Substance abuse- Theory and Practice.

Substance
Abuse- Theory
and Practice
AARADHANA REDDY
COUNSELLING PSYCHOLOGIST

Overview
Introduction
• Definition
• Diagnosis
• List of Substances
• Scales to Identify Substance Abuse in Clinical
Interview
• Risk Factors
Theory and Practice
• Transtheoretical Model of Change
• Cognitive Behavior Therapy
• Managing Withdrawal Symptoms

Substance use: It’s the use of substances to socilaize or experience its high or effects. It might
not be abusive. But it might lead to being harmful to oneself or others.
For example- Driving Under Influence ,Smoking or consumption of alcohol by women when
pregnant.
Substance Abuse: Substance abuse refers to the harmful or hazardous use of psychoactive
substances, including alcohol and illicit drugs. Dependence Syndrome: Psychoactive
substance use can lead to dependence syndrome - a cluster of behavioral, cognitive, and
physiological phenomena that develop after repeated substance use
Definition

Diagnosis
Substance Abuse: Use of alcohol or other drugs includes
at least one of these factors in the last 12 months:
-Continued use despite having persistent or recurrent social
or interpersonal problems caused or exacerbated by the
substance
Recurrent use leading to failure in fulfilling obligations at
work, home or school
-Recurrent use in situations that are physically hazardous
-Recurrent substance related legal problems

Diagnosis-
Substance
Dependence
Also known as addiction, a pattern of use that results in three or more of the following symptoms in a 12
month period:
-Tolerance, as defined by either of the following: a. A need for markedly increased amounts of alcohol to
achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of alcohol.
-Withdrawal: a. experiencing a range physical and psychological symptoms when the substance is not used; Ex:
tremors, sweating, psychomotor agitation, anxiety, seizures and in severe cases even hallucinations.
b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal
symptoms.
-Substance is taken in larger amounts and over a longer periods than intended
-Persistent desire or unsuccessful efforts to cut down or control substance use
A great deal of time or effort is spent in activities related to obtaining the substance, use of the substance or
recovering from its effects
Important social, occupational or recreational activities are given up or reduced because of the substance use
-The consumption of substance is continued despite knowledge of persistent or recurrent physical or
psychological problems caused or exacerbated by the substance
Important social, occupational or recreational activities are given up or reduced because of the substance use
-The consumption of substance is continued despite knowledge of persistent or recurrent physical or
psychological problems caused or exacerbated by the substance

Types of
Substances-
Alcohol
Alcohol (chemical name- ethanol)- used in a wide range of drinks- beer, wine,
whiskey etc. One of the oldest recreational substance. Diagnostic criteria of alcohol
intoxication are:
A. Recent ingestion of alcohol.
B. Clinically significant problematic behavioral or psychological changes (e.g.,
inappropriate sexual or aggressive behavior, mood lability, impaired judgment) that
developed during, or shortly after, alcohol ingestion.
C. One (or more) of the following signs or symptoms developing during, or shortly
after, alcohol use: 1. Slurred speech. 2. Incoordination. 3. Unsteady gait. 4.
Nystagmus. 5. Impairment in attention or memory. 6. Stupor or coma.
D. The signs or symptoms are not attributable to another medical condition and are
not better explained by another mental disorder, including intoxication with another
substance.

Types of
Substances-
Opioids
Have been used for pain treatment for thousands of
years.
The Sumerians in Mesopotamia were among the first people
identified to have cultivated the poppy plant around 3400 BC.
In the 1800s, through advances in biochemical methods,
morphine and codeine were isolated from opium
In 1803 morphine, an opioid analgesic, was extracted from
opium by Friedrich Serturner of Germany.
The first semisynthetic opium derivative—diacetylmorphine
or heroin in pharmacological studies, proved to be more
effective than morphine or codeine. The Bayer Company
started the production of heroin in 1898 on a commercial
scale. The first clinical results were so promising that heroin
was considered a wonder drug. In the early 20th century they
realized the addictive effects of heroin and morphine.
Continued opioid misuse can result in syndromes of abuse
and dependence and cause disturbances in mood, behaviour,
and cognition.
Heroin is most frequently associated with abuse and
dependence
The above picture shows the pod portion of the plant
only which can produce opium alkaloids. The skin of
the pod encloses the wall of the pod ovary.- which has
three layers- outer, middle and inner layers. The plant's
latex (opium) is produced within the ovary wall and
drains into the middle layer through a system of
vessels and tubes within the pod. The cells of the
middle layer secrete more than 95 percent of the
opium when the pod is scored and harvested.

Types of
Substances-
Cannabis
Cannabis is the most widely used ‘illegal’ drug in the world,
obtained from the plant Cannabis sativa. Most common cannabis
preparations are marijuana, hashish, and hash oil
Delta-9-tetrahydrocannabinol (THC) is the cannabinoid that is
primarily responsible for the psychoactive effects of cannabis
About 147 million people, 2.5% of the world population,
consume cannabis
Acute health effects of cannabis use:
Cannabis impairs cognitive development (capabilities of learning),
including associative processes; free recall
Cannabis impairs psychomotor performance in a wide variety of
tasks, such as motor coordination, divided attention, and operative
tasks of many type
Chronic health effects of cannabis use
cannabis use can exacerbate schizophrenia in affected
individuals;
•heavy cannabis consumption associated with a higher
prevalence of symptoms of chronic bronchitis and a higher
incidence of acute bronchitis.
•cannabis used during pregnancy is associated with impaired
fetal development leading to a reduction in birth weight
Hashish, which is more potent
than marijuana, is made from the
resin of the cannabis flowers.
THC is found in resin produced
by the leaves and buds primarily
of the female cannabis plant.

