187 Models of Treatment for Addiction | Addiction Counselor Training Series

187  Models of Treatment for Addiction  | Addiction Counselor Training Series


This episode was pre-recorded as part of
a live continuing education webinar. On demand CEUs are still available for this
presentation through ALLCEUs. Register at ALLCEUscom/CounselorToolbox. I’d like to welcome to everybody to
today’s presentation on the models of treatment. So what we’re really going to
talk about is some different theoretical approaches because not all of us
necessarily ascribe to the same theoretical approach and when we’re
working in multidisciplinary teams sometimes we have to think about the
different influences from each person in that team in order to make a compelling
argument for what we want to have happen in order to create that win-win
situation so that’s kind of what we’re going to look at today we’re going to
define the principles of effective treatment which hey you know good to
know explore current trends and practices in
treatment programs and those are rapidly changing some of the things that we used
to do we don’t do anymore and some of the things that we haven’t been doing we
may start doing in the not so distant future so I’m going to interject a
little bit of new stuff as it relates to the President’s Commission on opioid use
or whatever it was called that report that just came out will identify some
common approaches to treatment the main components of each approach we’re not
gonna go in depth we’re just gonna kind of hit the highlights like I said so you
can figure out if you’re working with somebody who uses that theoretical
framework how to create a win-win and how to work together harmoniously and
we’re going to compare and contrast each approach a little bit in terms of which
clients you might use it with and how it might work in different settings such as
mental health sandal own private practice versus community behavioral
health etc and maybe different ways that you might be able to implement it so
principles of effective treatment addiction and mental health issues are
complex but treatable conditions that affect the brain the body and behavior
so this is one of the new changes and we’ll talk about that later but we’re
really focusing on the whole person now we recognize that it’s not just the
way somebody thinks it’s not just their neurotransmitters it is a whole brain
body behavior thing and any change in any one of these areas can affect the
other area so if you start making better behavioral choices then potentially like
we talked about yesterday with people with alcohol-related brain damage if
they make better behavioral choices chances are their brain health is going
to improve and their body health will improve and their mood theoretically
will improve – no single treatment is going to be appropriate for everyone so
when people come into our clinic or facility or whatever you call the place
that you work we can’t necessarily assume that group 12-step treatment or
individual humanistic counseling is going to work for them we need to look
and say what does this person need now individual humanistic may work in terms
of addressing the cognitions and the mental health stuff but they also may
need some brain body stuff with either a psychiatrist or a physician and maybe
some social skills or something else so we need to look at the comprehensive
picture treatment needs to be available to be effective and you’re thinking well
duh but in the big scheme of things when we look at how many people actually are
able to access treatment only about 10% of people with addictions are able to
access specialized treatment each year and the numbers a little bit higher for
mental health but it’s not you know wonderful you know less than 50% of
people who have treatable mental health conditions receive treatment so we want
to look at why is that and one of the reasons soapbox warning is because
treatment is too expensive for a lot of people they have deductibles that are
$1,300 and up I look the average deductible for a person a single person
is $1300 which means insurance doesn’t cover
anything until they pay the first thirteen
hundred dollars out of pocket now if a clinician charges a hundred dollars a
session that’s thirteen sessions which could be virtually the entire course of
treatment before insurance even kicks in and a lot of people don’t have that kind
of money just kind of laying around so we want to look at the affordability and
availability of treatment which is one of the reasons I push groups a lot
because groups are a way that we can provide a lot of services for affordable
amounts for the clients and still you know put food on our own tables so
looking at how can we as clinicians make treatment more available to those in our
community virtual services that’s something that we can look at telemental
health so people don’t have to get babysitters don’t have to travel group
therapy having services on the weekends or or during the evenings those are
always great now you’re thinking well that’s what I want to be with my family
true so it’s always a trade-off you got to figure out you know could you do
evenings two days a week or something in order to be available and that’s
something that you know is a choice that you’ve got to make on your own I know
when we were setting up new programs we would always look at where the demand
was where did we have the waiting list was it the morning programs or was it
the evening programs and you know what kinds of services were in highest demand
so effective treatment attends to the multiple needs of the individual so
we’re not just doing that mental health assessment and going okay you’ve got you
need the criteria for major depressive disorder so we’re gonna treat that and
we’re going to talk about all the reasons that you’re depressed
well effective treatment is also going to look at their nutrition their social
their living environment is their stress their their work environment and you
know attending to any medical needs that may need to be addressed to also deal
with the depression current trends and practices focus on the client
competencies and strengths instead of saying we’re going to get rid of your
depression we’re going to say we’re going to help you feel better
yeah it’s the same thing but instead of getting rid of something we’re adding
something we’re putting something awesome in its place and one of the
