Hendrik G. Roozen

Community reinforcement and family training: an effective option to engage treatment-resistant substance-abusing individuals in treatment

AIMS Many individuals with substance use disorders are opposed to seeking formal treatment, often leading to disruptive relationships with concerned significant others (CSOs). This is disturbing, as untreated individuals are often associated with a variety of other addiction-related problems. Community Reinforcement and Family Training (CRAFT) provides an option to the more traditional treatment and intervention approaches. The objective of this systematic review was to compare CRAFT with the Alcoholics Anonymous/Narcotics Anonymous (Al-Anon/Nar-Anon) model and the Johnson Institute intervention in terms of its ability to engage patients in treatment and improve the functioning of CSOs. METHODS The electronic databases PubMed, PsycINFO, EMBASE, CINAHL and the Cochrane Library were consulted. Four high-quality randomized controlled trials were identified, with a total sample of 264 CSOs. Data were synthesized to quantify the effect with 95% confidence intervals, using the random effects model. RESULTS CRAFT produced three times more patient engagement than Al-Anon/Nar-Anon [relative risk (RR) 3.25, 95% confidence interval (CI) 2.11-5.02, P < 0.0001; numbers needed to treat (NNT) = 2] and twice the engagement of the Johnson Institute intervention (RR 2.15, 95% CI 1.28-3.62, P = 0.004; NNT = 3). Overall, CRAFT encouraged approximately two-thirds of treatment-resistant patients to attend treatment, typically after [corrected] four to six CRAFT sessions. CSOs showed marked psychosocial and physical improvements whether they were assigned to CRAFT, Al-Anon/Nar-Anon or the Johnson Institute intervention within the 6-month treatment window. CONCLUSION CRAFT has been found to be superior in engaging treatment-resistant substance-abusing individuals compared with the traditional programmes.

The impact of craving and impulsivity on aggression in detoxified cocaine-dependent patients

Patients with substance use disorders are frequently associated with impulsivity that may underlie elevated levels life-threatening types of behavior, including aggression. In addition, craving is a prominent feature of addiction and appears to be closely related to impulsivity. This study assessed the unique contribution of cocaine craving and impulsivity in predicting aggression by means of correlational and mediational analyses. Forty inpatient detoxified cocaine-dependent patients and 40 matched healthy controls were enrolled. These participants filled out the Obsessive Compulsive Drug Use Scale, the Dickman Impulsivity Inventory, and the Aggression Questionnaire. The patient group showed elevated levels of impulsivity and aggression as compared with the control group. Although cocaine craving is positively correlated with both impulsivity and aggression, craving did not mediate the relationship between both constructs. It is concluded that craving does not have an impact on the relationship between impulsivity and trait aggression in this patient sample.

The effects of psychiatric distress, inhibition, and impulsivity on decision making in patients with substance use disorders: A matched control study

In the present study, the decision making abilities of patients with substance use disorders were compared to those of healthy controls and, subsequently, the impact of psychiatric distress, behavioral inhibition, and impulsivity on Iowa Gambling Task (IGT) performance were evaluated. A total of 31 patients and 31 matched healthy controls performed the IGT and completed the Symptom Checklist-90-Revised (SCL-90-R) and the Behavioral Inhibition System/Behavioral Activation System (BIS/BAS). The results confirmed that the patient group had severe impairments on the IGT relative to the controls, which appeared to be virtually unrelated to the employed measures. It is concluded that self-reported psychiatric symptoms, behavioral inhibition, and impulsivity have no impact on the IGT performance in this patient sample.

Saved by structure? The course of psychosis within a prison population

About 4% of all prisoners can be diagnosed with a psychotic disorder, but it is largely unknown how these prisoners function during imprisonment. The present study aimed to describe symptoms of psychotic prisoners during imprisonment and incidents caused by them as well as care provided to these prisoners. A total of 61 prisoners were observed for a maximum of 12 weeks. Results show that poverty of speech and blunted affect significantly decreased over time. The largest group of psychotic prisoners either did not suffer from positive psychotic symptoms or the encountered positive psychotic symptoms exhibited a steady or decreasing pattern during their imprisonment. Reasons for these findings still remain unclear.

Advances in Management of Alcohol Use Disorders and Intimate Partner Violence: Community Reinforcement and Family Training

Substance use disorders are associated with life-threatening behaviours and substance use is found to strongly trigger criminal behaviour, including intimate partner violence (IPV). Although intimate partners are often subject to aggression and injury, most substance-using offenders refuse to enter formal treatments. Community reinforcement and family training (CRAFT) was developed to help intimate partners to (a) recognize and safely respond to potential violence, (b) improve communication with the substance user; (c) decrease stress, (d) improve self efficacy, and (e) assist in encouraging the unwilling substance user to enter therapy. The underlying operant-based belief is that environmental contingencies are key in encouraging or discouraging substance use. This article discusses why CRAFT may be effective in engaging treatment-resistant patients with substance abuse disorders in formal treatment and to diminish IPV. It is asserted that intimate partners, family members and close friends can make important contributions to assist substance-using offenders.