Types of Substances- Cocaine
Cocaine is an addictive drug made from the leaves of the Erythroxylon coca plant native to South America.
Its in the form of a white powder very fine like cornstarch. It can also be mixed with other drugs like opioids etc.
The method of use is usually through snorting, inhaled as smoke or injected into the vein
It can also be made into a rock crystal, heat and then inhale the smoke. Its called crack cocaine and freebase
cocaine.
Highly addictive due to its effect on the reward pathway, after a short use there is a very high risk of dependence.
It increases levels of dopamine and stops it from being recycled; causing large amounts of dopamine to get built
up. This results in reinforcing causing to take the drug again. The reward circuit gets used to the excess levels of
dopamine and becoming less sensitive to it; leading to taking larger amounts of cocaine to achieve the high
leading to dependence.
Effects might include loss of contact with reality, intense feeling of happiness or agitation, paranoia. Large
amounts can lead to unpredictive violent behaviour.
Long term use is associated with depression, exhaustion, insomnia, psychosis etc. Some health effects are:
•snorting: loss of smell, nosebleeds, frequent runny nose, and problems with swallowing
•smoking: cough, asthma, respiratory distress, and higher risk of infections like pneumonia
•consuming by mouth: severe bowel decay from reduced blood flow
•needle injection: higher risk for contracting HIV, hepatitis C, and other bloodborne diseases, skin or soft tissue
infections, as well as scarring or collapsed veins

• A hallucinogenic drug primarily alters perception,
cognition, and mood with relatively minimal effects on
memory and orientation
• Lysergic acid diethylamide (LSD), dimethyltryptamine
(DMT), phenethylamines like mescaline and 3,4-
methylenedioxymethamphetamine (MDMA or Ecstasy)
• -The drug user hears, sees, feels, smells, or perceives things
not actually in the environment, and is unaware that what
he or she is experiencing is, in fact, not real
• The picture shows LSD soaked papers which are squared, they
are called blotters. They are put on the tongue to feel the effects.
Types of Substances-
Hallucinogens

Types of Substances- Stimulants
Drugs that tend to increase the activity of CNS and the body
-These tend to have pleasurable and invigorating effect
Amphetamine
It’s a drug used in the treatment for ADHD and it is found in other medications such as Adderall, Dexedrine etc.
It is also used as performance and cognitive enhancer
Its method of use is in pills form, though some to get an immediate intense high may crush it or inject it through
dissolving in water.
Some physical and psychological changes caused by its abuse are:
•Increased heart rate and blood pressure
•Decreased appetite and weight loss
•Insomnia
•Mood swings
•Aggression
•Paranoia and anxiety
•Visual, auditory, or tactile hallucinations
These effects on the body when used in the long-term become health hazards with cardiovascular issues,
depression, insomnia etc.

Types of Substances- Stimulants
Caffeine
Naturally found in coffee, tea, cocoa and chocolate
It is found to be included in soft drinks and in larger amounts in energy drinks
20-200 or some say even 400 mg per day is generally a safe amount and can produce some pleasurable effects. But 400-800
mg per day is considered a dangerous amount.
Over-consuming caffeine can cause:
•insomnia
•jitters
•anxiousness
•fast heart rate
•upset stomach
•nausea
•headache
•a feeling of unhappiness (dysphoria)
The FDA estimates toxic effects, like seizures, can be observed with rapid consumption of around 1,200 milligrams of
caffeine, or 0.15 tablespoons of pure caffeine.
Bust Studies have shown that such doses of caffeine result in increased ratings on measures such as well-being, alertness,
energy, concentration, sociability, and motivation to work, also decrease in rating of feeling sleepy or tired

Types of Substances- Nicotine
A plant alkaloid of the tobacco plant. It’s a stimulant.
Nicotine dependence is the most prevalent, deadly, and costly of substance
dependencies
-Nicotine does not cause behavioural problems; therefore few nicotine-
dependent persons seek or are referred for psychiatric treatment
-It is highly addictive and as very high percentage of relapse
-The individual experiences a ‘kick’ when consumed; this is partly caused by
nicotine stimulating the adrenal glands, which results in the release of adrenaline
-Tends to cause a pleasurable effect, feelings of contentment and depending on
the dose taken can also act as a sedative

Risk Factors
Must take into consideration a
combination of biological. Social,
Personal and Environmental factors
A combination of risk factors used to
identify the level of risk- Parental
history of substance abuse and high
risk environment means a higher risk
of substance abuse and earlier
initiation of it.
Also look at protective factors

