Geoff Kane MD MPH HUB Teleconference April 14 2014 Themes Vulnerability Empathy Responsibility Accountability Honesty Feelings Emotions Authenticity Spirituality Outline Recidivism ID: 461871
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Slide1
How The Two Pillars of Recovery Promote Patient Responsibility
Geoff Kane, MD, MPHHUB TeleconferenceApril 14, 2014Slide2
ThemesVulnerability
Empathy ResponsibilityAccountabilityHonestyFeelings / EmotionsAuthenticitySpiritualitySlide3
OutlineRecidivism
Laws of Nature – NeurobiologyTwo Pillars of RecoveryMotivationEliciting StoryDiscussionSlide4
RELAPSE RATE OVER TIME
Abstainers (%)
Time (Months)
0 1 2 3 4 5 6 7 8 9 10 11 12
2 Weeks
100
90
80
70
60
50
40
30
20
10
0
Heroin
Smoking
AlcoholSlide5
Kane, MD 2013
Abstinence results from
Skill Power
not
Will Power
Slide6
Recidivism happens
Two universal mistakesTwo Pillars of RecoverySlide7
Relapse – The Usual MistakesIndividuals take insufficient responsibility for:The details of recovery management
Honest self-disclosureSlide8
Nature: Cause and Effect You either take responsibility
or take nature’s consequences.Slide9
“Addiction is like gravity; it is governed by the laws of nature and never takes
time off.” Slide10
Laws of Nature – Neurobiology Behavior
AddictionRecovery Slide11
There is more to who we are and more to why we do the things we do than what meets our own minds.Slide12
Lower centers of the Central Nervous System can, and routinely do, act independently of higher centers.Slide13Slide14
“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, 1991Slide15
-Robert Ornstein
“…unconscious decisions for action
go on constantly inside the head.”Slide16
-Robert Ornstein
“We’re worse off than Freud thought,
because many actions proceed
without our knowing anything about them.”Slide17Slide18
Addictive chemical substances change the brain and change behavior.Slide19
AddictionPositive reinforcement
Negative reinforcementConditioningAltered motivational hierarchiesSlide20
“…the essence of addiction: uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences.”
- Alan Leshner, PhDSlide21
AddictionSubjective: Powerlessness (loss of control)
Objective: Persistent use despite adverse consequencesSlide22
neurobiology of behavior
plusneurobiology of addiction
equals
neurobiology of powerlessnessSlide23
“I have a passion for alcohol.”
- 25 year old femaleSlide24
“Any addict knows, you’ll do anything to get it.”
- 23 year old maleSlide25
Pillar of RecoveryIt is the nature of addiction that you can’t trust yourself, so
Keep Your Distance!Slide26
Positive interpersonal relationships change the brain and change behavior.Slide27
27Slide28Slide29
“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, PhDSlide30
“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, MDSlide31
“ …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, MDSlide32
“Our limbic system sets the mind’s
emotional tone and stores our
highly charged emotional memories.”
- Tian Dayton, PhDSlide33
RELAPSE RATE OVER TIME
Abstainers (%)
Time (Months)
0 1 2 3 4 5 6 7 8 9 10 11 12
2 Weeks
100
90
80
70
60
50
40
30
20
10
0
Heroin
Smoking
Alcohol
Kane, MD 2013Slide34
“The treatment of addiction is [still] people.” Slide35
Suggestions Made in Addiction Treatment90 meetings in 90 daysObtain and use sponsor
Do some Step workParticipate in an aftercare groupParticipate in counseling/ psychotherapySlide36
Some Recovery Skills/TipsBe honestEmbrace your painMistrust yourselfKeep your distance
Seek people, not chemicalsPay attention!Slide37
Pillar of RecoveryIt is the nature of recovery that you can’t do it alone, so
Ask for Help!Slide38
Messages for PatientsThe 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?”Slide39
The Two Pillars of Addiction RecoveryKeep your distance!
