[PAPER
3:
PSYCHOTHERAPY–
OTHER
THERAPIES]
1
Treating substance use
Transtheoretical Model
The Transtheoretical Model (TTM) was developed by Prochaska and DiClemente
(1982). This was developed largely in response to increasing divergence in the
practice of psychotherapy and the authors attempted a (transtheoretical)
synthesis among the various therapeutic systems. They identified five common
processes of change from analyzing 18 psychotherapy models. These processes
were
(1) Consciousness raising – helping the patient gather information about self and
the problem
(2) Choosing – increasing awareness of healthy alternatives,
(3) Catharsis – emotional expression of the problem behaviour and the process of
change,
(4) Conditional stimuli – includes stimulus control and counterconditioning,
a. Stimulus control: Avoidance of stimuli associated with the problem
behaviour and the operant extinction cueing effect of the stimulus on
behaviour.
b. Counterconditioning: Training an alternative, healthier response to the
cue stimuli.
(5) Contingency control: Positive reinforcement from others and self appraisal and
improving self efficacy by self reinforcement.
From these five processes of change, Prochaska and DiClemente identified six
stages of change. These are (1) precontemplation, (2) contemplation, (3)
Preparation, (4) action, (5) maintenance, and (6) relapse. In the
precontemplation stage a person is not even considering changing his or her
behaviour, does not see the behaviour as a problem, minimizes and denies
associated risks, and avoids information to the contrary. In the contemplation
stage, the person has become aware of why the behaviour is a problem but is
ambivalent about changing, and likely sees equal or more benefits than costs
from the behaviour. During preparation, the person has made a decision to
change, and is planning a strategy for change, but has not yet taken action. In
action, the person has implemented a plan and is changing the behaviour. In
maintenance, the person has been able to sustain the change and avoid reverting
to problem behaviour for a significant period of time. In successful patients, this
usually is the last stage that continues lifelong. In relapse, the person does revert
to problem behaviour, ‘back to square one’ – this does not happen to everyone.
These stages are not linear in sequence but rather cyclical, in that a person can
relapse and reenter at a later stage such as preparation.
The stages do not operate in an invariant sequence (unlike Piaget’s models).
Each stage can be moved into back and forth (reversibility).
The stages are not qualitatively different.
Motivational Interviewing
Motivational Interviewing (Miller & Rollnick, 1991) is often used together with
TTM and stages of change. In line with Roger’s client centred therapy, Miller and
Rollnick did extensive work with substance-abusing patients and developed
motivational interviewing. The major principles are
1. It is more effective to work collaboratively with patients rather than directly
challenge them to change their behaviour.
2. Resolving the ambivalence towards changing can increase intrinsic motivation to
change – this increase in motivation is the main goal of motivational interview.
3. A change coming from the patient is more powerful than that prescribed by a
therapist.
© SPMM COURSE 2010
, [PAPER
3:
PSYCHOTHERAPY–
OTHER
THERAPIES]
2
Note that psychotherapies such as CBT assume that a patient is already in an
action stage of change and ready for treatment; motivational interviewing uses
TTM and evaluates the readiness to change before inducing an action.
There are five general principles of motivational interviewing: (1) express
empathy, (2) develop discrepancy, (3) avoid argumentation, (4) roll with
resistance, and (5) support self-efficacy.
Behavioural Couple Therapy
• A specific intervention for alcoholism.
It works directly to increase relationship factors conducive to abstinence.
• It assumes that family members can reward abstinence
• Patient and the spouse are seen together in BCT for 15 to 20 outpatient
couple sessions over five to six months. The couple starts BCT soon after
the substance user seeks help.
• The therapist arranges a daily "sobriety contract" in which the patient
states his or her intent not to drink or use drugs that day (in the tradition
of one day at a time), and the spouse expresses support for the patient's
efforts to stay abstinent.
• Witnessed and reinforced daily disulfiram ingestion may also be a part of
BCT.
• The spouse records the performance of the daily contract on a calendar
provided by the therapist.
• Both partners agree not to discuss past drinking or fears about future
drinking at home to prevent substance-related conflicts that can trigger
relapse. May include 12-step meetings or urine drug screens,
• BCT increases positive feelings and constructive communication e.g.
"Catch Your Partner Doing Something Nice" is a part of BCT that asks
spouses to notice and acknowledge one pleasing behaviour performed by
their partner every day.
• Teaching communication skills may be a part of BCT.
• Relapse prevention is the final activity of BCT. A continuing recovery plan
is formulated and reviewed at quarterly follow-up visits for an additional
two years.
• Evidence base exists to support BCT.