Biological Factors
• Children of alcoholics parents are at a higher risk for
developing alcoholism and drug dependence that
children of non-alcoholic parents
• -This pattern is seen even when children of alcoholic
parents are adopted by non-alcoholic parents
• -Studies have shown that genetic factors contribute
up to 48%- 58% for substance use and rest can be
attributed to environmental factors
Personality Factors
• Factors that have been implied that contribute for
substance use are greater impulsivity, adventurousness
and sensation and pleasure seeking.
• -Sons of alcoholic fathers seem to be more tolerant
to the intoxicating effects of modest doses of alcohol
• Environmental:
• Low acceptance by peers or wanting to fit in with
peers and peer pressure.
• -Association with drug using peers
• The above factors are major reasons for abuse
especially in adolescence.
Environmental Factors
• Child abuse is known to be a risk
factors for early initiation of substance
use and abuse.
• Parental or sibling alcoholism, parental
model, perceived parent permissiveness
to drug or alcohol use
• -Lack or inconsistent parental
disciplining, low parental education,
• -Overinvolvement
• -Negative communication patterns,
unrealistic parental expectations
• -Marital Discord
• Drugs widely available and at reduces
rates

Protective Factors
1.Parental Social Support- helping them to
deal with the problem, coping etc.
2. Education and Commitment to School
3. Secure Attachment with parents
4. Well-adjusted in school and other
environments.
5. Married or living with a partner in a
committed relationship
6. Stable and environment at home with
clear rules and boundaries

Scales to Identify
Substance Abuse in
Clinical Interview
CRAFFT (mnemonic acronym)
-Have you ever ridden in a CAR driven by someone
(including yourself) who was “high” or had been using
alcohol or drugs?
-Do you ever use alcohol or drugs to RELAX, feel
better about yourself, or fit in?
-Do you ever use alcohol or drugs while you are by
yourself, ALONE?
-Do you ever FORGET things you did while using
alcohol or drugs?
-Do your FAMILY or FRIENDS ever tell you that
you should cut down on your drinking or drug use?
-Have you ever gotten into TROUBLE while you
were using alcohol or drugs?
Tobacco, Alcohol, Prescription medications, and other Substance
-Consists of a 4-item screening for tobacco use, alcohol use, prescription
medication misuse, and illicit substance use in the past year and brief
assessment
-Available for self-administration and interviewer-administration to detect
substance use, sub-threshold substance use disorder (i.e., at-risk, harmful, or
hazardous use), and substance use disorders.
-The above is for 12- month use, there is another 8-item scale for 3- month
use only.

Scales to Identify
Substance Abuse
in Clinical
Interview
Screening to Brief Intervention Tool (S2BI)
• Includes questions on tobacco, alcohol and
marijuana
• The responses correspond well with DSM 5
• S2BI does not provide a formal diagnosis, clinicians
can use the result to select the appropriate level of
care
• Kids who report use “once or twice” in the past
year are very unlikely to have a substance use
disorder
• Those who report “monthly” use will generally
meet criteria for a mild or moderate substance use
disorder
• Those reporting “weekly” use will most likely meet
criteria for a severe substance use disorder

Scales to Identify
Substance Abuse
in Clinical
Interview
The Drug Abuse Screening Test (DAST
The Drug Abuse Screening Test (DAST) was
developed in 1982. It is a 28-item self-report scale. The
DAST has “exhibited valid psychometric properties”
and has been found to be “a sensitive screening
instrument for the abuse of drugs other than alcohol.
MAST (Michigan Alcoholism Screening Test
The measure is a 25-item questionnaire designed to
provide effective screening for lifetime alcohol-related
problems and alcoholism. MAST has been efficiently
used in varied settings with various populations. Brief
versions of the MAST are available as well.
Can be used with both adolescents and adults.
Administration usually takes 8 minutes although it may
take longer, depends on the clinician and client.

Scales to Identify
Substance Abuse
in Clinical
Interview
The Alcohol Use Disorders Identification Test
(AUDIT)
The Alcohol Use Disorders Identification Test
(AUDIT) is a 10-item screening tool developed by the
World Health Organization (WHO) to assess alcohol
consumption, drinking behaviors, and alcohol-related
problems.
There are both Clinician version and Self-Report
versions.
A score of 8 or more is considered to indicate
hazardous or harmful alcohol use. The AUDIT has
been validated across genders and in a wide range of
racial/ethnic groups and is well suited for use in
primary care settings.
Opioid Risk Tool (ORT)
Webster et al. developed the ORT questionnaire., in 2005 It is a
brief, self-report screening tool designed for use with adult patients
in primary care settings to assess risk for opioid abuse among
individuals prescribed opioids for treatment of chronic pain.
A score of 3 or lower indicates low risk for future opioid abuse, a
score of 4 to 7 indicates moderate risk for opioid abuse, and a score
of 8 or higher indicates a high risk for opioid abuse

• It is an integration of Cognitive and Behavior Therapy conceptualizations, theory and techniques.
• It’s a more inclusive and comprehensive form of therapy to understand and treat substance abuse disorders.
• Emphasis is placed on the cognitive distortions, attributions, expectations and appraisals that lead to the maintenance of
substance abuse.
Attribution:
• Attribution is an explanation given by an individual as to the causations of an event (why something happened).
• Attributional styles play a major role in the cognitive–behavioral theory of substance abuse disorders. The perception of
substance abuse and recovery depends on an individual’s style of attribution. The Styles of attribution are:
• Internal and External- Attribute causes to oneself or others, environment. For Example: I drink because I am weak
(Internal); I drink because I am surrounded by people encouraging me to drink (External)
• Stable and Unstable- If the person believes he can change. For example: I cannot change my drinking habits, cannot
get over it (Stable); With better coping strategies and effort I can get over my Addiction. (Unstable).
• Global and Specific: Attribution of causations to all areas of his/her life or just one specific? For Example: I
could not abstain because I am a weak person and cannot succeed (Global); I could not abstain because of one specific
event; and not because I won’t be able to or weak (Specific).
• How it affects the recovery process is further explained in Relapse Prevention.
Cognitive Behavior Therapy

