It Takes a Village to Resolve an Addiction…And Certain Kinds of Villagers Barbara S. McCrady...
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Transcript of It Takes a Village to Resolve an Addiction…And Certain Kinds of Villagers Barbara S. McCrady...
It Takes a Village to Resolve an Addiction…
And Certain Kinds of Villagers
Barbara S. McCrady
Center on Alcoholism, Substance Abuse, and AddictionsUniversity of New Mexico
Presented at the Addiction Summit “A Climate for Change”Melbourne, Australia
10 July 2008
Work Family of Origin
Nuclear Family>Spouse>Children
Friends
CommunityOrganizations:>Religious>Social>Service
SexAgeRaceEthnicityReligionSexual orientationFamily HistoryGeneticsTemperamentPersonalityPsychopathology
Individuals Live in Complex Social Environments
Work Family of Origin
Nuclear Family>Spouse>Children
Friends
CommunityOrganizations:>Religious>Social>Service
SexAgeRaceEthnicityReligionSexual orientationFamily HistoryGeneticsTemperamentPersonalityPsychopathology
Individuals Live in Complex Social Environments
Purpose of Talk
To briefly review what we know about social support and alcohol/drug use disorders
To discuss selected findings from outside our field that might help us think more broadly about how social support works
To pose some questions To present some modest propositions
Positive Social Support
“It takes a village to hold a world.” Photograph courtesy of Diane Walker
Harry Harlow’s Monkeys
Wire Milk Mother Cloth Mother
Social Support and Health“Social bonding and soothing behaviors mitigate the destructiveeffects of negative environmental events and promote enhancedhealth and well-being (Berscheid, 2003). Indeed, social isolationis now considered a major health risk (House, Landis, &Umberson, 1988). Moreover, married people tend on average tobe happier and healthier than unmarried people (Wood, Rhodes,& Whelan, 1989), and among married individuals, highermarital quality is associated with decreased risk of infection,faster recovery from injury, and a lower rate of mortality followinga diagnosis of life-threatening illness.”
Coan et al., 2006
Alcohol/Drug Use and Positive Social Support
Monkeys and Drinking
0
1
2
3
4
1 2 3 4 5 6 7 8 9 10 11 12
Months
NurseryReared
MotherReared
Eth
ano
l co
nsu
mp
tio
n (
g/k
g)
Davenport, Maxey, Daunals, & Friedman, 2008
Social Support and the Resolution of SUDs
Having more social support is associated with better drinking outcomes Support from the most important person Number of supportive persons
Having more nondrinking friends is associated with better outcomes
Both alcohol specific and general support are important
Quality of Relationships is Associated with SUD Outcomes
Family adjustment Family cohesion Active, recreational orientation Low conflict Quality of marriage Specific marital support
When Social Support Goes Awry
The Four Horsemen of the Apocalypse
Criticism Defensiveness Stonewalling Contempt
When Social Support Goes Awry for Alcohol and Drug Users
Negative Family Functioning
0
0.2
0.4
0.6
0.8
1
1.2
Low ExpressedEmotionHigh ExpressedEmotion
Days Since Entering Behavioral Couples Therapy
100
200
300
Pro
port
ion
Ab
sti
nen
t
O'Farrell et al. (1998)
Negative Social Environmental Predictors of Outcome
Support for drinking predicts negative outcomes
Having more drinking friends is associated with poorer outcomes
Certain partner behaviors predict a negative response to treatment withdrawing from the drinker avoiding dealing with drinking tolerating drinking
Social Support and Treatment
Social Support and Treatment
Involving a concerned significant other in treatment improves outcomes For persons who have not sought treatment
themselves For men and women with alcohol or drug use
disorders For teens
Influencing Problem Recognition and Help-Seeking
0
10
20
30
40
50
60
70
Al-Anonfacilitation
Unilateral(CRAFT)
JohnsonIntervention
% e
ngag
edin
tre
atm
ent
Unilateral Family Therapies
Miller et al., 1999
Engaging Families in Treatment - Alcohol Behavioral Couples Therapy
Focus on primary intimate relationship Based on cognitive-behavioral approaches to:
Alcohol use disorders Distressed relationships
Three major treatment elements Teach abstinence skills Teach partner behaviors to cope with drinking and
support change Improve intimate relationship
Alcohol Behavioral Couples Therapy and Abstinence
Treatment Follow-up
Months
Pe
rce
nt D
ays
Ab
stin
en
t
* * * * * * * * * * * *0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
ABIT ABCT
McCrady, Epstein, Cook, Jensen, & Hildebrandt, 2008
Alcohol Behavioral Couples Therapy and Heavy Drinking
Treatment Follow-up
Months
Pe
rce
nt D
ays
He
avy
Dri
nkin
g
* * * * * * * * * *0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
ABIT ABCT
McCrady, Epstein, Cook, Jensen, & Hildebrandt, 2008
Social Support in Detoxification
A simple meeting with the person in a detoxification program and a concerned other to recommend continuing care resulted in: 92% entering continuing care
vs 62% who received treatment as usual
O’Farrell, Murphy, Alter, & Fals-Stewart, 2008
A Pause
The first half of the talk:
We have a fundamental drive to connect and be connected
Positive social support plays a powerful role in change in addictions
Social influences also play a powerful role in perturbing the process of change
Treatments that involve significant others lead to better outcomes
What’s to come:
Three questions to contemplate: How does social support actually change a
person’s behavior? How do people elicit or repel social support? How do people effectively provide social
support?
