Welcome, everyone. Thank you for taking the time out to interact with this module entitled Psychosocial Treatment Protocols in Conjunction with Medications for Addictions Treatment. My name is Ken Carpenter. I'm a clinical psychologist conducting research and treatment both at the New York State Psychiatric Institute in New York and working as part of a not-for-profit CMC Foundation for Change, which is dedicated to helping families and loved ones support their loved ones who may be struggling with a substance use disorder. I'd like to acknowledge and thank my colleague, Dr. Nicole Kosanke, for her contributions to this work and her expertise in bringing these modules together. I have no relevant financial relationships with eligible companies to disclose or any conflicts associated with this educational activity. I just wanted to highlight that the overarching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well as for the prevention and treatment of substance use disorders. In this module, we'll be talking about strategies and skills that are most applicable in situations where there's ongoing interactions with healthcare providers and individuals who may be thinking about making changes in their use of substances. This can include a range of circumstances, including primary care, psychiatric care facilities, pain management clinics, and other healthcare counseling contexts. At the end of this activity, we're hoping that participants will identify the importance of evidence-based practices for substance use disorders, identify four key components of effective psychosocial treatment protocols, be able to identify skill-building exercises that can be utilized by clients, and to be able to describe the basic tenets of the community reinforcement and family training approach, also known as CRAFT. As we start off together, I'd just like to put a spotlight on why the need for evidence-based practices? Why is there such an important aspect to this? Well, approximately 11% of American adults meet DSM-5 criteria for an alcohol use disorder, and 4% will meet criteria for a current drug use disorder. These percentages are quite notable, and when we really break it down to raw numbers, suggest hundreds of thousands to millions of individuals are affected by the presence of ongoing alcohol use and drug use disorders. Unfortunately, of the vast majority of individuals who are struggling with alcohol or substance use disorders, most will not reach treatment. In fact, only about 6.5% of those with a current alcohol or drug use disorder will have sought help for their substance use problems by a trained professional. Of those that do, about a quarter of them will seek help from a private physician or another healthcare professional. When we think about the shared numbers of individuals who have been impacted by substance use disorders, and we can think that they have family members who are also on the front line, the magnitude of concern and magnitude of issues comes front and center. We do know only a minority of individuals receive evidence-based support and treatment for their substance use disorders, and their family members most often will be the ones on the front line, which suggests a continued need for community healthcare providers to be trained in evidence-based procedures and skills to help both those individuals who are struggling with substance use disorders, as well as the family members who most likely will be the ones trying to provide support in need for their loved ones. But why evidence-based approaches? There are numerous ways and roads that people make changes in their use of substances, and there are many different types of recommendations that are offered to families when they first are seeking help for their loved ones. But when we kind of roll up our sleeves and think about what clinical trials, you know, the evidence is quite clear. Both psychosocial and medication-based interventions do help facilitate change. They are impactful and yield greater success rates than other types of interventions such as providing suggestions or mandating treatments, etc. Importantly, both approaches seem to be additive. Counseling exerts an effect and psychosocial interventions can have an impact, and when combined with medications, that impact gets added and becomes greater. So neither one overlaps with the other, and a two-pronged strategy offers the most beneficial approach for many individuals looking to make changes. Often, there's a lot of criticism about substance use treatments because of the observed relapse rates. But we'd also like to highlight that when we look at substance use and substance use disorders as a chronic health condition, outcomes, long-term outcomes, seem to map and align quite well with other chronic medical conditions in which the expectations are not of sudden change, but of management, support, and change and remediation over the long haul. When we look at what psychosocial interventions have to offer, one of the major impacts they have is how they create an interpersonal context that can help support and maintain change. Individuals seek to make changes in their lives, not in isolation, but often in the context of the relationships that surround them and the loved ones that are part of their life. And it's these interactions that can be so important in providing the supportive scaffolding needed to maintain change over time. Psychosocial interventions not only help change the interpersonal context, they can help increase adherence to medication and other skills-based intervention strategies. By having a supportive counseling condition, individuals may be more likely to stay committed to their change process and stay with the process of learning new skills that can be challenging over time. As a result, psychosocial interventions can be effective for promoting abstinence and preventing relapse. Again, thinking about change is the long haul. And just as important, we know that change consists of many different processes, motivational, psychological, and the social scaffolding that surrounds individuals making their efforts to change. And psychosocial interventions can be tailored and used to address all three of those aspects of the change process. But how do we pick psychosocial interventions? We can go on websites and evidence-based practices. There are numerous ones that are offered and listed in many of the databases that are out there. But if we start to pull the curtain back and think about the commonalities among evidence-based psychosocial practices, we can notice that they try to address similar processes and circumstances. And if we really kind of put a spotlight on the components that are shared across many interventions, we can start to think about building psychosocial protocols and psychosocial scaffolding combined with medication-assisted treatment in a way that culls the active and core components of effective evidence-based treatments that have been developed over the years. So together in this module, we'll be discussing four components that seem to transcend many of the different and separate evidence-based protocols that are out there. And that many of the psychosocial protocols that have received support over the years pay particular attention to the process of listening and having effective communication and conversation, and to the process of listening and having effective communication to help promote change, particularly in the context in which individuals may be demonstrating ambivalence or the back and forth of wanting to change and also wanting to stay the same. Psychosocial interventions also try to help clients develop and strengthen effective coping strategies and to encourage the continued practice of these skills. Many psychosocial interventions are trying to help individuals expand their repertoire of coping strategies so that they can navigate and respond to the challenging situations, both of change and of maintaining that change as the pulls and pull of life unfold. These useful, helpful conversations addressing ambivalence and structured skill buildings are two critical engagements, but they do happen in the bigger context of individuals' lives. So a third commonality to many treatment protocols is helping clients connect with reinforcement for engaging in non-substance use behavior. Critical thing we can think about is that often when we think about making changes around behavior, particularly substance use, we can get pulled into the idea of removing behaviors or taking things away. But entailed in that process is the space that is left, and a critical part of changing is helping individuals bring new things into their life, things that can make their life rewarding and compete with the older behaviors that they've practiced over time. So connecting with reinforcement is one critical strategy in developing that scaffolding. Part of that scaffolding is also building and utilizing social support. Again, reiterating that previous comment that change does not happen in a vacuum, but happens often in the context of people's interpersonal relationships. So let's just take a little bit more of a tour of these four components, the first one being communication strategies