A. Baker, S. Bucci, & F. Kay-Lambkin Intervention for alcohol, cannabis and amphetamine use among people with a psychotic illness NDARC Technical Report No. 193 1 INTERVENTION FOR ALCOHOL, CANNABIS AND AMPEHETAMINE USE AMONG PEOPLE WITH A PSYCHOTIC ILLNESS Amanda Baker, Sandra Bucci, & Frances Kay-Lambkin Technical Report Number 193 ISBN: 1 877027 84 7 2 © Centre for Mental Health Studies, School of Medical Practice and Population Health, Faculty of Health, University of Newcastle 2004 TABLE OF CONTENTS ACKNOWLEDGEMENTS..........................................ERROR! BOOKMARK NOT DEFINED. 1. INTRODUCTION............................................................................................ 7 1.1 Context...............................................................................................................................7 1.2 Organisation of this Manual...........................................................................................7 2. BRIEF BACKGROUND TO THE STUDY AND SUMMARY OF RESULTS OF EVALUATION................................................................................................. 9 2.1 Introduction......................................................................................................................9 2.2 Participants and Procedure.............................................................................................9 2.3 Measures............................................................................................................................9 2.4 Design................................................................................................................................9 2.5 Components of the Interventions...............................................................................11 2.5.1 Motivational Interviewing...................................................................................................11 2.5.2 Cognitive Behaviour Therpay (CBT)..................................................................................11 2.5.3 Therapists..........................................................................................................................11 2.5.4 Control Condition..............................................................................................................11 2.6 Summary of Main Results............................................................................................11 3. THE INVERVENTION....................................................................................14 3.1 Rationale and Principles of Treatment.......................................................................14 3.2 Goals of Treatment.......................................................................................................14 3.3 Monitoring Symptomatology.......................................................................................14 3.3.1 Suicide Risk Assessment....................................................................................................14 3.4 Therapist Checklist........................................................................................................15 3.5 Format of Therapy........................................................................................................15 3.5.1 Timing and Length of Intervention......................................................................................15 Missed Appointments...................................................................................................16 3.5.2 Phases of Treatment...........................................................................................................16 3.5.3 Conducting the Therapy......................................................................................................17 Abstinence versus Harm Reduction Approaches.....................................................16 3.6 Getting Started...............................................................................................................16 3.6.1 The Case Formulation (Persons, 1989)..............................................................................16 SESSIONS 1 – 4: MOTIVATIONAL INTERVIEWING.............................................19 Phase 1: Build Motivation to Change.......................................................................................20 Phase 2: Strengthen Commitment............................................................................................32 Homework...................................................................................................................................38 SESSION 5: INTRODUCTION TO CBT.......................................................................42 Review past week and Homework Exercsise. Set Agenda....................................................43 CBT Rationale and the Process of Treatment........................................................................43 Link between Thoughts, Feelings and Behaviours................................................................44 Assessing and Avoiding High Risk Sitautions........................................................................49 Homework...................................................................................................................................50 SESSION 6: CBT - SEEMINGLY IRRELEVANT DECISIONS, PROBLEM SOLVING, MANAGING UNHLPFUL: THOUGHTS..............................................52 Seemingly Irrelevant Decisions.................................................................................................53 Problem Solving Skills................................................................................................................54 Idenitfying Unhelpful Automatic Thoughts...........................................................................58 3 Homework...................................................................................................................................59 SESSION 7: CBT – COPING WITH CRAVINGS/URGES TO USE AODS. ABSTINENCE/RULE VIOLATION EFFECT, ACTIVITY SCHEDULING..65 Review past week and Homework Exercise. Set Agenda.....................................................66 Coping with Urges to use AODs..............................................................................................66 Devising a Craving Plan.............................................................................................................68 Dealing with a Lapse...................................................................................................................72 Activity Scheduling.....................................................................................................................73 Homework...................................................................................................................................74 SESSION 8: CBT – DRINK/DRUG REFUSAL SKILLS, LIFESTYLE ISSUES........................................................................................................................................78 Review past week and Homework Exercise. Set Agenda.....................................................79 Drink/Drug Refusal Skills.........................................................................................................79 Lifestyle Issues.............................................................................................................................82 Foreshadow Treatment Termination.......................................................................................84 Homework...................................................................................................................................84 