principles of behavior modification is that you don’t want to just punish a
behavior you don’t want to just get rid of things because if you get rid of it
you have to have something to put in its place so too often parents and
caregivers and clinicians even sometimes will get in the habit of taking away
things you know or let’s take people they make new year’s resolutions I’m
gonna stop smoking I am going to stop eating sugar I am going to stop doing
this and stop doing that well that’s just grand but all those things serve a
purpose so what are you going to do instead and that’s one thing that we
want to ask what are we working towards what’s our goal and what strengths does
the person have maybe their social skills are weak okay you know maybe
they’ve got a lot of social anxiety that contributes to their other mood issues
okay well we’ll deal with that but let’s look
at what strengths they have maybe they’re really articulate maybe they’re
really smart maybe they are introverts and they just don’t really realize that
people who are introverted tend to get more stressed out in large groups so we
can help educate them about their strengths as an individual so we want to
focus on strengths and build clients up we want to focus on what’s worked in the
past instead of saying okay you’re in my treatment program let’s start at square
one we’re saying okay you’re in my treatment program what’s worked for you
before so let’s build this foundation and figure out what kinds of tools you
already have in your toolbox before we start trying to put more stuff in there
and that will also help us figure out like I said what’s worked before if see
cognitive behavioral hasn’t worked for them before then we don’t want to throw
a bunch of cognitive behavioral tools in their direction we might ask what about
it didn’t work for them so we can you know make sure that we’re going down the
right path but we’re going to figure out for that person what helps the most and
the CBT works well for people who have um unhelpful thoughts and cognitions
sometimes but sometimes if they’ve got emotional dysregulation they may feel
like the clinician just doesn’t get how intense this is when the clinician says
well you just need to change the way you’re thinking about things they’re
like it ain’t that easy doc so we want to make sure that we provide
individualized client centered treatment and shift away from labeling you notice
I try really hard not to say addicts alcoholics I say people with addictions
or addictive issues I try not to say a person with depression I try to say a
person who has depressive symptoms because I want to look at the person I
want to emphasize that the person is in there and for me when I say a person
with depressive symptoms that reminds me that depression doesn’t look the same
for most people you know there there’s a huge variation and what depression looks
like so I want to look at that person and what symptoms they’re prevent
presenting with acceptance of new treatment goals other than for example
with with substance abuse or addictive behaviors abstinence there are some
addictions especially the behavioral ones but even eating disorders that you
cannot completely abstain from you can’t not eat you could argue the point about
sex addiction some people say well you don’t have to ever have sex you know
when we’re talking about the totality of the human organism that’s a choice that
each person has to make but those are the things that we want to look at in in
terms of what is the person willing to do and what is going to help them lead
the healthiest and happiest life what does happiness look like for them for
some people you know their definition of recovery from depression may be very
different from mine but I want to look at what are their treatment goal
adoption of a recovery paradigm away from problem focused acute care model
which means we want to help them figure out how to achieve a rich and meaningful
life not just eliminate depression but we also want to look at a recovery
paradigm a recovery network if you will it’s not just your symptomatic right now
we’re gonna treat it right now it’ll go away when it comes back you come back
for more treatment you know because we know that people who have major
depressive disorder for example will have recurrences most likely what we’re
looking at is okay let’s treat what you’ve got going on right now let’s help
you start feeling better and help you continue to feel better
ie not relapse and have another episode so we want to make sure that we’re
looking not just at eliminating the present symptoms but keeping them away
integration of addiction treatment in multiple disciplines especially primary
care mental health and addiction so we want to make sure that addiction
counselors know the basics about working with clients with have mental health
issues we want to under the primary care physicians have an understanding of how
to screen for substance use issues evidently less than 20% of primary care
physicians ever receive training in that that was from the report that came out
anyhow and we want to make sure that each area is aware of the impact of the
other areas so mental health practitioners are aware of the impact of
even behavioral addictions like we’re talking about Internet addiction which
is in the dsm-5 and other other sort of sorts of
behaviors we also want to make sure they’re aware of the impact of
physiological problems like polycystic ovarian syndrome and hypothyroid okay
another trend is the use of evidence-based practices and if you are
in a clinic you’ve probably heard about this if you are in individual practice
you may not have but I do want to show you this really cool little tool and I
will deficit by saying evidence-based
practices are awesome however in many circumstances about 85%
of them require you to get go through a certain training curriculum or whatever
that can be quite expensive which is why a lot of agencies have difficulty
adopting new EB T’s because it requires that every staff member be trained on it
and that training is often several thousand dollars so the new mandate that
we start using that came out that treatment facilities start using
evidence-based practices well that’s wonderful we’ve been saying that for a
long time but how how can we make it effective and affordable for agencies to