and listening and developing conversations that can help with ambivalence addresses this first question. Why should we focus on conversational style when we're thinking about helping people trying to make changes in their substance use? Well, we can look at some of the research that exists, that often individuals, when they seek help, are still in a state of ambivalence, and that is simultaneously wanting to make changes in their behavior, but also having reasons to maintain their current behavior. Substance use serves a purpose for people. It offers desired outcomes. Even when there's negative outcomes, there are things individuals get from their use of substances. And because of that, when people start entertaining the idea of making changes in substance use, they're left with a dilemma, saying goodbye to something that's been helpful and useful to them, and at the same time wanting to be able to cope with their life and develop a life that would be rewarding without substances. That in-between space of trying to say goodbye to something, but at the same time noticing that it can have a usefulness is captured in this construct or idea of ambivalence, and research suggests ambivalence is a normal part of the change process. But importantly, how people sit with ambivalence is related to how practitioners and loved ones respond to it. Often, if people are ambivalent and they're sitting in conversations that are more about confrontation, arguing, lecturing, people get more committed to the status quo. In fact, they may actually be ambivalent, but in the context or a conversation that asks them to choose, people may wind up defending the very behavior they want to change. So establishing collaborative conversations that help people work through their ambivalence and discuss their reasons for making change, that can highlight their belief in making change and their commitment to do this, when practiced and done strategically, actually can tilt their ambivalence towards making change. In essence, it's helping people give the mic to their change voice, as opposed to inadvertently giving the microphone to their stay the same voice. These conversational styles and being able to practice these conversational styles has been really captured in motivational interviewing. Motivational interviewing really can be defined as a collaborative conversational style for helping people strengthen their own motivation and commitment to change. Research has suggested that practitioners who develop conversational styles that align with the motivational interviewing principles can promote reductions in substance use, alcohol, drug use, help increase people's commitment to treatment, regiments, and compliance, and also help create a conversational space in which people are more likely to commit and follow through on other lifestyle behaviors, such as diet and exercise. If we unpack motivational interviewing, we can see two major components in these kind of conversational styles. There's the relational component, and also known as the spirit, and the technical components, which are what are the nuts and bolts of the words and conversational strategies that practitioners are using. We're going to highlight that here, but I also want to let people know that in practicing and learning motivational conversational styles, there are much more comprehensive training strategies and modules in the PCSS library. I refer people to explore and experiment with the motivational interviewing module for more information and more guidance on how to get better at this particular way of having conversations. But as a way of providing you an overview, the first thing we're going to talk about is, well, what is the spirit of a helpful conversational style? And motivational interviewing spirit really defines the relational stance taken by practitioners that helps create a context of collaborative conversations, and it's got four critical components. As I outline these components, just think about your own interactional style. And again, I want to highlight there's no right or wrong here. It's more just about the stance you take based on your beliefs and the way you want to step into conversations with the people you're talking about change with. The first critical component is the idea of partnership, is the idea of partnership, and that in a motivational interviewing style, there's an active collaboration between the practitioner and client, which is all about directing the conversation to meet and be in the service of the client's own goals. It's about listening to what the client would like to accomplish, the vision they have for themselves in their life and their desires and hopes, and having conversations that are in the service of helping them move towards that. In the context of that partnership, there's an acceptance of the client's worth and potential, and supporting their autonomy in the change process. And what you'll notice here is that individuals, our view is having strengths and autonomy, and have the right and perspective to be able to make their own decisions around their health behaviors and the direction they would like to go, including substance use. This acceptance stance and partnership creates a context of compassion, which is supporting and prioritizing the client's needs and trying to bring forth their motivation to change. This can be manifested in the way we try to have conversations that are all about helping individuals become the voice and the vocal piece of their change goals and initiatives. As we said before, it's the process of giving their change voice the microphone, so that we can pull forth from them their reasons for making change. And this is a little different often than other styles, which is about giving individuals something. Evocation is about pulling forth from a client. These four critical ingredients define the spirit and the overarching context in which the nuts and bolts of motivational interviewing conversations take place. The nuts and bolts of a motivational interviewing conversational style, in other words, how and what our counsel is saying, can be captured in the acronym of the ORSCOS. And in the practice of MI, practitioners are encouraged to use open questions more so than closed questions. As open questions promote a client's input, they send invitations for a client to talk more. They invite counselors to see the strengths that clients bring to the situation and try to affirm those strengths when they are seen. It's a way of helping promote and build self-efficacy and see the entire person that's seeking change, just not the parts of struggle. Critically helpful in conversational styles and motivational interviewing is the use of reflective listening practices and summary statements. And for practitioners rolling out an MI conversational style, they're often relying on reflective statements, giving back to an individual what they hear them saying, and summarizing what they hear an individual say in a way that communicates that a client is being listened to and helps open the door to make sure that what a clinician is hearing aligns with what the client is hoping to be saying. And it's this delicate balance of the ORSCOS that defines the nuts and bolts of an MI conversational style that is more about offering an invitation to bring people into the conversation and give them the microphone to change compared to other types of counseling strategies that are about informing or lecturing. Psychosocial interventions that use collaborative conversation styles set the stage for more partnership and partnering interaction that opens the door for a justification for the skills and strategies that we'll be talking about in the next three ingredients of a psychosocial intervention. As we talk about the skills building and we talk about reinforcement and other strategies, notice how they all be couched in the idea of their being in the service of helping clients meet their goals and changes in their lifestyle. So the second ingredient, second component of psychosocial interventions that have been shown to be effective in helping individuals make changes in their substance use is interventions that incorporate skill building and the practice of those skills. When we use that set of lenses, skill building treatment frameworks assume that substance use is a learned behavior and serves a range of functions for an individual. There's a reason why substance use remains in an individual's behavioral portfolio and if we're going to be asking individuals to step away from using substances, the idea is what can we help individuals bring into their life to take the place of what substances we're serving for. And this is a key assumption with skill building treatment approaches, that individuals can use the skills or need to practice and bolster their cognitive, emotional, and behavioral coping skills, particularly in a context in which they're no longer going to use substances to meet those needs. And when we think about an additive treatment strategy, combining psychosocial and medication interventions provide a wide net to be able to address the biological, psychological, and behavioral factors that contribute to ongoing substance