Effective strategies for facilitating engagement

Angela Williams, PhD.

› Describe the underlying biological processes associated with Addiction.

› Identify and differentiate biologically driven behaviors from self-directed conscious behaviors.

› Apply strategies to overcome biologically driven behaviors to engage parents in treatment.

PsychologicalSocial

Biological

Addiction

Brain Disorder=

Neuroplasticity+

Salience Theory

› Brain Disorder = Neuroplasticity + Salience Theory of Addiction

› The structure and function of the brain is changed, sometimes irreparably, through the use of psychoactive substances, so that the drug becomes the most important thing to survival.

› To the brain survival means:– The survival of your genes, even at the expense of the body

– It relies on neural pathways built in youth.

› Neurons

› Neurotransmission

› Neurochemicals

› Neural pathways

› Neural systems

Sending neuronReceiving Neuron

Receptors Neurotransmitter

(Neurochemical)

› Certain chemicals motivate you to go towards rewards that promote survival.– Dopamine, endorphin, serotonin, oxytocin.

› While other chemicals alert you to avoid obstacles to survival.– Cortisol.

› There is a natural ebb and flow to these chemicals and duration is brief, therefore:– We have to do more to get more.

– This is why we keep seeking certain chemicals as if it is a matter of life and death.

Neurochemical Purpose

Dopamine

Implicated in memory, learning and motivation by creating

a pleasurable reward. Pleasure reward is activated for

taking action, or the anticipation of taking action towards

meeting a survival need.

Endorphin (natural opiate)Masks pain so you can do what it takes to survive. Also

implicated in the reinforcement of addictive behaviors.

Endocannabinoids

Inhibits goal directed behaviors in favor of habitual

behaviors in part of brain that has to do with decision

making.

Serotonin

Provides feelings of fear or relaxation based upon social

context. Implicated in mood, and mental focus, learning

ability, mental clarity (Mental fog).

OxytocinTogether protect someone from revisiting life-threatening

situations by deeply embedding a traumatic

experience and flagging the memory for importance. They

strengthens memories of traumatic stress or experiences

that evoke fear so that thy are readily available in memory.Cortisol

› Neuroplasticity – the ability of the brain to create new connections due to experience.

– The ability of the neurons to rewire different parts of the brain together in response to stimuli.

– The greater the stimuli the more neurons respond and the stronger this neural pathway becomes.

– Automatic or habitual behavior occur when the pathway does not require conscious thought to be activated.

› Drugs of abuse mimic naturally

occurring neurotransmitters

(chemicals) in the brain, and they

can do several things:

– Attach onto the receptor.

– Block the natural neurotransmitter from

attaching.

– Stop the reuptake of the natural.

neurotransmitter when it is released from

the receptor.

› Drugs of abuse act upon the brain and makes changes in important ways:– Firstly, when a drug enters the brain it floods the corresponding

receptors.› This flooding creates a sense of euphoria that signals the brain that this is

a very important experience for survival.

› With repeated use of the drug naturally occurring neurotransmitters such as dopamine, endorphin and serotonin effectively stop being produced.

› Secondly, with repeated experience the neurons begin to create new neural pathways (neuroplasticity) in order to create connections between areas of the brain that are associated with this feeling of pleasure.

– The brain:– Quickly learns the behaviors necessary to produce this euphoric feeling.

– Provides the motivation for these behaviors, by anticipating the euphoria.

– And remembers the behaviors needed to acquired the drugs.

› As the person continues to use drugs these new neural pathways become stronger and create super neural pathways.

– Behaviors become habitual, and may appear impulsive and illogical.

› Thirdly, damage to the neurons occurs.– When a neuron’s receptor sites become

flooded with a drug the receptors begin to switch off to protect themselves and less of the natural neurochemical is produced.

– Over time more of the drug is needed to feel the same effects› This is called tolerance.

– When there is insufficient drug to occupy receptor sites, this leads to the experience of withdrawal symptoms and cravings.› This is called dependence.

– Sometimes, the neuron becomes so damaged that it dies, and this creates permanent brain damage.

– Finally, withdrawal signals to the brain that survival is threatened, and that the body needs to go and get more of the drug.

› Withdrawal

– Without the drug the brain has difficulties functioning correctly and this creates negative physiological symptoms.

› For example: body temperature regulation may be affected resulting in symptoms such as profuse sweating and chills.