Cognitive Appraisals:
• An individual’s estimation of stressful situations and the ability to cope with the demands of stressors influence
the initiation and maintenance of substance abuse. Folkman and Lazarus described two different cognitive
appraisals:
• The Primary Appraisal: This is the individual’s appraisal of the level of stress or threat involved
• The Secondary Appraisal: Represents the individual’s evaluation of his/her ability to meet the challenges and
demands specific to the situation.
• The evaluation of the ability to meet the challenges is based upon the nature, and availability of coping skills
the individual possess; which influences the individual’s perception of stress and emotional response.
• If the individual perceives that he/she has the necessary coping mechanisms to deal with the situation; then
he/she appraises the situations as less stressful or threatening. If the individual feels that they don’t have the
necessary coping mechanisms; then the situation is perceived as more threatening and stressful- this person’s
emotional response will be anxiety, depression, helplessness etc.
Cognitive Behavior Therapy

Cognitive Appraisals: Coping Behaviors
In substance use-related situations, coping “refers to what an individual does or thinks in a crisis situation so as to handle the risk for
substance use.” (Brief Interventions and Brief Therapies for Substance Abuse, Treatment Improvement Protocol (TIP), Substance
Abuse and Mental Health Services Administration (SAMHSA), 1999.)
The theory holds the view that substance users lack or are deficient in their ability to cope or use inappropriate coping mechanisms to
cope with interpersonal, social, emotional, and personal problems. Hence these problems become threatening and stressful and
unsolvable. Hence, in an attempt to cope in the absence of more appropriate coping skills, the individual resorts to substance use and
abuse.
Some types of Coping are: Problem focused coping (focused on solving the problem), Emotion Focused Coping (focus on regulating
emotional responses to stress- relaxation etc.) and Avoidant (Avoiding the stressor ad problem)
In the context of substance abuse-
Anticipatory coping is employed: as one anticipates and attempts to plan how to deal with upcoming situations- situations of stress,
cues, withdrawal symptoms etc. What can I do if? The therapist and client discuss what coping methods to use if the anticipatory
situation occurs.
What can I do now?- The therapist and the client discuss what coping mechanisms to use when the client is dealing with a difficult
situation.
Restorative Coping Strategies- What can I do now that I’ve- employed when one fails to cope and finds himself using substances
again. The therapist and the client might go through the situation, why the coping failed, how the client was feeling about himself
(attributional processes), what were some of the obstacles he faced etc.

Self-efficacy expectancies are determined in part by the individual’s coping skills and the effectiveness of these coping
strategies to the specific demands of the situation.
Bandura in 1977 hypothesized that self- efficacy will determine whether coping behavior will be initiated or not, the
amount of effort that will be put and how long a coping attempt will continue in the face of obstacles.
Cognitive–behavioral approaches to substance abuse disorders postulate that low levels of self-efficacy are related to
substance use and an increased likelihood of relapse after having achieved abstinence (cite). Because a person with low
self-efficacy and a lack of coping skills will have negative thoughts, global/internal/stable attributional processes, which will
lead to a lack of motivation to even try and cope leading to helplessness and depression etc., which might lead to a relapse
or continuation of substance abuse.
Self-efficacy is the individual’s belief about his/her capacity or ability to successfully
execute an appropriate response in order to cope with a given situation.
Fig. 1: Annis and Davis (1991). Brief Interventions and Brief Therapies for Substance Abuse, Treatment Improvement
Protocol (TIP), Substance Abuse and Mental Health Services Administration (SAMHSA), 1999.

Substance Related Effect Expectancies
As substance use is reinforced by the positive effects of the substance being taken, it is
also likely that the individual will develop a set of cognitive expectancies about these
anticipated effects on her feelings and behavior.
Alcohol Drinkers anticipated that alcohol would serve as having positive effects on
mood, social and interpersonal behavior, assertiveness, and tension reduction. Positive
effect expectancies for marijuana include relaxation and tension reduction, social and
sexual facilitation, and perceptual and cognitive enhancement. Different substances have
varied expectancies, may also have individual differences.
Positive alcohol- and cocaine-related expectancies are associated with a greater
likelihood of relapse and poorer substance-related outcomes whereas negative alcohol
effect expectancies are related to decreased likelihood of relapse and less alcohol
consumption.

High Risk Situations
Over time, with repeated exposure, aspects of a situational context (e.g., the people, places, feelings, activities) can
come to serve as conditioned cues that can elicit a strong craving or desire to use.
Marlatt et.al (1996) have characterized a number of situations in which substances are abused:
Intrapersonal–Environmental Determinants
• Coping with negative emotional states- Anxiety, depression, frustration and anger, grief, loneliness, guilt etc.
• Coping with negative physical/physiological states- withdrawal symptoms or any physical pain, illness etc.
• Enhancement of positive emotional states- pleasurable sensations (high) or celebrations.
• Giving in to temptations or urges- in the presence of substance.
• Testing Willpower- to see their level of self-control or to see if therapy worked.
Interpersonal Determinants
• Coping with interpersonal conflict- to cope with the emotional distress caused by the conflict etc.
• Social pressure to drink or use- direct pressure (peer pressure etc.) and indirect pressure