use and the development of substance use disorders. I'm going to invite you to think about a cognitive behavioral formulation of relapse, and this is a set of lenses that underlies many of the skill building approaches to substance use interventions. That the probability of using substances is really influenced by the interaction of three factors. The extent to which individuals are experiencing physical symptoms of withdrawal, their cognitive and psychological processes that can be related to things such as their self-efficacy or belief they can make change, their belief they can handle the situation without substances, their belief that they have other skill sets that can be just as effective, and their motivation, that it's important for people to change and maintain non-substance use alternatives in a given situation, and their current emotional state, which can impact both the cognitive processes and be associated as well with physical symptoms withdrawal. But the interaction of these three processes is what determines the situational probability that an individual may find substance use helpful and reinforcing in this moment. By combining psychosocial and medication intervention strategies, we can cast a net that also helps touch and alleviate some of the challenges that the interaction of these three processes have for an individual who's trying to make these lifestyle changes. So how can we think about building coping skills in the context of psychosocial intervention? Coping skills interventions really are utilizing both cognitive and behavioral strategies to help educate individuals about their experiences of the situation and their experience of the change process, and start to think about developing skills and strategies to meet the needs of the situations they may find challenging throughout the course of their life. And we can think about these sets of ideas and strategies as being kind of grouped into four different sets. Recognition skills, avoidance skills, coping skills, and evaluation skills. So we'll start off with recognition skills. Recognition skills are really trying to help individuals sensitize their lenses so they can start to identify the environmental and psychological and subjective contexts in which substance use is likely to occur. This process has often been captured in words of people looking to recognize triggers or cues. The important point here is often in the change process, individuals may find themselves feeling like they can't predict their cravings or urges or predict when they'd be more likely to want to use substances. So by starting off discussions about recognition skills or offering them a set of lenses to make their experiences a little bit more predictable, that they can start to identify circumstances that might call forth pages of their learning history that show up by inviting them to engage in old practice behaviors such as substance use in given circumstances. Recognition skills can be forced and developed through various strategies. Often self-monitoring and recording of urges or cravings to use drugs or alcohol is one helpful strategy. And it also has been identified under another term called functional analysis. So training individuals to conduct their own functional analysis or an analysis of their behaviors to make their behavior more predictable and start to open up doors to think strategically about how to come up with ways to cope with those situations that can be challenging. So let's do a deeper dive on a functional analysis. It's a fancy term, but most often all we're asking again is helping individuals think strategically about their behaviors. What are the circumstances that send invitation for old behavioral patterns to show up? So a functional analysis exercise is an awareness building exercise, and it's going to help individuals start to make links between environmental circumstances and stimuli, the occurrence of certain thoughts and feelings, and the occurrence and desire to engage in certain behaviors. And an example here, those links for an individual could look like noticing that in the context of being in a bar, they start to feel really strong desires to drink and stop feeling anxious. And they notice a strong urge and desire to want to buy alcohol. It's contextualizing their desire to drink. Importantly, not only are we looking at what happens before the behavior, but it's also very helpful to think about what follows the behavior. What were the positive outcomes or the reinforcing outcomes? And what were some of the outcomes that were not reinforcing, that were undesirable or punishing? Because it's the combination of those reinforcing and punishing outcomes that either strengthen behavior or weaken behaviors over time, which can be critically helpful to people when they think about why certain behaviors have been in their repertoire for a long period of time. So that's putting a lot of thinking caps in our lenses. We're going to think about a liar. And this is just a clinical vignette about how functional analysis may be helpful to someone in the context of discussions about their outcomes. The liar was speaking with the nurse practitioner at her physician's office after a recent physical exam. Her blood work came back and it indicated elevated liver enzymes. Other aspects of the blood work were perfectly fine. It fell within the reference ranges. But in providing feedback, the nurse practitioner wanted a liar to think about where these elevated enzymes could be coming from, what could be contributing to that. So they discussed what factors could contribute to these elevated levels. And a liar was surprised that they were elevated, but in this context of conversation and a conversational style that was collaborative and open, she was noticing that perhaps she was drinking more than she had in the past. And enough for her to be thinking this is something she even made a New Year's resolution about. Up to this point in time, though, she has not had as much success as she would like in cutting back on her drinking. So the conversation really focused on this curiosity, the liar, about, well, what could be going on with her drinking? What could she notice? Would she be open to doing a functional analysis? Just a way of recording her experiences and circumstances around alcohol use to shed light on the next conversation of what she did notice and how that can inform her strategies and ideas about next steps. Again, the importance of the conversational style, since it was collaborative, nonjudgmental, and aligned with the liar's own goals of thinking that alcohol could be something she may want to explore. She was open and interested in at least trying it out for the weekend. And she sought to complete this behavior analysis form for Saturday and Sunday nights. This is a very busy form, but let's walk through it together. All a liar was asked to do in a form that looked like this was to complete certain columns around a drinking event. She was asked to think of triggers, or what was the context or situation that was involved in the drinking episode. She was asked to think about her thoughts and feelings, what was she thinking before she had that drink, to record what she did drink in that circumstance, and then to think about the positive consequences and the negative consequences following that. She had two drinking episodes that she wanted to report back to the nurse. The first was being at a friend's house watching movies with people on a Saturday night. She noticed she had these thoughts when she was sitting in the context of friends, that she was looking forward to the drink, she would feel much better. And she was also noticing that the chatter in her mind was saying she had a tough week and the drinking would help her take away some of that anxiety and relax. So she made herself a promise to only have one glass of wine, and she wound up having four to five glasses of wine over the course of the evening. She also noticed that afterwards, she actually did feel good and less anxious, and kind of enjoyed the evening with friends, she was more socially connected and more outgoing. But later on, she was feeling guilty. She'd got home later than she had planned. And she slept later on Sunday and missed her morning run, which kind of bummed her out. So notice what we did, and Aliyah did here, was she was able to put her drinking on Saturday night in the context of the situations and thoughts that preceded it, in both the positive and negative consequences. She also had a drinking episode on Sunday, after she got off the phone with her brother. And it was a tough phone call, and she was got into a fight. And she was feeling angry and upset. She also knows she was sitting home and was bored and had feelings of disappointment. So she did a nice job of being able to outline the trigger, the context and what her thoughts and feelings were. And she noticed that in that particular drinking episode, she had three glasses of wine. And she justified it to herself, because of the day being a tough one, and the argument adding to the stress of the day. And again, the positive and negative consequences were fleshed out, she started to feel relaxed, the conversation