› Other withdrawal symptoms can include sleep disturbances, joint pain (perceived as severe), heart palpitations, seizures, nausea and vomiting, and anxiety/panic attacks. Some of these can be life threatening.

› Many addicts liken withdrawal to the worse flu they ever had.

– These highly negative symptoms create stress on the body and releases cortisol.

– The release of cortisol signals the brain as an immediate threat to survival that produces a fear response and drives drug seeking behaviors.

– Finally, withdrawal signals to the brain that survival is threatened, and that the

body needs to go and get more of the drug.

› The more chronic the addiction, the more the brain will find ways of avoiding

withdrawal and acquiring the drug leading to automatic behaviors, that often appear

impulsive.

› Once the neurons signal they require more drug, cravings for the drug are

experienced.

› Cravings are a signal to consciousness that action needs to be taken.

– Memory circuits are activated to motivate behavior towards acquiring more of the drug.

– Oxytocin is released which increases the salience value of the drug.

– These become the driving force that leads people to act in ways they never thought possible.

– Withdrawal, craving and acquisition of the drug are traumatic stressful events, and trigger an

oxytocin and cortisol response. This means that once this new behavior is learned it becomes

readily available in memory to be used again.

– Because the brain has the ability to predict outcomes, these behaviors will often be employed

to avoid withdrawal at all costs.

Drug

› The neurons begin to heal shortly after cessation of the drug.

– Receptors begin to switch back on.

– Natural neurochemicals begin to be replenished.

› However, it can take months, if not years for natural functionality to return.

– Receptors do not turn on until there are sufficient neurochemicals that require their

use.

– The lack of these natural neurochemicals can lead to:› Anxiety and panic attacks; depression; difficulties in experiencing pleasure; lack of

motivation.

› A sense that memory is failing (memory loss, lack of concentration, difficulties in following directions and problem solving).

› Feelings of shame and guilt; feelings of being a failure; anger, agitation and irritability.

› Physical symptoms such as joint pain “in the bones;” difficulties falling or staying asleep; fatigue.

› How quickly these natural neurochemicals are replaced is

dependent on several factors:

– Food that is consumed.

› Dopamine has to be metabolized from eating leafy green vegetables and seafood,

and drinking milk.

– Living with, or being in the company of non-judgmental supportive people.

› Substance abuse treatment, peer support groups such as 12 step programs etc.

– Refraining from ingesting nicotine as it can prolong the healing process.

– Avoiding triggers – people, places and things.

– Compliance to psychiatric medications.

– Good sleep hygiene.

› Post Acute Withdrawal Syndrome (PAWS):

– Following the cessation of certain drugs, there can be a period of instability called

post acute withdrawal syndrome that occurs between 45-90 days following last use

and can last as long as 2 years, although the symptoms diminish over time. These

symptoms:

› Can include intense craving for the drug, drug dreams, and upon waking there may be a feeling of being “high” or symptoms of withdrawal may be experienced.

› Are generated when the healing dopamine receptors first begin to fire in part of the brain associated with craving and dreams (VTA).

› Also occur at a time when the neurons have not had time to sufficiently rewire the old drug seeking pathways towards more pro-social behavior pathways.

› Are powerful triggers for relapse.

– They occur at the time that cases are being closed and/or transfer to case management.

– It may appear that that any progress made is stalled or that the parent may have

been insincere in their attempt at treatment or in working a safety/case plan.

› Short term solutions– To reduce cortisol: Stress management is essential, avoid re-traumatization.

– Oxytocin: Built trust, promote positive social interactions.

– Increase serotonin: Anger management, promote good sleep hygiene.

– Improve goal-directed behavior: Stop using marijuana.

› Longer term solutions– To improve mood: Increase naturally occurring dopamine through:

› Diet, eating certain foods such as green leafy vegetables, shellfish, and milk.

› Living in a safe, supportive, non-judgmental environment.

› Regularly attending peer support groups such such as 12 step programs, having a sponsor.

– To improve overall sense of well bring increase endorphins: › Exercise, accomplishing small goals.

– Manage symptoms of mental health through compliance to prescribed medications.

› Repetition of positive emotionally rewarding new behaviors are essential to building new neural pathways.

› Challenges:– The old pathway = survival.

– The new pathway doesn’t feel good at first, and requires significant energy to keep repeating behaviors.

– Old pathway never completely does away.› If linked to traumatic experiences can be

reactivated quickly.

› Therefore a person with an addiction is never cured, the disease is only ever in remission. as recovery.