CBT uses learning processes to help individuals reduce their drug use.
CBT treatment include the following:
• Functional analysis of substance abuse- The antecedents and the consequences.
• Recognizing and coping with craving, managing thoughts about substance abuse, problem solving, planning
for emergencies, recognizing seemingly irrelevant decisions, and using refusal skills
• An examination of the client’s cognitive processes related to substance abuse
• Identifying the future high risk situations.
• Review of the skills
• Practice of skills within sessions using techniques like role plays etc. (Carroll, 1998).
Cognitive Behavior Therapy- Practice

Motivational Interviewing: Motivational Interviewing (MI) is an approach based on targeting ambivalence toward
behavior change relative to drug and alcohol use, with subsequent application to motivation and adherence. Posits
that ambivalence about treatment and giving up substance use is normal.
• Five Principles of MI are:
1. Empathetic and Reflective Listening: Acceptance, non-judgmental stance, gentle persuasion.
2. Show discrepancy between client’s goals and behavior: Raise discrepancy by helping the client become aware
of the negative consequences of substance abuse. It is important to listen to the values that the client expresses.
Discrepancy can be made clear by contrasting substance-using behavior with the importance the clients ascribe to
their relationships with family, religious groups, and the community. After the client has understood the
discrepancy, the arguments for change must come from the client. Other tools such as media messages similar to
the client’s situation and its application to the client can be useful in raising discrepancy as well.
3. Avoid argument and direct confrontation: Arguments, labelling, lack of empathy only create defensiveness
from the client. Try and change strategies when the client is still showing resistance.
4. Adjust to client resistance than opposing it: Try and roll with resistance, try reflecting and sometimes changing
perspective- like a wife nagging about drinking problem to a wife who is concerned about drinking but is showing
it in a way that is negative and bugging. Resistance might show that the client views the situation differently, try
and see the difference with empathy.
5. Support self-efficacy and optimism.
6. Affirmations: Use affirmations like- That is a good suggestion, That must’ve been very difficult and stressful for
you etc.

Functional Analysis
It involves identifying the antecedents and consequences of substance abuse. It takes a look at what is triggering
and maintaining substance abuse.
Antecedents may be many, it may be emotional (as shown in Marlatt’s taxonomy), social or familial stressors like
divorce, marital conflict, economic, environmental cues that a person might have been conditioned to, physical etc.
Taking in information about the high-risk situations that the person might have been in the past, his/her thoughts,
antecedents of it, cues. This step is helpful in helping the client cope better with future high risk situations and
identifying the high risk situations.
Awareness of the antecedents and consequences is key here; because it helps the client understand what is
initiating his substance use and what are its consequences. Knowing this the client can anticipate, be prepared and
understand how to cope with the situation better, should he be put into it again.
Knowing the consequences; can help the client in decisional balance (pros and cons). It can help the client see the
negative consequences or negative substance related effects, which he/she might have missed (cons). And also
asking the client to see the pros, helps the therapist in strengthening the relationship; as the client feels the
therapist understands him.
Assessing the person’s attributional processes, coping abilities, self-efficacy, substance-related effect expectancies
are important for the therapist to understand; as it helps with the treatment goals and therapeutic interventions.

Coping Skills Training
The primary goal of CBT is to help the individual develop and execute functional or appropriate coping
skills that deal with the demands of high-risk situations without having to resort to substances as an
alternative response.
Coping skills maybe specific to substance abuse (e.g., coping with craving, refusal skills, cue
management, contingency management) or more general interpersonal and emotional areas (e.g.,
communication skills, coping with anger or depression, assertiveness training, conflict management,
building interpersonal relationships and their management etc.). They maybe both behavioral and
cognitive in nature.
The therapist might teach the client effective coping skills with regard to a situation. For Example:
Refusing a drink. This might involve communication and assertiveness training. The therapist might help
the client frame his refusal in an assertiveness manner; and practice this skill through role playing. This
help the client practice his skills before using it in a real-life situation.
Home works maybe given, asking the clients to take these skills to real-life situations and practice. The
next session starts with the review of the homework, how the client felt doing it, what difficulties or
obstacles he faced etc.

Coping Skills Training
The cognitive domain involves two categories of coping: As suggested by Litman (1986)
(1) Negative thinking- thinking about the negative consequences of substance abuse and a desire to no
longer experience these.
(2) Positive thinking- thinking about the benefits that are gained from being clean and sober and
wanting to maintain these benefits.
The behavioral domain also has two types of coping: As suggested by Litman (1986)
(1) avoidance of situations that have been previously associated with substance abuse (avoiding cues).
(2) seeking social support when confronted with the temptation to drink or use drugs.
Litman (1986) suggests that initially, when clients are trying to abstain from substances, they appear to
rely more heavily on behavioral strategies. As the period of abstinence increases, there appears to be a
transition from predominantly behavioral strategies toward a greater reliance on cognitive methods of
coping.