switch over so that being said little soapbox may be a big one the National
Registry of evidence-based programs and practices by Samsa is great because you
can find an intervention search by keywords
I love databases if you can’t tell let’s look for major depression there we go
we’re just running a little slow so there are two programs that came up in
the search results depression prevention managing your mood and partners in care
now this shows whether its promises promising outcomes or effective outcomes
the depression prevention program has evident effective outcomes evidence of
effective outcomes in research for depression and depressive symptoms so
you’re thinking to yourself well that might be something we want to implement
so then you can click on that la dee da dee da and learn more about about it how
to access that evidence-based practice now let me go back here one more time
because I think this is a useful tool seeking safety which we’re going to talk
about later is it an evidence-based practice and that’s one you can get
relatively inexpensively but you can search by program type so let’s say a
mental health treatment by age let’s say we’re working with adolescents sure why
not outcome categories mental health race
ethnicity so we’re getting to more detail about what’s going to work with
this population let’s say Hispanic or Latino and LGBTQ I TS let’s just throw
that one in there I don’t know if we’re gonna get anything that matches all of
those criteria but yeah that pushed it over a little bit
once I added the special population but you can do based on the population you
serve you know them best how old are they what they’re presenting issues are
what their gender is what kind of setting you have whether it’s inpatient
outpatient court school or classroom so there’s a lot of stuff you can look at
here and find the different evidence-based practices so ebps are not
going away they are really cool they are awesome motivational interviewing is an
EBP that a lot of us have gotten trained in over the years but you see how many
years it took for that to actually get completely integrated into practice
where most people had had some training in it okay use of medications is a new
current trend in practice when you read a lot of the insurance guidelines for
reimbursement on the level of care guidelines one of the statements in
every single provider that I’ve ever worked for in the level of care
guidelines is medication is used unless contraindicated and I mean it may be
contraindicated because the person says you know I don’t want to be on
psychotropics or pain meds or whatever it is and that’s that’s cool but all of
the insurance companies that I’ve ever worked with actually have a line item in
there that says you need to consider the use of medications for treatment and
telehealth technologies are becoming huge partly because it makes services
more accessible and to a little extent a little more affordable you’re still
paying for the clinicians time and the technology but there are a lot of other
ways we can use telehealth such as support groups in the rooms is an online
chat room for people with substance abuse issues people can log into daily
virtual support groups or you can even host one on your own website if it’s a
support group you have less HIPAA issues especially if you host it on
website other than your own you create a secondary arm that’s your aftercare
support thing talk to your attorney about HIPAA and hi-tech confidentiality
issues there but there are a lot of different things you can do you can
provide chat support to your clients so they can get more immediate in the
moment support for something that’s going on maybe there in the first month
of recovery you can have forums available forums have kind of gone by
the wayside over the past 15 years or whatever but they still get used some
and it allows people to communicate asynchronously and provide each other
feedback one that I participate in spark people it has an app is a nutrition and
health and wellness app but there’s a lot of really good interpersonal support
that goes on on that in that chat room so that’s a good place and oh there was
another one I met the man the other day that created pocket rehab is the name of
the app and is only available on Apple devices right now but pocket rehab and
he has a really great program that allows people to both do private
journals as well as to receive lifeline support from other people who are in
recovery and he incorporates all addictions not just substances but also
shopping and in Internet addiction and all those sorts of things so an online
video psychoeducation if you have certain topics that you
teach every single group that comes through like when I when I was at the
clinic in South in Florida there were certain groups I did every single 30
days so you can record those and it doesn’t have to be super fancy it can be
like this or it can be super fancy whatever you want and have those
available online they can be password protected so only your clients can get
to them if you want to so they can watch them at their leisure and and or you
know they can participate in the group and then they can go back and review the
video later if they need sort of a tune-up so
how else can we make treatment more available and that’s one of the things
that’s going to kind of plague us because there’s the balance between or
struggle if you will between making services available but we can make them
available but we’ve making them affordable is almost more challenging
than making them available a lot of people kind of shy away from groups
especially face-to-face groups because you know they don’t necessarily want to
see their neighbor when they walk into a room online groups have the benefit of
people can’t see each other or you don’t have to do video so people can see each
other most of the time they can’t so people feel like they maintain a little
bit more anonymity online services that’s another thing so I would
encourage you to continue to think about that principles of effective treatment
duration and treatment for at least three months is generally critical for
substances definitely critical for mental health you know really 12 weeks
is not a long time for somebody who’s struggling with major depressive
disorder you know to really get some traction in their recovery now if you’re
dealing with some acute adjustment issues obviously three months isn’t what