(avoid the negatives)Ask for help! (chase the positives)Slide40
MotivationA state – not a traitYou
are a brain treatmentSlide41
Professionals Influence Client MotivationExpectations influence outcomes
Differences in drop-out ratesDifferences in outcome ratesSimple actions decrease drop outEmpathic professionals have better outcomes
-Obert and FarentinoSlide42
Determinants of Client “Change”Client factors 40%Relationship factors 30%Expectancy & Hope 15%
Model/technique 15%- Michael Clark, MSWSlide43
Counseling TipsBe Empathic, Nonconfrontational
Offer ChoicesEmphasize Patient’s ResponsibilityConvey Confidence In Patient’s Ability To ChangeSlide44
“…people will forget what
you said, people will forget
what you did, but people
will never forget how you
made them feel.”
- Maya AngelouSlide45Slide46
Motivational InterviewingElicits Behavior ChangeRespects AutonomyTolerates Patient Ambivalence
Explores Consequences- Obert and FarentinoSlide47
Four Principles of Motivational InterviewingExpress empathyDevelop discrepancyAvoid argumentation
Support self-efficacySlide48
What Motivational Interviewing is not:Giving informationGiving advice
Using logic to persuadeWarningConfrontingAgreeingTheresa Moyers, PhDSlide49
StyleAcceptingNon-judgmentalEmpowering
SupportiveUnderstandingPatient- elicitedCollaborativeAmbivalence normalFacilitative-Obert and FarentinoSlide50
Building MotivationOpen-ended questioningAffirmingReflective listening
Summarizing- Obert and FarentinoSlide51
Reflective Listening: Key-ConceptsListen to what patient says and to what patient means
Check out assumptionsCreate an environment of empathy (non judgmental)Patient and change agent do not have to agreeBe aware of intonation (statement, not question)
- Obert and FarentinoSlide52Slide53
Providers help ensure recovery success when they promote continuity of:Healthcare
CaringAccountabilitySlide54Slide55
Influences on Cognitive and Emotional Responses to Pain Pain
IntensityCharacterLocationDurationPrecipitantsTreatments/ pharmacology
Relevant factors
Current context
Meaning
Past experiences/
expectations
Fatigue
Depression/anxiety
Distraction
“Stress”
Coping techniques
Addiction- Adapted from Compton et al. 2009Slide56
Contributors to Increased Opioid DependenceAvailabilityDecreased price/Increased purityRemoval of the injection barrier
Speed of physical dependenceSlide57
“Truth”
Unreliability of memory
Vagaries of psychopathology
What is historically untrue may
be emotionally true
Conflicts of interest create
distortions Slide58
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.
“Turning the Tables”
- Adapted from Ted Parran, MD 1997Slide59
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.Slide60
If You Have an Addictive Illness: Avoid These Medications
BenzodiazepinesOpioidsBarbiturates (esp. Butalbital)StimulantsMeprobamate (including carisoprodol or Soma)AlcoholSlide61
And Be Cautious Taking Any of These:
AntihistaminesMuscle relaxantsSedating medications (psychiatric and other) Slide62
Your Responsibilities With PrescribersLook for alternatives before accepting an addictive medication
Tell them you have an addictive disorder even if the problem was a long time agoIt’s best to tell them this before you are sickRemember 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 medicationSlide63Slide64
Biomedical Ethics:Basic PrinciplesRespect for Autonomy
NonmaleficenceBeneficenceJusticeSlide65Slide66
SpiritualityInvolves Relationships With:SelfOther Human BeingsNature
Creator, God, Higher PowerSlide67
Patients help ensure recovery success when they embrace:Abstinence
Mental and emotional changesSpiritual changesDaily spiritual practiceSlide68
A Model for RecoveryEmotional ArousalSense of HopeSense of Mastery
Love and Humor- Modified from Jerome Frank, MDSlide69
Additional Informationaddictiontreatmentbareessentials.com
The Two Pillars of RecoveryKeep Your Distance!Ask for Help!Adverse Childhood Experiences
“Can I have just one?”
Sedative-hypnotics