Contingency Management
As treatment for substance abuse starts and in a period where the client initially starts abstinence, the main
challenge countered is the reinforcing effects of the drug.
Contingency management (CM) approaches which are based on operant conditioning, involves the giving of
non-drug reinforcers (e.g., vouchers for goods) when the client shows abstinence from substances.
Lottery-type techniques of reinforcements are utilized. For example: Punchbowl method rewards negative
screenings for drug use with a draw from a “punchbowl. Most prizes have low monetary value (e.g., $1), but
the inclusion of rarer large prizes (e.g., $50) is there as well.
These reinforcement procedures maybe stable or escalation.
With consideration of traditional CM rewards monetary prizes, vouchers for goods, or treatment “privileges”
(e.g., take-home doses of methadone) the arrangement of social contingencies is important as well.
When the goal of abstinence and non-drug activities is achieved, treatment becomes a more natural rewards
for abstinence should be emphasized on in treatment. For example: Relationships, employment chances, social
success, increased self-efficacy, better coping with stress, self-efficacy etc.
Other general techniques include cognitive restructuring, confidence building etc.

• Relapse Prevention involves steps from the previous aspects like coping skills training, identifying high risk
situations from functional analysis. Other aspects include improving the self-efficacy of the individual and
focusing on cognitions involved in the relapse process.
• Self-efficacy: In increasing self-efficacy, the graduated homework model is often used. After the client is
taught to handle situations or skills; as a form of homework the client is asked to be exposed to increasingly
difficult situations; which have the greater relapse risk; but the client is expected to cope with them, use the
skills learnt and not use substances.
• In the sessions after the homework, the client’s accomplishments are affirmed and reinforced to increase hi/her
self-efficacy.
• Substance Positive Expectancies: The clients are asked to consider both the positive and negative
consequences or effects of substance use. The decisional balance techniques of pros and cons can be listed
collaboratively and help the client see the negative consequences that are not being attended to.
• The client might also have automatic scripts like I will feel more relaxed if I drink; while that maybe true, the
client might not be paying attention to other scenarios created as a result of drinking; like I will drink too
much, I will have a fight with my wife and I will sleep, have a hangover and not go to work.
Relapse Prevention

• Relapse Prevention also involves, preparing for relapse and planning and practicing skills on how to avoid it.
• Sometimes clients maybe hesitant to talk about relapse; in such situations the fire drill metaphor can be used to
explain why its important to talk about it. Saying that, although having a plan and drill doesn’t mean that the
fire will happen; but in case it does we can get out of the fire without being injured; and that’s why talking
about relapse is important.
• It is important to have a very concrete plan with numbers of people who are supportive of the client’s recovery
process etc.
• It is also important to stress on maintaining a healthy and balanced lifestyle. A possible trigger for relapse is
stressors in life; and this should be dealt with by helping the client cope with these stressors effectively and
appropriately. It is important for the client to engage in non-substance related activities that the client takes
pleasure in, which are rewarding and enjoyable to the client. These two are important in maintaining a balance
(Marlatt and Gordon, 1985).
• There are some protective factors as well that protects the client form relapse. One of them is the behavioral
and cognitive coping categories previously mentioned in Coping skills training by Litman; which is shown to be
a protective factor.
Relapse Prevention

• The first use of substance after abstinence is called a Slip.
• Abstinence Violation Effect is an negative attribution process (Internal, Stable and Global. ) after a slip that
can lead to a full relapse.
• The cause of the slip is seen to be Internal, Stable and Global.
• Substance abusers who have these negative attributions after a slip will feel depressed, worthless, helpless, and
hopeless. This is associated with and may lead to “learned helplessness”. They may believe that they are weak,
don’t have the ability to get over the substance, they are hopeless and believe that there is no point trying
because they cannot change.
• Helplessness and negative emotional states increase the likelihood that the initial lapse will develop into a full-
blown relapse.
• The therapist should work on the resulting negative attributional processes of the slip and help the client see
the slip to be more external (attribute cause to the environment), unstable (that he has the ability to change)
and specific (attribute cause to that one specific event and it does not reflect his whole self or life).
Abstinence Violation Effect

Fig 1: Shows a
Cognitive Behavioral
Model of Relapse
Process. Adapted
from Kadden, 1995.
Brief Interventions
and Brief Therapies
for Substance Abuse,
Treatment
Improvement
Protocol (TIP),
Substance Abuse and
Mental Health
Services
Administration
(SAMHSA), 1999.

• Given by Prochaska and DiClimente. This model emerged from an analysis of leading theories of psychotherapy and
behavior change. The model is integrative that allows to conceptualize the process of intentional behavior change.
• The transtheoretical model of behavior change claims that, behavior change involves progress through six stages of change.
Stages of Change
1. Pre-contemplation stage: Individuals in the pre-contemplation change are not even thinking of changing and not intending
to take any action. People may be in this stage because they are uninformed or underinformed about the consequences of their
behavior. Or they may have tried to change a number of times and become demoralized about their abilities to change.
The four Rs for people to be in this stage-
 Reluctance- they lack knowledge and inertia and do not want to consider change. They avoid reading, talking about their
high risk behaviors.
 Rebellious- they have a heavy investment in drinking and they are resistant to being told what to do.
 Resigned- they have given up hope about change and seem overwhelmed by the problem. Many have made many attempts
to quit or control their drinking, but have failed.
 Rationalizing- they have plenty of reasons as to why drinking is not a problem, or why drinking is a problem for others but
not for them.
Transtheoretical Model of Change