Parents have good intentions but fail to follow through.

– Example: I will call tomorrow. I left a message but no one called me back.

› Parent has some motivation to change –this is a good thing!

– Need to reinforce positive behaviors.

– Be specific with directions.

– Set an achievable goal within a short time interval for task to be performed.

– Follow up with acknowledgement of accomplishment or encouragement to

continue.

– Don’t do the task yourself.

– Repetition, Repetition, Repetition.

› Parents who have tried before, but failed to remain substance free or complete their case plan.– Example: “What’s the point in even trying?”

› Lack of motivation and goal directed behaviors, due to:› Low levels of naturally occurring neurochemicals and increase in cortisol.

› Anxiety and Depression.

› Agitation and irritability.

› Use of Marijuana.

– Give small tasks that the parent is capable of accomplishing themselves.

– Provide resources to address diet and exercise.

– Model anger management and stress management skills.

› Parents don’t believe they have a drug issue, even when presented with facts to the contrary.– Example: A parent over sedated on methadone may say: “Not my

problem.” “I’m not a junkie, I was prescribed these meds by a doctor!”

› Denial and justification.– These are psychological defenses underwritten by low levels of serotonin.

› Parent does not want to appear to be socially outcast.

› Need to promote pro-social behaviors.

– Sustained by oxytocin.

› Wanting to fit in with society.

– Building trust.

– Education.

– Modeling Anger Management.

› Parent who adamantly refuses to cooperate and has all the answers.– Example: Parent who insists on a trial regardless of continued drug use and

several recent arrests related to drugs.

› Dual issue:

– Strong neural pathways associated with Addiction, but also strong neural

pathways that were developed in childhood that are sympathetic to

addiction, e.g. pathways associated with personality disorders.

› These are persistent neural pathways that keep being reinforced with substance use

and personality related behaviors.

› Typically it is going to take the intervention of a mental health clinician to facilitate

effective change.

› Detoxification and intensive substance abuse treatment is likely the best way that this

parent will have a chance at engaging.

› However getting a parent into treatment or working a case plan can be challenging.

– An opportunity may arise if a parent has a narcissistic crisis. A narcissistic crisis are thoughts

that are contrary to the parent’s self-concept (how they view themselves).

– Challenging a narcissistic crisis requires that you have already established some form of

rapport and trust with the parent.

– Narcissistic crises often provoke questions intended to validate self-concept.

› The question is presented with the intention that that the other person will disagree with the abhorrent

thought in order to revalidate the parents self-concept. Neutral responses such as “It’s not my place to

be judgmental,” will have the same effect. Since these responses are consistent with the parent’ self-

concept it poses no psychological treat and hence no threat for survival.

– However, when a response is received that is contrary to expectation and validates the

original abhorrent thought, this creates a phenomenon called cognitive dissonance.

› Cognitive dissonance creates a stress response that increases cortisol levels, thus alerting the brain that

there is a treat to survival.

› Cognitive dissonance also acts as a catalyst for neuroplasticity whereby new neural pathways are

created as the brain seeks ways of interpreting this threat.

› If this threat to survival is followed up by a learning experience that includes a positive reward then this

experience is assigned to memory and a new neural pathway is built.

Example of a narcissistic crisis: “You must think I am a terrible parent?”

› Our instinct and training is to say “no” or “I’m not here to be judgmental,” which reinforces the belief that I

am a good parent.

› By responding “Yes,” this creates cognitive dissonance, and an opportunity for change.

› However, before responding “Yes” to the question, there must already exist some form of positive rapport

between yourself and the parent, a level of trust. This is needed so that you can qualify your statement

and make it a learning experience so that pathways can be built to memory. It also needs to be spoken

with a non-judgmental attitude.

› After responding “yes,” and within the same sentence you need to qualify your response. So the dialog

may go as follows:

– “Yes, so while you may feed and bathe your child, and read them stories at bedtime, that is only one part of being a parent.

– Using drugs in the presence of your child allows them to learn that behavior from you, or they may see you high or sick and that can confuse a child and make them feel unsafe.

– This is very scary for a child and can lead to behavioral problems and they may become anxious or depressed.

– They may have problems in school and fail to make friendships as they don’t want their friends to see their parents.

– Then yes, there are areas in which you are a terrible parent.

– But you can change, and I believe you have it within you to change and this case plan will be that roadmap for you.”

› Each one of the statements is building neural connections between the experience and memory.

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