in her mind quieted a bit. She also later on in that day, wound up feeling not as well, having a headache, and not sleeping well and starting to work week off on a negative foot. This behavior analysis helped Aliyah just think of patterns and situations, and what she's getting out of drinking and some of the consequences that she's experiencing as a result of her drinking. It's helping her build recognition skills. Aliyah's work here is going to help her understand her behavior is a little bit perhaps more predictable, that she'll notice the context and situations that may make alcohol seem very appealing to her. It's also going to help her go back to the nurse and think about ways to prepare and strategize for those situations that might arise again. And again, increase the probability of a substance use. It sheds a light on her thought and feeling process. That may also factor in to her use of alcohol in the situation, as well as what she's getting out of it, particularly the reducing of anxiety and feeling more social. In this circumstance, if she's going to use alcohol less for that, it does raise the curiosity to have conversations about how can she accomplish those goals and get those similar outcomes with a different set of behaviors and skills. And that opens up entry points for developing a change plan. So how did Aliyah benefit from her recognition skills? Well, when she went back and discussed this, she noticed anxiety, anger, and boredom increase her desire to drink. And certainly, it's not confined to just one type of circumstance, both social and being alone circumstances can increase the probability of her to think about alcohol. And it really highlighted for her the challenge will be to think about other ways to manage her feelings of anxiety and anger when they do arise. She thought this was a good starting point and was looking forward to speaking with the nurse about her ideas, maybe to start to sculpt out a change plan and set of strategies to address these elements that were highlighted in her functional analysis. Another way to help build recognition can just be through an urge and craving diary. In this particular circumstance, what's highlighted is just asking individuals to document the days and times and situations that may be associated with urges or thoughts to consume alcohol or use substances. And this can be a simple self-monitoring device to help, again, build recognition skills for individuals who are just trying to better understand their use of substances. And in this example, you'll notice certain columns, both highlighting the dates and times in which cravings and urge developed. The same recognition practice of contextualizing those experiences by highlighting the situations, thoughts, and feelings that show up. And in this case, we may want to ask individuals of the intensity of their cravings. Notice some circumstances may actually prime really strong desires to use substances and others less so. Importantly, we can ask people to also document the length of struggle, giving them further recognition skills and understanding what some of the challenges will be in their attempts to make changes. And for those individuals that feel like they're successfully dealing with these strategies and skills, they can have a column for how I coped, a nice way to highlight alternative behaviors that are starting to be pulled into play to make these change strategies come to life. In the context of recognition skills, making behavior more predictable, avoidance skills try to capitalize on that, for there may be situations and circumstances that individuals can strategize about that will help minimize the likelihood they'll come into contact with high-risk situations. And by minimizing coming into contact with high-risk situations, we can help individuals decrease the probability of having to struggle with cravings, thoughts, emotions that may set them up to think more favorably of drinking or drug use. Examples of avoidance skills can be altering travel routes, neighborhoods, avoiding or changing members of social networks, removing drug or alcohol paraphernalia from the home. Often people have described this as people, places and things, and the philosophy is leveraging that power of recognition skills, that if I know I'm going to come into contact with certain triggers, I can help myself by putting some distance between myself and those triggers by avoiding and finding alternative strategies and contexts. While avoidance strategies are particularly helpful, often, or at least in some circumstances, we can't avoid all circumstances. Individuals know they'll be running into high-risk situations, and if they can't avoid it, a different set of ideas need to be pulled into play. So skill-building approaches want to help individuals by developing alternative coping strategies. Using recognition and avoidance skills, we want to add to those to help individuals build cognitive and behavioral techniques for responding to their cravings and thoughts in ways that offer other strategies and other pathways to obtain desired outcomes. Numerous strategies can fall into this bucket. They can be under the context of refusal skills, learning how to say no, learning how to buffer oneself from offers to use drugs or alcohol, strategies that help individuals manage their own thoughts about using, particularly in circumstances where their mind may be offering justifications or reasons why substance use makes sense in that moment, to help individuals practice and learn other decision-making skills, often the ability to think through short-term positive outcomes and think about further long-term positive outcomes that may be more in line with their long-term change plans, and then to develop skills and strategies to adhere to treatment programs and treatment strategies that can maintain a commitment to the different components in their treatment program. So let's walk through some strategies to manage thoughts about using. This is one bucket of coping skills that often individuals are asked to utilize and practice in the context of trying to make change. As people get to recognize and know what they can and can't avoid, we can start to strategize around those situations that they can't avoid and how to deal with their experiences and challenges in those situations. And some examples of managing thoughts about using can involve thinking through remembering the end of the last high. What does that mean for individuals? Often just asking individuals to list and practice recalling the negative consequences of their use can keep that more accessible to them, particularly in those circumstances when their mind is more likely to be reminded of the positive outcomes of those substance use. And remember our behavioral analysis program that offered and asked individuals to record both the negative and positive consequences. The insight gained from that exercise can help them start to think about those long-term consequences that they identified when their decisions to use substances have brought them further away from the way they wanted to be. Other active strategies include challenging thoughts to use substances, and that could be listing responses to the positive thoughts again on the card. Notice the accessibility invitation for people. Often being caught in a toggle war in your mind can make some of the useful thoughts less accessible. So these lists and these strategies to have people put them on paper in a way that they can access them in those difficult moments can be particularly helpful. Distraction techniques are also very helpful, helping individuals guide their attention to other aspects of the situations or thoughts or activities as a way to help dampen the allure and the pull of reminders or triggers or cues that have been associated with substance use in the past. Lately, meditation practices have become more and more pronounced in both self-care strategies and in a lot of different health domains. And mindfulness techniques can also be a very useful strategy for helping individuals manage thoughts about using. And for certain individuals, they can practice observing their thoughts or the experience of a craving, not as something that's a mandate to use substances, but just as another internal experience that is passing through. For those individuals that have a basis for practicing mindfulness techniques, this can be a very useful strategy to turn towards the experience of thoughts and cravings towards an event and create a little distance between what their mind might be telling them in the moment and the ability to make a decision that's more in line with their long-term goals. So let's look at just another vignette in which coping skills were being used to help an individual make changes in their substance use. And I introduce you to Kyle, who's a 40-year-old single male who's been using cocaine on and off the past 15 years. And he recently reached out to a friend who has been working as an assistant in a group medical practice. They've had a nice relationship, and it goes back for a while. And Kyle is starting to look for strategies to help him meet his recent goal of abstaining from cocaine use, at least for the