2. Contemplation Stage:
• In this stage people are intending to change. They are aware of the pros of changing, but are also aware of the cons. If
there is a balance between pros and cons, may produce uncertainty about changing and they may be stuck in the stage for a
long period of time. This phenomenon is called chronic contemplation and behavioral procrastination.
3. Preparation Stage:
• People in this stage are willing to take action in the immediate future. They might have typically taken some action in
the past year. People in this stage have some action plans; such as buying a self-help book, some self-devised plan or with
the help of an external agency such as counselors etc. However, without a realistic plan commitment to change without
appropriate skills and activities can create a fragile and incomplete action plan. They may begin to anticipate problems and
pitfalls and come up with concrete solutions that will become part of their ongoing treatment plan.
Stages of Change

4. Action Stage:
• Individuals in this stage, have made some overt specific overt modifications in
their life styles within the past 6 months.
5. Maintenance Stage:
• In this stage people are working towards maintaining the maintain the behavior
changes they brought and are also working towards preventing relapse. They are less
tempted to relapse and increasingly more confident that they can continue their
changes. The longer the maintenance, the lesser the change of relapse.
6. Termination Stage:
• In this stage, the individual has no more temptation and behavior change has
occurred completely. No matter whether they are depressed, anxious, bored, lonely,
angry, or stressed, they are sure they will not return to their old unhealthy habit as a
way of coping. But, termination may not be a practical reality for most people.

• Ten processes of change have been identified to produce change.
• There are 10 cognitive and behavioral strategies that causes the change.
• These 10 covert and overt processes need to be implemented to successfully progress through the stages of
change and attain the desired behavior change.
Cognitive Processes of Change
1)Consciousness raising – learning new facts & tips about healthy behavior change
2) Dramatic relief – experiencing negative emotions that go with unhealthy behavioral risks
3) Self-reevaluation – realizing the change is part of one’s identity
4)Environmental-reevaluation – realizing that the impact of the behavior on one’s social and physical environment
5) Social-liberation – realizing the social norms are changing in favor of the healthy behavior
Process Of Change

Behavioral Processes of Change
6)Counter-conditioning: substituting alternative healthy behaviors for unhealthy ones
7) Helping Relationships – seeking/using social support networks for behavior change
8) Reinforcement management – increasing rewards for a positive behavior and decreasing ones for a negative
behavior
9)Self-liberation – making a firm commitment to change (e.g., written contract)
10) Stimulus control – removing reminders or cues for unhealthy behaviors and adding ones for healthy behaviors
• Apart from these Self-efficacy, decisional balance and temptations also influence the process of change.
• Decisional balance reflects the individual’s relative weighing of the pros and cons of changing.
• Temptation reflects the strength of urges to engage in a habit when in a difficult situations.
Process Of Change

• Clients need support appropriate to the stage of change they are in. If motivational and
other strategies are not used according to the stage of change they are in, there might be
resistance from the client.
• There are six elements critical to a brief intervention to change substance abuse behavior
given by Miller and Sanchez in 1994. They can be arranged in the acronym of FRAMES.
F- Feedback is given to the individual about personal risk or impairment.
R- Responsibility for change is placed on the participant.
A- Advice to change is given by the provider.
M- Menu of alternative self-help or treatment options is offered to the participant.
E- Empathic style is used in counseling.
S- Self-efficacy or optimistic empowerment is engendered in the participant.
Transtheoretical Model of Change- Practice

• Pre-Contemplation: Since, the client at this stage is not thinking of change; raising awareness of the negative
consequences of substance abuse is necessary. For this psycho-educational interventions are necessary. General
education about the consequences of substance abuse, why people get into substance abuse etc. can be given to
the client. Handouts maybe used for this purpose or a video etc. Motivational Interviewing strategies maybe
used here as well.
• Group Therapy maybe especially beneficial for clients who are still in denial, hearing other client’s experiences
and struggles may create a sense of bonding since they are going through similar experiences. It might help
them stay in the group, feel validated and might open up discussions that might lead to contemplating and even
action. Th ideal size if the group is 6-8 members and length is one and a half hour.
• The discussions in groups can help the members go deeper and open up. There will be processing of the
activity once the educational activity like a video etc. is over. This process is especially important for opening
up, going deeper, sharing experiences etc.
• It is important that screening of members is done as to the stage they are in. If group members are in different
stages it is difficult to plan the session and activities. In non-voluntary groups, since screening is not possible,
the inner circle/outer circle technique is used. Those who are interested sit in the inner circle and discuss; while
the outer circle sit and listen to the discussions and not disturb the session. This is especially useful when there
are members who are in the pre-contemplation stage who are forced to join or join to please their loved ones.
Interventions in Each Stage

• In this stage the client might show ambivalence towards change. This client should explore feelings of
ambivalence and the conflicts between substance abuse and personal values or goals. This technique of
showing discrepancy is used in motivational interviewing as well. Pros and cons maybe listed out, bringing the
cons to the client’s notice.
• Showing the benefits of stopping substance abuse may also be shown to the client.
Preparation Stage
The client is ready for change, hence identifying potential change strategies and choosing the most appropriate
ones is necessary. Giving the client a list of treatment options and choosing which one is best for the client is
another technique.
Giving information on the potential high risk situations, explaining cues and creating a concrete action plan and
teaching and practicing coping strategies maybe important interventions in this stage. Cue management on how to
cope when faced with a cue like alternate things to do, avoid cues, refusal skills, communication skills, assertiveness
etc. can be taught to the client. These skills can be practiced among the group members and feedback can be given
to each other.
Contemplation Stage