SESSION 9: RELAPSE PREVENTION.........................................................................86 Review past week and Homework Exercise. Set Agenda.....................................................87 Relapse Prevention......................................................................................................................87 Relpase Management Plan.........................................................................................................88 Homework...................................................................................................................................89 SESSION 10: RELAPSE PREVENTION.......................................................................93 Review past week and Homework Exercise. Set Agenda.....................................................94 Rationale for Relapse Prevention.............................................................................................94 Identification of High Risk Situations......................................................................................94 Preparation for High Risk Situations.......................................................................................94 Regualte the Consequences.......................................................................................................95 Using the Relapse Prevention Plan...........................................................................................95 Termination..................................................................................................................................96 Appointment for Follow-Up.....................................................................................................96 4. REFERENCES................................................................................................99 4 TABLE OF FIGURES Figure 2.1 Study Protocol..................................................................................................10 Figure 3.1 Questions for assessing suicidal ideation......................................................15 Figure 3.2 The Case Formulation.....................................................................................18 Figure 3.3 Pros and Cons Balance Sheet.........................................................................25 Figure 3.4 Personal Feedback Report..............................................................................29 Figure 3.5 Change Plan Worksheet..................................................................................36 Figure 3.6 Treatment Contract.........................................................................................37 Figure 4.1 Symptom Monitoring Form...........................................................................39 Figure 4.2 AOD Monitoring Form..................................................................................40 Figure 4.3 Therapist Checklist – Sessions 1-4................................................................41 Figure 5.1 Self Monitoring Record...................................................................................47 Figure 5.2 Changing Unhelpful Thinking.......................................................................48 Figure 5.3 Therapist Checklist – Session 5.....................................................................51 Figure 6.1 Seemingly Irrelevant Decisions......................................................................54 Figure 6.2 Problem-Solving...............................................................................................57 Figure 6.3 Unhelpful; Automatic Thought Patterns......................................................61 Figure 6.4 Steps in Managing Unhelpful; Automatic Thoughts..................................62 Figure 6.5 Managing Unhelpful Thoughts......................................................................63 Figure 6.6 Therapist Checklist – Session 6.....................................................................64 Figure 7.1 Facts About Cravings......................................................................................69 Figure 7.2 Coping with Cravings......................................................................................70 Figure 7.3 All Purpose Coping Plan.................................................................................71 Figure 7.4 Activities List....................................................................................................75 Figure 7.5 The Activity Record.........................................................................................76 Figure 7.6 Therapist Checklist – Session 7.....................................................................77 Figure 8.1 Refusal Skills.....................................................................................................81 Figure 8.2 Dealing with worries about weight gain.......................................................83 Figure 8.3 Therapist Checklist – Session 8.....................................................................85 Figure 9.1 Relapse Management Plan..............................................................................90 Figure 9.2 Therapist Checklist – Session 9.....................................................................92 Figure 10.1 Relapse Preparation Sheet.............................................................................97 Figure 10.2 Therapist Checklist – Session 10..................................................................98 5 ACKNOWLEDGEMENTS The authors would like to acknowledge the National Medical Health and Research Council (NHMRC) for their financial support of the evaluation of the treatment described in this manual. The authors would also like to thank the NISAD Schizophrenia Register, Australia, for assisting with the recruitment of volunteers participating in this research. The authors acknowledge the additional investigators appearing on the original grant application supporting this research: Mr Terry Lewin, Professor Vaughan Carr, Ms Margaret Terry and Mr Richard Clancy. Thank you to the Centre for Mental Health Studies and the University of Newcastle research staff who worked tirelessly to complete the randomised controlled trial described in this manual. We thank them for their efforts, dedication and enthusiasm. Parts of this manual were adapted from various sources which are acknowledged throughout. Dr Hermine Graham generously allowed adaptation of parts of her treatment manual and provided comments on this manual. Finally, we would like to thank all the people who participated in the research project and who gave generously of their time, effort and personal information, so that it could be of use to other people in their situation. 