next three months. He doesn't like how it's taken over more of his life, and he's leveraging the collaborative relationship he has with this individual to take the risk of starting to talk about making these changes in his life. Kyle has some shame around this part of his behavior. One thing Kyle noticed is that he really finds it hard to stop thinking about cocaine on weekend nights. And he really starts to get anxious as the weekend approaches, because he knows that's going to be another tug of war that he has to fight through. So they discuss some strategies to help him manage these thoughts. Notice how Kyle uses recognition skills to notice that the weekend is going to be a challenging situation, as the weekend is a trigger, a cue to start to engage in cocaine using thoughts and self-talk. So his first step here was going to write down the thoughts that he has, and then just discuss how he responded to them with his phone. And again, just another simple form that Kyle was using. This particular strategy invited Kyle to actually articulate the thoughts he was having on the weekend. And he noticed certain ways his mind was talking to him. Such as, I could use a pick me up, and I have more social, I'd be more social and have more fun if I were to use cocaine. But in his practice, he was also trying to come up with arguments against that or alternative ways to talk to himself when those thoughts arose. And his strategy and thinking skills here were to think through. And here he knows he's been social in the past without cocaine, there's evidence that he can offer that thought. And he has started to practice starting conversations with his therapist, and he's going to start trying to practice those skills on the weekend. In response to the thoughts of using cocaine, telling him that's the only way he can be more social. He also noticed on the weekend, he can think that his mind tells him it's payday and he's got some extra cash. It would be nice to treat himself to some cocaine as a reward for a tough week. That can be very alluring. Kyle's strategy and response here is to engage in other kind of thoughts or thought patterns. And he thought through to that column of negative consequences. When he really looks at his history, it's never really just been a little. And he's always wound up spending more money than he plans. So in lieu of listening to that thought, he's going to now try to call a friend and see if he can make plans on the weekend in a way that doesn't leave space to start thinking or entertaining the idea of cocaine use. Third set of context in which his thoughts show up for cocaine use is in the context of feeling low, a low mood. And his mind can also remind him that a couple of lines will make the mood go away and he'll actually feel better for some time. And when he starts to think about feeling better, he even notices his body gets tense and excited when entertaining the thought of using cocaine. His recognition skills of that's how he talks to himself, he used that to pivot a little bit. And he engages in a different response to that thought. He tries to remind himself to take a breath and just notice where his tension is. He notices that he gets a little anxious and excited when the thought of cocaine arises. So instead of acting on that, he just wants to bring some observation to that. Some mindfulness skills. Creating that space of not reacting to the thought, but just noticing it allows him to make room to stop bringing other ideas and thoughts and ways of talking to himself that remind him of the changes he wants to make and the benefits he'll get by staying true to his change plan. Building skills and practicing in one's life can help individuals meet success and promote change. And then other times they don't always land and work the way the individual initially plans or envisions it. So evaluation skills, the fourth bucket of the coping skills, psychosocial intervention, helps individuals assess the outcomes when they're trying their different skills in a way that allows them to see the successes that happen and allows them to collect data that allows them to continue to discuss and refine their coping strategies to increase the likelihood that they're able to continue and maintain the changes they're looking to develop. Critically important here when we think about change, it's change as a process and change that's built on practice. And I do ask you all to think about the process of change, again, not being by subtraction. In fact, when we think about all the behaviors we've had and learned over life, there is no race button on that. However, change is by adding new behaviors on top of the old behaviors that we've already learned in the course of living. So evaluation skills help individuals assess, track the behaviors they're trying to add so that they can contemplate and see if they're helping them get their desired outcomes in a way that allows them to compete with the older behaviors they're trying to not rely on. And these evaluation skills incorporate tracking and monitoring devices like the behavior analysis skills and the thought management skills we highlight in the vignettes. These skills are facilitated by asking individuals to bring their tracking records to a treatment visit to go over and discuss their take on what they notice and to collaborate around what would be useful next steps based on what they notice. Evaluation skills can also be aligned with monitoring systems, part of the treatment protocol such as your monitoring systems. We'll talk about this in the next set of skills, but your monitoring systems can be helpful, not as a way of being a punitive device, but to help individuals leverage different forms of scaffolding to support their desire to change. So these strategies can be particularly useful in the iterative process of helping individuals understand what's working and what's not. So these strategies can be particularly useful. In the iterative process of helping individuals refine their recognition, avoidance and coping strategies over time. Critical to all these behavioral practice strategies is practice. Practice is the process of addition. And it's important to help individuals think about how they can practice in between sessions in their life. And also I invite you all to think about how in session conversations can also be used as practice sessions. For example, if someone's practicing refusal skills, an in-session conversation can be a wonderful place to help individuals practice refusing offers for drugs or alcohol in a given situation. The evidence supports the use of these practice skills and individuals who demonstrate greater skill acquisition in complete practice sessions do better, accumulate more skills than those kind of strategies that don't invite individuals to practice. And importantly, they yield better outcomes. Individuals who actively try to get better and use those recognition and avoidance strategies and coping strategies tend to have better treatment outcomes than those that don't. Psychosocial interventions that include skill building and practice protocols. There's flexibility there. They can be used in individual treatment conversations and for treatment situations that have group support aspects to it. And the use of coping skills protocols and psychosocial interventions can be used in group formats as well. And they've been used across a range of substances. And they've been investigated and are delivered in conjunction with pharmacotherapy. Thinking about the additive properties of that. Again, adding pharmacotherapy aspects to treatment can totally align with the use and practice of skill building programs. And skill building programs demonstrate better outcomes than just general forms of support and counsel. One thing to keep in mind when we think about teaching individuals coping skill strategies, that there's some evidence to suggest individuals who have impaired cognitive functioning may require more prolonged practice or other ways of coming into contact with skills that they don't readily learn as quickly as other individuals. So in short-term studies, their outcomes are a little less favorable than those who have cognitive functioning in the normal range. The third critical ingredient in psychosocial interventions that we can think about is the idea of competing reinforcement. While our interactions with individuals we're trying to help can be guided by the use of those motivational interviewing skills, that when we help individuals think and start to practice recognition and avoiding skills and coping skills, and that more effectively help them deal with their life, the process of stepping away from substance use and trying to bring other factors into life relies on this idea of competing reinforcement. And the science is pretty helpful here. That we know the value of drug or alcohol use for any given individual is really in part based on the availability of reinforcers also available in their life. And that is for individuals who are using substances, if there are no other rewarding behaviors or outlets in their life, the value they place in substance use is much greater than individuals who have other things of value and