How Does Social Support Change a Person?
Coan, Schaefer, & Davidson, 2006
Social Support Affects Brain Function
Responses measured in fMRI when• Husband hand-holding• Research assistant hand-holding• No hand-holding
Social Support Affects Brain Function
The unpleasantness of the threat was lower when anyone held the woman’s hand
Neural activation to the threat was lower when her husband held her hand than when no one held her hand in:
Right dorsolateral prefrontal cortex, left caudate–nucleus accumbens, and superior colliculus
Neural activation to threat was lower when anyone held her hand in:
Ventral anterior cingulate cortex, posterior cingulate, right postcentral gyrus, and left supramarginal gyrus
Coan et al., 2006
fMRI Results
How Does Social Support Change a Person with an Alcohol/Drug Problem? Does it impact psychological functioning?
Motivation? Self-efficacy? Outcome expectancies? Coping skills? Affect regulation?
Does it damp down craving responses to alcohol cues?
Does it impact neural function?
Social Support Affects Motivation
Unpublished research from McCrady graduate student, Dorian Hunter-Reel:
Used structural equation modeling to test the impact of pretreatment social support on 3-month motivation
Then tested the impact of 3-month motivation on 9-month drinking outcomes in a sample of women with alcohol use disorders
Pretreatment support for drinking was a negative predictor of 3-month motivation
Motivation partially mediated the relationship between support for drinking and 9-month drinking outcomes
AAExposure
AbstinenceSelf-
Efficacy
PositiveOutcome
Social Support Affects Self-Efficacy
.30 (SD = .05)
Reduced to = .21 (SD = .06)
.21 (SD = .08) * .33 (SD = .11) *
Forcehimes & Tonigan, in press
Does Social Support Affect Neurocognitive Function?
A study in progress: Exposure to alcohol cues for persons with
alcohol use disorders in an fMRI Present these alcohol cues with and without
intimate other present and holding the drinker’s hand
Examine changes in brain function in regions associated with reward
Ladd, McCrady, Hutchison, & Tonigan, in progress
How do People Elicit or Repel Social Support?
What does a Person do to Have Good Social Supports?
How does a drinker/drug user find social networks that will support nonproblem alcohol or drug use?
How does a drinker/drug user engage others to provide support?
We don’t have answers to these questions
What Does a Person Do that Makes it Hard to Obtain Social Support?
Can a drinker or drug user drive others away through alienating behaviors (other than those associated with the substance use)?
Alienating Interpersonal Behaviors
Variable B SE B Beta Adjusted R2 Change
Step 1: Baseline 0.39 0.08 0.43 0.13**Percent Drinking Days
Step 2: Tx Condition 5.77 4.76 0.11 0.01
Step 3: Baseline 1.06 0.36 0.03 0.07**Alienating InterpersonalBehaviors
** p < .01Hunter Reel, McCrady, & Epstein, 2007
What Do Other Persons do to Provide Effective Social Support?
Providing Effective Social Support
Having a sponsor is one of the strongest predictors of success in AA But, we know nothing about effective and
ineffective sponsoring We know that having a supportive family
enhances outcomes, but we have not isolated effective family behaviors
Implications for Change
Some Modest Propositions We should consider the universality of the need
for bonding, attachment, and love in thinking about the change process
Treatment should create an environment of bonding and attachment
Treatment should help individuals learn to elicit support from others
We should help individuals in the social support system learn to delicate balance between “enabling” and effecting change
We should find more ways to bring treatment to people in their existing social environments
Some Research Needs
Study the psychological interface between the social environment and the individual – what happens at a psychological level?
Study the brain functions that underpin positive social support to learn to enhance the impact and understand more about how it goes awry
Study people who are particularly effective at eliciting positive social support
Study people who are particularly effective at providing positive social support, even in the face of negative behavior
It Takes a Village to Resolve an Addiction…And Certain Kinds of Villagers