Adaptación de un modelo de intervención cognoscitivo-conductual para usuarios dependientes de alcohol y otras drogas a población mexicana: Un estudio piloto

RESUMEN

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ABSTRACT

Abstract The chronical abuse of addictive substances is a major public health problem, due to the seriousness of the consequences fatal automobile accidents or others involving traumatic injury and emergency medical care, chronic physical diseases such as cirrhosis of the liver, cardiovascular complaints, cerebrovascular problems and pancreatitis, as well as disability and disruption in different functional areas of daily life, whether social, psychological, legal, personal, family, economic or professional. These factors include depression, anxiety, loss of sleep, loss of support networks, suicide, violence, injury in fights, homicide, financial debt, divorce, loss of employment, hospitalization, crime and imprisonment, among others. It is therefore required to establish multidisciplinary intervention models that respond to the seriousness of the problem. In Mexico, reports show that there is a need for the development of more intervention models for chronic users of addictive substances, which include systematic implementation and evaluation as well as medium- and long-term measurements to assess effectiveness. Intervention services often do not go beyond support for the initial detoxification. Additionally, the high cost of most treatment schemes makes them inaccessible to the majority of the people affected by these problems. Intervention models must be designed and developed to include elements from other models that have proven to be reliable and effective on the basis of empirical evidence. The Community Reinforcement Approach or "CRA" intervention model has gained recognition in scientific literature and from international institutions (the National Institute of Drug Addiction, NIDA, and the National Institute of Alcoholism and Alcohol Abuse, NIAAA) as one of the most effective means in reducing consumption by chronic users of addictive substances. Consequently, the objective of this research was to use a pilot project to adapt, systemize, implement and assess the impact of the Community Reinforcement Approach intervention model in reducing consumption patterns among chronic dependent users of alcohol and other drugs within the Mexican population. A cognitive-behavioral intervention model was applied to 9 chronic users who had requested psychological help at the Psychological Service Centers of the Faculty of Psychology. The average age of the users was 35. Seven of them were male and two female. The most commonly consumed addictive substance was alcohol by six users, with other drugs accounting for three (benzodiazepine, marihuana, cocaine, solvents and amphetamines). On average, the subjects had spent 14 years in schooling. Five of them were single, one was married, one cohabiting and two divorced. With regard to the occupations of the sample, one was a student, two had abandoned a course of study, four were employed before treatment and two were unemployed. The criteria that the users had to meet for inclusion in the study were to be aged 18 or over; to be able to read and write; to have a medium-to-severe level of alcohol dependence corresponding to a range between 22 and 47 points on the Alcohol Dependence Scale (ADS) and/or a substantial-to-severe level of dependence on other drugs of between 11 and 20 points according to the Drug Abuse Questionnaire (DAQ); to consume a quantity of 14 or more measures of alcohol per occasion and/ or 20 or more measures per week for men, and 10 or more per occasion or 15 or more per week for women; to have been treated or interned on at least one previous occasion; to suffer consumption-related difficulties in different areas of daily life. The duration of the treatment period was from 15 to 24 sessions, depending on the specific training needs of each user. Sessions lasted 1% hours, and were given twice a week. The methodology used was single case with repetitions and follow-up. The cognitive-behavioral model included the following intervention components Functional Analysis, Demonstration of Non-Consumption, Daily Life Goals, Communication, Problem Solving, Consumption Refusal, Marriage Guidance, Employment Searches, Recreational and Social Skills and Prevention of Relapses. The didactic techniques used in the training for each of the aforementioned components were verbal instruction, modeling, behavioral trials and feedback. The original model (CRA) was adapted to include the following changes 1) More communication skills were integrated, including listening, starting conversations, giving and receiving criticism, giving and receiving recognition, and sharing positive and negative feelings; 2) Relapse prediction variables were assessed self-effectiveness and triggers; 3) New skills for refusing consumption were added interrupting interaction, justification for non-consumption. Occurrence records were kept for the application in natural settings of the skills taught. In addition, teaching materials were prepared, along with information brochures on different addictive substances and the different training components, lists of community resources and therapist checklists to guarantee the systematic implementation of the model. The pre-post-test evaluation methods were Retrospective Baseline (RETBAS), Self-Recording, Situational Confidence Scale and/or Drug Consumption Self-Confidence Scale, Daily Life General Satisfaction Scale, Inventories of Drug Consumption Situations and/or Inventories of Alcohol Consumption Situations. The significant changes identified in this preliminary research were decreases in consumption patterns during and after treatment, since in the pre-post-test statistical analysis for paired samples the results t= 4.75 p = .001 were obtained in the comparison of baseline and treatment, and t= 4.28 p=.002 in the comparison of the baseline and follow-up; increases in the levels of general satisfaction in daily life following treatment and during follow-up, since in the pre-post-test statistical analysis for paired samples the results t=-3.94 and p=.004 were obtained, and t=-4.03 and p=.004 in the pre-follow-up comparison; increases in levels of self-effectiveness after treatment and during follow-up, since in the pre-post-test statistical analysis for paired samples the results t= -5.08 and p=.001 were obtained, and t= 4.37 and p=.002 in the pre-follow-up comparison; decrease in the number of consumption triggers after treatment and during follow-up, since in the pre-post-test statistical analysis for paired samples the results t= 5.80 and p=.000 were obtained, and t= 5.3 and p=.001 in the pre-follow-up comparison. As a result of the foregoing, the researchers were able to verify the effectiveness of this intervention model in significantly reducing consumption patterns in nine chronic dependent users of addictive substances. Similarly, the model had a significant impact on consumption prediction variables, as well as increasing self-effectiveness levels and eliminating triggers to avoid relapses. Users learnt how to create a more satisfying day-to-day lifestyle, by including activities incompatible with consumption. Finally, in repetitions of the implementation of this intervention model, it is recommended that a training component be introduced for emotion management (depression, anxiety and anger), as well as an assessment of cognitive functioning as a relapse prediction variable, and the participation of users that have been part of a social-recreational activity group to reinforce sustained abstinence in the long term.