• In heterosexual couples in which men are entering outpatient treatment
for alcoholism or other drug abuse, behavioural couples therapy was more
effective than individual based therapy for improving the psychosocial
functioning of their children
Treasure, J. Motivational interviewing. Advances in Psychiatric Treatment (2004) 10: 331-
337
Kelley ML, Fals-Stewart W.Couples- versus individual-based therapy for alcohol and drug
abuse: effects on children’s psychosocial functioning.J Consult Clin Psychol 2002;70:417–2
© SPMM COURSE 2010
3:
PSYCHOTHERAPY–
OTHER
THERAPIES]
1
Treating substance use
Transtheoretical Model
The Transtheoretical Model (TTM) was developed by Prochaska and DiClemente
(1982). This was developed largely in response to increasing divergence in the
practice of psychotherapy and the authors attempted a (transtheoretical)
synthesis among the various therapeutic systems. They identified five common
processes of change from analyzing 18 psychotherapy models. These processes
were
(1) Consciousness raising – helping the patient gather information about self and
the problem
(2) Choosing – increasing awareness of healthy alternatives,
(3) Catharsis – emotional expression of the problem behaviour and the process of
change,
(4) Conditional stimuli – includes stimulus control and counterconditioning,
a. Stimulus control: Avoidance of stimuli associated with the problem
behaviour and the operant extinction cueing effect of the stimulus on
behaviour.
b. Counterconditioning: Training an alternative, healthier response to the
cue stimuli.
(5) Contingency control: Positive reinforcement from others and self appraisal and
improving self efficacy by self reinforcement.
From these five processes of change, Prochaska and DiClemente identified six
stages of change. These are (1) precontemplation, (2) contemplation, (3)
Preparation, (4) action, (5) maintenance, and (6) relapse. In the
precontemplation stage a person is not even considering changing his or her
behaviour, does not see the behaviour as a problem, minimizes and denies
associated risks, and avoids information to the contrary. In the contemplation
stage, the person has become aware of why the behaviour is a problem but is
ambivalent about changing, and likely sees equal or more benefits than costs
from the behaviour. During preparation, the person has made a decision to
change, and is planning a strategy for change, but has not yet taken action. In
action, the person has implemented a plan and is changing the behaviour. In
maintenance, the person has been able to sustain the change and avoid reverting
to problem behaviour for a significant period of time. In successful patients, this
usually is the last stage that continues lifelong. In relapse, the person does revert
to problem behaviour, ‘back to square one’ – this does not happen to everyone.
These stages are not linear in sequence but rather cyclical, in that a person can
relapse and reenter at a later stage such as preparation.
The stages do not operate in an invariant sequence (unlike Piaget’s models).
Each stage can be moved into back and forth (reversibility).
The stages are not qualitatively different.
Motivational Interviewing
Motivational Interviewing (Miller & Rollnick, 1991) is often used together with
TTM and stages of change. In line with Roger’s client centred therapy, Miller and
Rollnick did extensive work with substance-abusing patients and developed
motivational interviewing. The major principles are
1. It is more effective to work collaboratively with patients rather than directly
challenge them to change their behaviour.
2. Resolving the ambivalence towards changing can increase intrinsic motivation to
change – this increase in motivation is the main goal of motivational interview.
3. A change coming from the patient is more powerful than that prescribed by a
therapist.
© SPMM COURSE 2010
, [PAPER
3:
PSYCHOTHERAPY–
OTHER
THERAPIES]
2
Note that psychotherapies such as CBT assume that a patient is already in an
action stage of change and ready for treatment; motivational interviewing uses
TTM and evaluates the readiness to change before inducing an action.
There are five general principles of motivational interviewing: (1) express
empathy, (2) develop discrepancy, (3) avoid argumentation, (4) roll with
resistance, and (5) support self-efficacy.
Behavioural Couple Therapy
• A specific intervention for alcoholism.
It works directly to increase relationship factors conducive to abstinence.
• It assumes that family members can reward abstinence
• Patient and the spouse are seen together in BCT for 15 to 20 outpatient
couple sessions over five to six months. The couple starts BCT soon after
the substance user seeks help.
• The therapist arranges a daily "sobriety contract" in which the patient
states his or her intent not to drink or use drugs that day (in the tradition
of one day at a time), and the spouse expresses support for the patient's
efforts to stay abstinent.
• Witnessed and reinforced daily disulfiram ingestion may also be a part of
BCT.
• The spouse records the performance of the daily contract on a calendar
provided by the therapist.
• Both partners agree not to discuss past drinking or fears about future
drinking at home to prevent substance-related conflicts that can trigger
relapse. May include 12-step meetings or urine drug screens,
• BCT increases positive feelings and constructive communication e.g.
"Catch Your Partner Doing Something Nice" is a part of BCT that asks
spouses to notice and acknowledge one pleasing behaviour performed by
their partner every day.
• Teaching communication skills may be a part of BCT.
• Relapse prevention is the final activity of BCT. A continuing recovery plan
is formulated and reviewed at quarterly follow-up visits for an additional
two years.
• Evidence base exists to support BCT.
• In heterosexual couples in which men are entering outpatient treatment
for alcoholism or other drug abuse, behavioural couples therapy was more
effective than individual based therapy for improving the psychosocial
functioning of their children
Treasure, J. Motivational interviewing. Advances in Psychiatric Treatment (2004) 10: 331-
337
Kelley ML, Fals-Stewart W.Couples- versus individual-based therapy for alcohol and drug
abuse: effects on children’s psychosocial functioning.J Consult Clin Psychol 2002;70:417–2
© SPMM COURSE 2010