6 1. INTRODUCTION 1.1 Context Despite the widespread co-occurrence of psychosis and substance use disorders, and the adverse effects of substance use on functioning and outcome among people with psychosis (Teesson et al., 2000), there have been few randomised controlled trials specifically aimed at reducing substance use among people with psychotic disorders. One-session motivational interventions among psychiatric hospital inpatients with mixed diagnoses and co-existing alcohol and/or other drug use problems have reported promising but short-term intervention effects (Hulse & Tait, 2002, 2003; Baker et al., 2002). Cognitive behaviour therapy (CBT) has been shown to be effective for alcohol (Shand et al., 2003), cannabis (Copeland et al., 2001) and amphetamine use disorders (Baker et al., in press) and has also shown benefits for psychotic symptomatology (Haddock et al., 2000). In the first RCT to investigate the effectiveness of CBT among people with comorbid schizophrenia and substance use disorder, Barrowclough and colleagues (2001) randomly assigned 36 patient-caregiver dyads to either routine care alone or combined with motivational interviewing and CBT (total 29 sessions) plus a family intervention of 10-16 sessions, over nine months. Eighteen months following entry to the study, the treatment group had significantly superior general functioning (GAF) and negative symptom scores, with no difference in percentage of days abstinent from substances (Haddock et al., 2003). The authors suggested that studies with larger numbers of subjects, examining the efficacy of different components of CBT interventions, are required. The trial this treatment manual was written for investigated whether a 10- session CBT intervention among a large sample of people with psychosis and substance use disorders was more effective than routine treatment in reducing substance use and improving symptomatology and general functioning. 1.2 Organisation of this Manual This manual has been written for the project "Randomised controlled trial of cognitive- behaviour therapy for alcohol and other drug problems among people with a psychotic illness", funded by the National Health and Medical Research Council (NHMRC) in 2000. The manual is not intended to stand alone. Rather, it is to be accompanied by extensive reading of the research and clinical literature, training in the approaches used and ongoing supervision. The intervention described in this manual was delivered over 10 weekly, individual sessions. The manual firstly describes some of the theoretical and contextual background information relevant to the treatment delivered to participants, and its evaluation in the randomised controlled trial conducted over 2000-2003. Outcomes of the research are briefly summarised in a subsequent section. Each subsequent section contains a detailed session-by-session guide to the substance use intervention evaluated in the randomised controlled trial. All handouts, homework activities and therapist and client resources are provided. Each session is preceded by a Therapist Summary Sheet that lists all the strategies and information to be covered in the relevant session. Each session description concludes with a Therapist Checklist to assist with clinical note taking, and to ensure all the essential components of the therapy session were covered where possible. 7 Format of therapy Guidelines for the delivery of the treatment sessions are given for each of the ten sessions in this manual. These guidelines are general, around which a therapist will be able to add his or her own style and experience. In order to provide clients with effective motivational enhancement and coping skills, the following topics are covered: • Motivational interviewing (Sessions 1-4 and further sessions if necessary) • Symptom management (Sessions 1-10 as applicable) • Thought Monitoring (Sessions 1 and 2) • Conceptualising treatment: Introduction to CBT, Assessing and Avoiding High Risk Situations (Session 5) • Seemingly Irrelevant Decisions, Problem Solving, Managing Unhelpful Thoughts (Session 6) • Coping with Cravings/urges to use AODs, The “Breaking The Rule” Effect, Activity Scheduling (Session 7) • Drink/Drug Refusal Skills, Lifestyle Issues (Session 8) • Relapse Prevention/Management (Session 9 and 10) • Treatment Termination, Follow-Up Appointment (Session 10) 8 2. BRIEF BACKGROUND TO THE STUDY AND SUMMARY OF RESULTS OF EVALUATION 2.1 Introduction The present study builds on a pilot study conducted by Baker and colleagues (2001) which evaluated a brief intervention for substance users among people with a major mental illness. The researchers found a modest, short term reduction in polydrug use, although this effect was not sustained over a 12 month period. Baker et al (2001) recommended that a longer term intervention specifically targeting the three primary substances (alcohol, cannabis and amphetamine) be evaluated among people with a psychotic illness. 2.2 Participants and Procedure Participants in the research project described in this manual consisted of 130 people who were recruited into the study between August 2000 and June 2002 from the Hunter Region, NSW. Participants met ICD-10 diagnostic criteria for psychosis and were regular users of alcohol, cannabis and/or amphetamines at hazardous levels. Hazardous use of alcohol was determined as consumption exceeding recommended guidelines for hazardous use produced by the National Health and Medical Research Committee (NHMRC): four standard drinks per day for men and two standard drinks per day for women (Pols & Hawks, 1992) within the past month. Regular hazardous use of cannabis and amphetamines was classified as meeting at least weekly consumption on the Drug Use Scale of the Opiate Treatment Index (OTI; Darke, Ward, Hall, et al, 1991) in the month prior to interview. Participants were excluded if they were acutely unwell, non- English speakers, had evidence of organic brain impairment and/or were not likely to reside in the geographical area within the next twelve months. 2.3 Measures Data were collected on demographic characteristics, past and present alcohol, cannabis and/or amphetamine use and mental health, treatment history, stage of change, reasons for using substances, quality of life, personality and cognitive functioning. Assessments were scheduled at pre-treatment, post-treatment (15 weeks post initial assessment), 6 months and 12 months following the initial assessment and were conducted by interviewers blind to group allocation. 2.4 Design The study protocol is displayed in Figure 2.1 Participants were randomly allocated to either an active treatment condition (ten sessions of motivational interviewing and CBT) or a control condition (self help booklet and treatment as usual) that occurred over ten weekly sessions. The self help booklet was developed by CEIDA (2000) to address mental health and substance use. The treatment was manualised and was designed to work in such a way that session one to four consisted of motivational interviewing and session’s five to ten, CBT. 9 Recruitment • Outpatient Mental Health Settings (Community Health Centres, Rehabilitation Centres, Early Psychosis Service, Dual Diagnosis Service); In-patient Mental Health Settings Include if: Exclude if: • Psychotic illness (schizophrenia, • Non-psychotic disorder schizoaffective disorder, schizophreniform • Using substances below recommended disorder, bipolar disorder with psychotic harmful levels symptoms) • Non-English Speaking • Meet threshold for substance use • Cognitive impairment Initial Assessment • Includes mental health and substance use measures (self-report, clinician rated) • Participants are reimbursed $20.00 for each assessment completed • Interview is conducted over one or two sessions depending on the patient’s availability and functioning Randomisation Control Group Treatment Group • Participants receive the CEIDA information booklet • Ten weekly, individual sessions of Motivational • Continue with treatment as usual Interviewing and CBT • Discuss referral to the community for treatment (approximately 10 minutes) Follow-up Assessment • Post-treatment (15 weeks post initial assessment), 6 months and 12 months post-initial assessment • Includes mental health and substance use measures (self-report, clinician rated) • Participants are reimbursed $20.00 for each assessment completed Figure 2.1 Study Protocol • Interview is conducted over one session Figure 2.1 The Study Protocol Figure 2.1 Study Protocol 10