importance. And this can be demonstrated in experimental studies, even when you ask people to make a choice between self-administering drugs or choosing alternative reinforcement. The mere presence of alternative reinforcement decreases the probability individuals choose drug over alternative valued items. This kind of experimental evidence has been called and incorporated in treatment protocols in which they try to help individuals build social environmental contexts that offers competing reinforcement to drug use. And this can be part of the treatment protocol, as well as the larger context of social support. One process of building competing reinforcement can be found in the contingency management literature. And really what we mean by contingency management is it's a very systematic way of thinking of providing positive reinforcement for non-substance use behavior. And the goal of contingency management protocols is to create a context in which both therapeutically appropriate behavior and substance use are followed by predictable consequences in a way that increases the probability of an individual's drug use. This can be found in clinic-based procedures for reinforcement, and that can be geared towards abstinence. It can also be geared towards treatment adherence and attendance. And just as importantly, these skills can be taught to families. This can be found in clinic-based procedures for reinforcement, and that can be geared towards abstinence. It can also be geared towards treatment adherence and attendance. And just as importantly, these skills can be taught to family members to help create a context at home that uses contingency management in a way that supports treatment seeking and long-term behavior change. The implementation of contingency management procedures is found in community reinforcement approach or CRAFT, which we'll also discuss in a little bit. So let's step back for one moment. What's this thing of reinforcement? We hear it all the time. We can think about it. And yet it can be used very specifically in the behavioral science literature. So I just want to go over some definitions and show where reinforcement is positioned when used strategically as part of a psychosocial intervention. The term reinforcement really, when we think in behavioral science terms, it's a consequence that adds or subtracts something from a person's environment, which has the effect of increasing the chances that a specific behavior is going to happen again. In other words, it's kind of arranging things so that the world responds in a way that makes a behavior more likely to happen again. And the response can be adding something to the person's world or taking something away from the person's world. Positive reinforcement is adding something to an individual's world. Positive reinforcement is adding a desired consequence that's contingent on a specific behavior happening, such as meeting a therapeutic goal. It can take all shapes and sizes. It can be a simple compliment on the person's success. It could be something tangible. It could be a smile. But it is a contingent response to a desired behavior. Negative reinforcement is removing something that is kind of aversive or unwanted in response to a behavior that occurs. The negative part means something is taken away. The reinforcement means we're strengthening a behavior. It's interesting we can think about it. Often ways of trying to motivate people to change, like nagging, and for some people, they may engage in threats and other things. That's an example of negative reinforcement, that when the behavior happens, the nagging stops or the threat is taken away. In contingency management protocols, positive reinforcement is the preferred strategy for increasing behavior. All the reinforcement strategies I'll be talking about use positive reinforcement and step away from trying to use negative reinforcement as the therapeutic agent. Or a component of a behavioral protocol. While reinforcement is used to increase behaviors, we can think of this idea of punishment as a response or way a world responds to decreased behaviors. And we can think about it in similar ways that we did just about reinforcement. When the world responds to a behavior and adds something or subtracts something that strengthens that behavior or makes it more likely, well, I'm sorry, less likely to occur, we consider that punishment. And that can happen in two ways. Positive punishment is delivering or adding an aversive consequence contingent on the occurrence of a behavior we don't want to support. That can be a lot of different examples from verbal disapproval to other responses to add aversiveness, yelling, things along those lines. Negative punishment is removing something positive from an individual's environment that's contingent on the occurrence of a behavior we don't want to support. Negative punishment can look like the removal of attention, the removal of money, the removal of, in case with children, video games or access to positive reinforcement. Behavioral protocols want to use negative punishment as the preferred strategy for decreasing behavior. So the pairing of these behavioral science principles is positive reinforcement is used to strengthen behavior and the removal of something positive or negative punishment is used to decrease behavior. And it's this combined approach of positive reinforcement and negative punishment that creates a context for supporting change. Well, how well does it work? If we think strategically about creating contexts in which people are going to meet with positive reinforcement for making change and losing reinforcement for engaging in other behaviors that we don't want to support, the evidence is pretty compelling. Contingency management programs facilitate some of the quickest and most significant reductions in substance use relative to other treatments that do not systematically apply reinforcement or punishment principles. And these effects have been demonstrated across all types of substances from alcohol use, cocaine use, opioid use, as well as polysubstance use. And that when we really want to harness the power of reinforcement and think through strategically, it exerts a significant effect. Just as importantly, while this can be done in the office, families can learn the utility of positive reinforcement and the removal of reinforcers to help create a context at home that can support motivation for their loved ones to seek treatment, as well as decrease unwanted behaviors. This harnessing was developed in a treatment protocol that was developed in 1999 and published under the term CRAFT. So let's take a look at CRAFT. I'm going to hit pause on that for one moment. You can take a slight detour. Before CRAFT, we're going to talk about office-based CM programs. How would that look in an office? How would that look in a situation where people come into a clinic? Often, clinics employ CM protocols by clearly defining the treatment-related behavior that they want to support. That's an important first step. What are we looking for? And can we help communicate that to individuals who are looking to make change? Clearly defining a treatment behavior could be the absence of certain substances, decreasing substances, staying or adhering to medication protocols, could be also increasing social interactions. Clearly defining a treatment-related behavior is the first step. The second step is being able to see it and objectively assess it. While defining really clarifies what we're looking for, we have to be able to assess it in a way that allows us to note that the behavior occurred. Often, this is done by explicitly linking behaviors to what clinics can assess and measure. That could be a urine analysis that does not have or cannot detect the substance we're hoping individuals are going to change. For an individual looking to be cocaine abstinent, that a urine testing for the presence of cocaine metabolites comes back negative. It could be the presence of medication, either by returning medication bottles or the presence of the medication in the urine. It could be the completion of outer session assignments. Notice all these definitions are things that can be observed and tracked. Upon being able to track that, the other step is offering a tangible outcome or reinforcer when that behavior or that outcome is detected. And that can vary in many shapes and sizes. Typical research studies have shown draws from a prize ball for cocaine-free urine, or if medication adherence is demonstrated, people get vouchers to buy things at local supermarkets. Methadone maintenance clinics have used take-home medicine privileges if individuals are opioid negative in the urine analysis. So there's a lot of creative ways to think about it. The power in this is defining the behavior, tracking it, and having some tangible positive reinforcer that's available if the behavior does occur. And the system is set up in a way that applies these contingencies consistently, and that is available each time the behavior happens, and immediately, that individuals can experience the reward close to when the behavior happens. These are key critical ingredients to implementing CM procedures in office-based