• Emotional coping strategies can be taught as well like distress tolerance, emotion focused coping
etc.
• An important consideration should be given to managing withdrawal symptoms; such as providing
handouts on what withdrawal symptoms are, a list of withdrawal symptoms the client might
experience and how he/she can manage them. Either by medications or attending detox programs
etc.
• The therapist can ask them to read the handouts, discuss them and see how the clients might be
feeling about this and clarify their fears and doubts about it.
• One activity of goal walk maybe especially useful when seeing what are some of the obstacles the
clients feel they may face during abstinence. Goal walk is done by a single member of the group
and others participate as his/her obstacles and supportive and protective factors and that member
walks past these obstacles while being supported by the protective factors which maybe his/her
family members etc. It helps the clients realize the obstacles and protective factors and how to use
the protective factors to get over the obstacles.
Preparation Stage

• The client tries to abstain and practice the new skills learnt in group therapy. Members share their experiences
of practicing their new skills and of abstinence and also share their obstacles they faced and how they managed
them. Contingency management techniques of punchbowl etc. can be used in this stage among the group
members.
• Affirmations and positive feedback for increasing their self-efficacy and self-confidence maybe used. Rounds
can be done where one member given positive feedback and tells the strengths of every other member in the
group. This will be done with each member and processing will be done after.
• This might help in keeping the members motivated to continue their abstinence.
• Brief interventions could be applied to prevent relapse and normalizing and acknowledging the client’s feelings
and experiences as a normal part of recovery process.
Maintenance Stage
• Relapse prevention can be discussed and reassuring, evaluating present actions, and redefining long-term
sobriety maintenance plan can be devised in this stage.
Action Stage

Links to Scales
https://www.mcpap.com/pdf/S2BI_postcard.pdf - S2B1
https://med.dartmouth-hitchcock.org/documents/CRAFFT-adolescent-
substance-use-screen.pdf - CRAFT
https://cde.drugabuse.gov/sites/nida_cde/files/TAPS%20Tool%20Parts%20I
%20and%20II%20V2.pdf - TAPS
https://www.drugabuse.gov/sites/default/files/audit.pdf - AUDIT
https://www.drugabuse.gov/sites/default/files/opioidrisktool.pdf - ORT
https://pubs.niaaa.nih.gov/publications/assessingalcohol/instrumentpdfs/42_m
ast.pdf - MAST

Brief Interventions and Brief Therapies for Substance Abuse, Treatment Improvement Protocol (TIP), Substance Abuse and Mental Health
Services Administration (SAMHSA), 1999.
Diagnostic Statistical Manual- V
[The history of heroin, S Hosztafi (2001), Acta Farm Hung, https://pubmed.ncbi.nlm.nih.gov/11862675/.
Opioids and the Treatment of Chronic Pain: Controversies, Current Status, and Future Directions, Andrew Rosenblum,1,* Lisa A.
Marsch,1 Herman Joseph,1 and Russell K. Portenoy, 2008 Experimental and Clinical Psychopharmacology,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2711509/
Cannabis, World Health Organization, https://www.who.int/substance_abuse/facts/cannabis/en/
Cocaine Drug Facts, NIDA. 2020, Retrieved from https://www.drugabuse.gov/publications/drugfacts/cocaine on 2020
Cocaine and mental health, Health Direct, 2019, Retrieved from https://www.healthdirect.gov.au/cocaine-and-mental-health
What’s An Amphetamine? Addiction: Signs, Symptoms, and Treatment, American Addiction Centers, 2019, Retrieved from
https://americanaddictioncenters.org/amphetamine.
Spilling the Beans: How Much Caffeine is Too Much?, US Food and Drug Administration, 2018, Retrieved from
https://www.fda.gov/consumers/consumer-updates/spilling-beans-how-much-caffeine-too-much
Classic Hallucinogens, National Institute of Drug Abuse, 2020,. Retrieved from https://www.drugabuse.gov/publications/research-
reports/hallucinogens-dissociative-drugs/what-are-dissociative-drugs on 2020, August 18
References

Substance Abuse and Dependence in Adolescence: Epidemiology, Risk Factors and Treatment, Cecilia A. Essau, 2014,
Routledge,
https://books.google.co.in/books?id=zZJIAwAAQBAJ&pg=PA99&dq=risk+factors+of+substance+abuse&hl=en&sa
=X&ved=2ahUKEwibsfDMkpvrAhUC63MBHaROCHwQ6AEwBHoECAgQAg#v=onepage&q=risk%20factors%20o
f%20substance%20abuse&f=false
Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health, 2016 Substance Abuse and
Mental Health Services Administration (US); Office of the Surgeon General (US). Washington (DC): US Department of
Health and Human Services; https://www.ncbi.nlm.nih.gov/books/NBK424850/table/ch3.t3/016 N
Cognitive-Behavioral Therapy for Substance Use Disorders R. Kathryn McHugh, Bridget A. Hearon, and Michael W.
Otto, 2010, Psychiatric Clinics of North America, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897895/
Enhancing Motivation for Change in Substance Abuse Treatment, Treatment Improvement Protocol (TIP), Substance
Abuse and Mental Health Services Administration (SAMHSA), 1999.
https://www.ncbi.nlm.nih.gov/books/NBK64964/.
Group Counseling Strategies and Skills Seventh Edition, 2012, Ed E. Jacobs, Robert L. Masson, Riley L. Harvill,
Christine J. Schimmel, Brooks/Cole Cengage Learning, California.
References

Thank You
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