Behavioral Therapies + Integrated Care
Module 4 of 11 · 45 min
CBT, contingency management, motivational interviewing, integrated co-occurring disorder treatment, peer support.
Learning objectives
- •Describe evidence-based behavioral treatments for SUD
- •Apply motivational interviewing techniques in brief encounter
- •Recognize co-occurring mental health conditions + their interaction with SUD
- •Refer to appropriate level of care
Evidence-based therapies
Cognitive Behavioral Therapy (CBT): identifies + restructures thoughts → behaviors → relapse triggers. Contingency Management: tangible rewards for verified abstinence (highest effect-size of any SUD therapy). Motivational Interviewing: explores ambivalence, builds intrinsic motivation, non-confrontational. 12-Step facilitation (AA, NA, SMART Recovery). Family therapy. Mindfulness-based relapse prevention. Combination of MAT + behavioral therapy outperforms either alone.
Motivational interviewing for the CRNA
OARS framework: Open questions, Affirmations, Reflective listening, Summaries. Roll with resistance — don't argue. Express empathy, develop discrepancy (between current behavior + values), support self-efficacy. Brief intervention (5 min): 'You mentioned drinking 6 beers a night. What's going on?' Reflect, ask permission to share concern, propose change (referral, follow-up). MI works because it respects autonomy; lecture/scolding fails because it triggers reactance.
Co-occurring disorders
50%+ of patients with SUD have a co-occurring mental health diagnosis (depression, anxiety, PTSD, bipolar). Reciprocal: substance use worsens psych; psych drives self-medication. Treat BOTH simultaneously — sequential treatment fails. Implications for CRNA: opioids + benzos together can be synergistic for respiratory depression, especially in trauma + PTSD. Document both conditions. Engage psychiatric care.
Levels of care
ASAM continuum: Level 1 (outpatient, < 9 hr/wk), Level 2 (intensive outpatient, 9+ hr/wk), Level 2.5 (partial hospitalization), Level 3 (residential), Level 4 (medical management/withdrawal). Match severity + biopsychosocial assessment to level. Buprenorphine + methadone often appropriate at Level 1; severe OUD with multiple failed attempts may need Level 3.
References
- · NIDA Principles of Drug Addiction Treatment 3rd Ed
- · ASAM Criteria 4th Ed
- · Miller MI textbook