counseling situations. As I mentioned before, a craft is the same kind of harnessing, but often it's training family members to how to use contingency management as a way of supporting and providing scaffolding for themselves and their loved ones. Craft Studies first came out in 1999 and hasn't found its way into the world as fast as we would like, but it is a unilateral therapy for family or concerned significant others. And why is a unilateral therapy important? Often, as we noted in the beginning of our talk, it's a very small percentage of individuals struggling with substance use and substance use disorders that will actually seek help. So families are on the front line and families are being asked to support their loved one, even if their loved one is not seeking support or wanting support in that moment. So unilateral therapy really is working with the families, irrespective of what their loved one desires at that point. And the idea of offering family members the skills and strategies they can use without an individual wanting or needing treatment in that moment. What a craft does is it promotes an active, positive participation from family members. That helps them implement motivational strategies that solely stem from the use of positive reinforcement, all with the goal of trying to enhance their loved one, to increase non-substance use behaviors, and to decrease their use of substances. And so families can perhaps seek help for their substance use disorders. Over the years, craft has been modified to help parents of adolescents, as well as adults. So it is helping family members help loved ones across a whole continuum of age and development. It's also helped improve retention among individuals who are already enrolled in opioid use disorder treatment protocols. And the results have been pretty impressive, that when families reach out and learn the skills and strategies embedded in craft, 60 to 70% of their loved ones who had no interest in seeking help prior, reach out to a treatment provider and start to engage in the treatment process. So craft is a skills-based approach, as it is helping families learn strategies and skills that they can use in the house. And while it was developed to help motivate and invite loved ones to seek help, it can also help families after their loved one decides to make changes in their life by providing them a set of communication and behavioral strategies that can be implemented throughout the course of a loved one's recovery. So let's just talk about the three goals of craft. When positive reinforcement is used to help family members, it's striving to improve the emotional, physical, and relational functioning of concerned significant others. In other words, help family members take better care of themselves. That alone in and of itself is a huge help to family members who've been on the front lines often for years before loved ones may seek assistance. It helps increase the chances that a loved one using substances will initiate treatment. And it also decreases a loved one's frequency of substance use, even before they may decide to seek help. So let's go about trying to address these three objectives. They have eight core components I'm just going to touch base on right now. Craft wants to provide an introduction and treatment rationale to families. It validates the experience of family members. It invites them to think about how they can respond differently to their loved one, to help promote change in the loved one that they're concerned about. And it really highlights the power of positive reinforcement, which is a key component as we said in contingency management principles. Craft also identifies that sometimes the circumstances in which families are trying to build scaffolding around their loved ones, and in some circumstances, there is concerns about violence and dangerous behavior. So Craft wants to help strategize with family members to have plans around violent responses from their loved ones or other dangerous activities in a way that provides family members support, but offers them options if their substance user is more likely to start to respond in aggressive ways. Craft trains family members to engage in functional analysis of their loved one's behavior, to establish skills, do a kind of behavior analysis, we all did at the beginning of this talk. Not only can loved ones do that to understand their own behaviors, family members can start to do those behavior analyses to understand their loved one's behavior, which helps start to invite them to think about certain strategies and ways to help promote change. Communication skills are a key component of Craft. Most change efforts happen in the context of human interaction and discussions. As we discussed in the beginning of psychosocial protocols, how conversation styles are implemented are critically important often in how individuals respond to their own ambivalence. And Craft wants to help train family members different ways of communicating positively to increase the likelihood of more productive conversations and conversations that can help set the stage for change. Positive communication training encompasses seven steps that family members practice and roll out at home, particularly in circumstances when they're trying to offer advice or feedback to their loved ones. These seven steps are about practice and being brief, how to word things in an affirmative way, how to stay narrowly defined to specific behaviors when talking as opposed to broad characteristics of an individual, the benefit of labeling feelings, trying to offer understanding statements, which is seeing the world through their loved one's eyes, and to be collaborative, that when it makes sense to take partial responsibility of their own actions and where appropriate to offer help. These seven ingredients or steps allow for conversations to be tailored in ways to make them more impactful. Major component of Craft is the use of positive reinforcement training and how to put in contingencies that add something to an individual's life to help promote new behaviors when they occur. We discussed this in the contingency management part of the protocol. The families are also trained in how to respond favorably and reinforcing to their loved ones change directed behaviors. Just as important, when we talked about negative punishment or the removal of reinforcements in response to behaviors that we don't want to support, family members learn this in the context of setting limits and setting expectations for their loved one about how they will respond to behaviors they no longer want to support. The last two components of community reinforcement family training, and importantly, is self-care. Family members are on the front line. Often they're the ones interacting with their loved ones. They're the ones trying to support their loved ones. They're trying to figure out how to support their loved ones. They're trying to figure out how to best get their loved ones to think about change. And since most individuals will not come into contact with a treatment professional, families are critically the main players on the front line. Often we talk about change as being a marathon and not a sprint and helping family members think about this marathon of change and their own self-care is critically important in keeping them engaged in the process of treatment, the process of support over the long haul. Often you can hear that in terms of first thing you're supposed to do on an airline is put on your own oxygen mask while helping others. That metaphor applies to self-care here because for many families, self-care falls to the bottom of the list. Implementing seven of these core components supports the idea of when and finding times to suggest treatment for a substance user. Families are trained in how to use motivational hooks and use their positive communication skills at the appropriate time and the right time to invite their substance using loved one to sample or explore treatment. It is the use of these kind of planned timing conversations that increases the likelihood they would be impactful and leverages the motivation a loved one may have at that given point in time for wanting to make things different. Why do we include CRAFT as part of a psychosocial intervention or something to think about as a health care provider? You may come into contact with family members asking for help before you'll actually come into contact with someone looking to make changes in substance use. Health care professionals are front line individuals and often families who feel connected to their health care provider may probe and ask questions about how they can support a loved one who may be struggling. We know that research supports CRAFT as a way of helping families engage their loved one and help themselves in this process of supporting a loved one with a substance use disorder. We know that training families in the eight components can increase treatment impact and provide opportunities for collaborations in a way that differ from other ways that families are instructed to respond to their loved one's behavior. And by training concerned significant others or family members in the