Does Alcohol Craving Mediate the Impulsivity–Aggression Relationship in Recently Detoxified Alcohol-Dependent Patients?

Background: The relationship between the use of alcohol and aggression is complex and represents major public health issues. Delving into the nature of this association is vital, since various underlying factors may contribute to the expression of aggression. Objective: This study examined trait aggression by assessing correlates and, subsequently, the unique contribution of alcohol craving, and dysfunctional impulsivity, by means of correlational and mediational analyses. Methods: Forty inpatient detoxified alcohol-dependent patients were recruited. These participants completed the Desire for Alcohol Questionnaire (DAQ), Dickman Impulsivity Inventory (DII), and the Aggression Questionnaire (AQ). Results: The findings indicated that aggression, dysfunctional impulsivity, and alcohol craving were all positively intercorrelated. The association between dysfunctional impulsivity and aggression was robust. The mediational analyses yielded that craving partially mediated this relationship, although not very substantial. Conclusion: It was shown that impulsivity, as a personality characteristic, is strongly associated with aggressive behaviors, whereby the impact of craving on the relationship between impulsivity and trait aggression in alcohol-dependent inpatients was weak. Scientific Significance: Since it has been posited that factors such as impulsivity and craving may contribute to the lucid association between substance use and aggression, these findings mirror previous research on stimulant users and, subsequently, substantiates that craving exerts only a minor weight on the strong impulsivity–aggression relationship.

Terugvalmanagement bij verslaving

Terugvalpreventie is een wijdverbreide interventie en omvat een set van cognitief-gedragstherapeutische interventies om verslavingsgedrag te beïnvloeden. Doel is terugval in gebruik te voorkomen, met abstinentie als resultaat. Verslaving wordt in toenemende mate beschouwd als een chronische hersenziekte die juist gekenmerkt wordt door recidive in de vorm van terugval in alcohol- en/of drugsgebruik, waarbij voor velen abstinentie niet haalbaar blijkt. In dit perspectief wordt de abstinentiedoelstelling uitgebreid met stabilisatie en reductie van het schadelijke gebruik van alcohol en/of drugs. Als alternatief voor terugvalpreventie wordt daarom de term ‘terugvalmanagement’ geïntroduceerd. Uitgangspunt is niet zozeer terugval te voorkomen, maar met terugval om te gaan in een perspectief van verbetering. Farmacologische interventies passen binnen de doelstelling van terugvalmanagement en kunnen worden ingezet om vermindering van alcohol en drugsgebruik te realiseren. Derhalve is terugvalmanagement een biopsychosociale benadering.

CRAFT-procedure 5: Het geven en inhouden (time-out) van positieve bekrachtiging (IP)

Veel families raken verstrikt in het middelengebruik van de IP en de negatieve gevolgen ervan. Doordat in veel gevallen verantwoordelijkheden worden overgenomen, ontstaat er een situatie die wordt gekenmerkt door een negatieve, neerwaartse spiraal. Zo kan het effect hebben op tal van leefgebieden. Deze CRAFT-interventie beoogt om de eigen verantwoordelijkheid van de IP weer te vergroten, maar wel onder de conditie dat dat niet gepaard gaat met middelengebruik. Deze procedure gaat in op een aantal strategieen om het prosociale gedrag van de CSO te laten toenemen, evenals het prosociale gedrag van de IP, aan de hand van plezierige activiteiten.

CRAFT-procedure 7: In behandeling gaan

Uit onderzoek blijkt dat vaak pas vele jaren na de eerste tekenen van problematisch alcohol- en druggebruik er een formele behandeling wordt gezocht.20, 21 Dit is zorgelijk, want gebruikers die in een vroeg stadium van een verslaving in behandeling gaan, hebben doorgaans meer kans op goede resultaten. Gelukkig groeit het bewustzijn dat familieleden een belangrijke rol kunnen spelen in het aanmoedigen van patienten om professionele hulp te zoeken voor hun drugsproblemen en om in behandeling te blijven.

CRAFT-procedure 6: Veiligheid in huis

Uit de literatuur blijkt dat er een sterke relatie is tussen de verschillende verslavende middelen (zoals alcohol) en agressie.15 Het blijkt dat individuen onder invloed van alcohol en/of drugs gemakkelijker impulsieve beslissingen nemen en sneller ongewenst gedrag laten zien dat normaal gesproken niet voorkomt. Alcohol speelt in veel gevallen een belangrijke rol bij verkeersagressie, caferuzies, en ook bij huiselijk geweld. Huiselijk geweld wordt door de overheid omschreven als: ‘geweld dat door iemand uit de huiselijke kring van het slachtoffer gepleegd is’. Geweld hoeft niet alleen een fysieke betekenis te hebben, maar kan ook betrekking hebben op het psychische en seksuele domein.16