review goals and assess their feasibility. Make motivational interventions. Refer to specialists and physicians when you believe they will enhance treatment.

Recommend inpatient care sparingly. It is not effective if patients do not accept a 12 Step approach. Many programs do not use proven medications. And it is not necessarily helpful when patients have relatively stable lives.