skills of CRAFT, it actually can bolster the efficacy of other treatment approaches when loved ones seek treatment and engage in the process of change. So a comprehensive skill building approach that may include medication protocols, behavioral protocols, can significantly be enhanced when scaffolding and supportive scaffolding are placed around an individual's loved one's change efforts and family is on the front line of that scaffold. So CRAFT can be a useful thing to think about and help families engage in and explore as they seek their loved one. This springboards us to the fourth component of effective psychosocial interventions. We have helpful conversations, skill building, the use of positive reinforcements, and scaffolding around change. And that also highlights the importance of social support. We know that chronic substance use can result in social isolation. And social isolation is a significant predictor of poor outcomes. We know on the other hand, greater social support predicts better treatment intention and greater treatment outcomes, better treatment outcomes. And that most individuals do have social connections. And family and close ones are the primary members in a lot of these social networks. When individuals engage in family activities during treatment, or significant others or family members are brought into the treatment process, we see better treatment intention and greater rates of abstinence. Social support plays a critical component in the change process. And there was one study in particular that just showed that family members that come in for as little as one session can improve retention, medication compliance, and outcomes among individuals who are seeking help for an opioid use disorder. In recognition of the importance of social support, there have been many studies and many treatment protocols that try to leverage the power of individuals' social networks. And family while seeking help. Some of these are listed on this slide. There are behavioral couples therapies, behavioral naltrexone therapy used to leverage social support for medication adherence. Network therapy, directly seeking to bring together the social network of individual making changes as to support their dedication and commitment to the treatment protocol. As we discussed, community reinforcement and family training, which can be implemented if an individual is in treatment or even if the individual is not engaged in treatment. And evidence-based protocols like multidimensional family therapy, which is working with the family system to help individuals who are struggling with substance use disorders. The commonality among all of these treatment protocols entails practicing communication skills, practicing reinforcement principles to support pro-treatment change, and to think through about effective ways to respond to behaviors that are not consistent with therapeutically directed change efforts. As we noted, family-focused treatments help increase medication adherence and compliance, can be used for medication monitoring agreements, can also just be used for socially reinforcing and acknowledging an individual's ongoing efforts to stay true to their treatment plan. It can be used to help them stay and receive reinforcement for ongoing abstinence. And it can actually change the overall quality of family interactions in a way that can sustain the change process and enhance the quality of family life. And importantly, it gives family members a frame of reference to understand the process of change, that particularly in substance use and the chronic nature of that, that change can often follow a phasic nature or a phasic trajectory in which significant efforts and change happens that can be interspersed with periods of relapse and old behaviors happening. But it does help family members orient towards that in a way that is more useful and more productive and supportive than if that awareness was not offered to them. I don't want to miss out on the opportunity to talk about social support that happens outside more formal treatment arrangements. And we can think about that in mutual support groups, which leverage the same strengths of social support and social commitment and the breaking of isolation, which can be found in 12-step programs such as Alcoholics Anonymous, Narcotics Anonymous, which all support abstinence-based goals. And certain research has shown that it's the use of social supports in the long-term that help promote better treatment outcomes. And when combined with formal treatment programs, the one-two formal treatment programs and long-term social support offers the most supportive scaffolding for long-term benefits available. So I want to thank you for staying for this longer journey and talking about critical elements to psychosocial interventions. We started out by highlighting that combining psychosocial and medication-based treatments, we can increase the probability of better outcomes for individuals looking to make changes. That we pull back and look at all the different treatment programs and strategies that are out there. We can kind of group them into holding four key components that effective psychosocial interventions can leverage, utilize, and do include in promoting change. Conversational styles matter. That if we allow space for people to be ambivalent and practice conversational styles that are collaborative and structured in helping provide individuals' own voice for change come to the forefront, that individuals are more likely to tip towards committing to making changes in conversational styles that are more confrontational and do not allow for ambivalence. As individuals step into the change process, change happens by adding new skills and coping strategies to one's behavioral portfolio. And these strategies can help build recognition skills, skills to avoid, skills to better cope, and skills to evaluate the effectiveness of the strategies that provides the ability to tweak, alter, and change strategies as circumstances change. But the inclusion of all these in the pursuit or in the service of removing substance use from one's individual's kind of repertoire opens up space in the question for what's going to take its place. Helping individuals contact positive reinforcement for bringing new behaviors, new non-substance use activities into their life are critically important for long-term change and can be incorporated in office-based procedures that utilize positive reinforcement and contingency management strategies. What could be handed to families to think about how to use positive reinforcement and competing reinforcement in the context of their own family and social interactions? Competing reinforcement is also found in the building of social networks and social connection that can support long-term change. And by being able to encourage individuals and help carry on conversations that ask them to entertain, how to go about building more supportive networks can be a critical ingredient as part of the psychosocial program for supporting change. I want to thank you for taking the time. And there are numerous references I will be just going through here for your own exploration and certainly your own further analysis of the outcome studies that supported these four dimensions that we spoke about. I would like to make you aware of two resources also that are available to you, in addition to the references that were scrolled through. And these two resources are offered through PCSS and may be of interest to you. First, PSS mentor program is designed to offer mentoring assistance to those in need of more one-on-one interactions with one of our colleagues to address important clinical questions. You have the option of requesting a mentor from our mentor directory, where we are happy to pair you with one. To find out more information, you can visit our website using the web link noted on this slide. Second, PCSS offers a discussion forum, which is comprised of our PCSS mentors and other experts in the field who help provide prompt responses to clinical cases and questions. We also have a mentor on call each month. And this person is available to address any submitted questions through the discussion forum. You can create a new login account by clicking the image on the slide to access the registration page. Just want to simply note the consortium of lead partner organizations that are part of the PCSS project. And please note in reference that we have other contact info. We have a website you can access and Twitter and Facebook handles to find out more about our resources and educational offerings. Thank you for your time. And I hope this was informative in your thinking about how to build a scaffolding around individuals looking to make changes in their substance use, particularly in the combined perspective of psychosocial interventions and medication-assisted treatment.

psychosocial treatment protocols

addictions treatment

evidence-based practices

opioid use disorders

communication strategies

skill-building exercises

reinforcement for non-substance use behavior

social support

motivational interviewing

trigger recognition

coping skills

family-focused treatments

contingency management