we’re talking about but you know major issues that are going on that’s really
what we want to look at treatment plans must be assessed continually and
modified to assure that it meets the person’s changing needs so you’re going
along for three weeks and all of a sudden the person loses their job or
separates from their spouse or something else happens or maybe even they get a
promotion at work score that’s awesome but you may still need to adjust the
treatment plan based on what the expectations were for that person to do
how much time they have to devote to treatment and the current pressures in
their life if they get a promotion then they also might have new added stressors
if you will of this new job so you might have to kind
segue over and add that as an additional treatment plan ischium treatment doesn’t
need to be voluntary to be effective what needs to happen is for us to
effectively engage the person and develop mutually agreeable goals whether
you know if they’re seeing you for anger management issues their boss said
they’ve got to come to counseling for anger management okay well they’re
probably going to be pretty ticked off but they’re having to go to these groups
I don’t blame them so let’s talk about what is it that you can get out of these
groups how might this help you you know your goal is to keep your job my goal is
to help you with your anger management how can we make these two goals kind of
work together harmoniously and I used to ask my involuntary clients my probation
of parole clients what is it that you always wanted to learn or what skill or
tool might be useful in your life as long as probation and parole is paying
for it and you’re stuck with me for the next 16 weeks what is it that I can help
you work on might as well take advantage of it because you’re stuck with me
so that helps a little bit also putting the power back in their court and
empowering them to identify their treatment goals and let you know again
what they’re gonna do instead hopefully you have the flexibility so if they say
I’m not going to 12-step meetings for example you can say okay well you need
some you need a support group or you need some sort of pro-social activity so
many hours a week what are you going to do instead the medical model of
treatment looks at these issues mental health and substance abuse more as a
chronic disease issue with mental health we’re looking at neurotransmitter
imbalances with and we also have neurotransmitter imbalances with
addiction these treatments are often hospital or doctor’s office based so you
may be working with somebody it’s likely that you’re working with somebody who is
also seeing their primary care physician or a psychiatrist for psychotropics okay
so if you are that’s fine but we need to look at it
and say okay that person is addressing this aspect of the depression or the
anxiety or the addiction I’m going to address this aspect over here we’re not
really going to overlap but as the clinician we probably are the single
point of contact so we need to make sure everything is merging together well the
medical model does use a biopsychosocial approach with an emphasis placed on
physical causes and pharmacotherapy but they do look at the psychological and
social aspects a little bit and the doctor may make some recommendations but
he’s not gonna do counseling and he’s not gonna do life skills training you
may see people get detoxification medication for symptom reduction
medication for a version like antabuse which is what they used to give
alcoholics and they do still some and medical maintenance or medication
assisted therapy the spiritual model views mood issues and addiction as being
caused by spiritual emptiness which leads to character defects such as pride
resentment and anger now the 12-step models are largely based
in the spiritual model but you also might be working with somebody who’s
been working with their spiritual guide or their spiritual leader so we want to
be able to understand where that person has been telling the client this is
probably what’s causing your your issues right now less weight in the spiritual
model is given to causation and more of an emphasis is put on a spiritual path
to recovery development of values and a sense of meaning and purpose so what
we’re looking at developing hope faith courage discipline those sorts of things
which really won’t hurt anybody the 12-step models which are mutual help and
many people aren’t real familiar with twelve steps they’ve heard about them
they know well if somebody has a substance use issue they go to a a or NA
well there’s a lot of a programs out there a lot of Anonymous’s they
emphasize that one cannot help once self and recovery requires surrender of
one’s will to a higher power now for some people as soon as they hear that
their skin starts to crawl and they’re like oh heck to the no and for other
people they embrace that and go you know what you’re right I’ve been trying and
trying and trying and I can’t do it on my own so one of the challenges we have
if we’re working with somebody who either doesn’t believe in a higher power
or who is angry at their higher power how do we help them embrace that and one
tool and I’m going to ask you to think about other ways we can help people
integrate into 12-step communities if they don’t believe in a higher power but
one tool that I’ve always been taught is to view God as good orderly direction
that is to get to your goals to get a reaching meaningful life always think
first before you act is what I’m getting ready to do going to help me move in a
good orderly direction towards my goals or is it gonna you know throw me off
track so if we’re thinking about good orderly direction in terms of a higher
power or a higher direction sometimes that can help people deal with 12-step
meetings if they were a bit resistant because sometimes the court just
requires 12-step meetings and you can’t you have no way to get around it you can
advocate till you’re blue in the face and it ain’t gonna help so one thing
that I do want to point out with that is emotions Anonymous I said there’s a lot
of eyes out their emotions Anonymous is designed for people basically who have
emotional dysregulation issues where their emotions they go from 0 to 240 and
1.2 seconds and they feel like they’re not able to control their anger their
depression their anxiety any of those dysphoric feelings if they’re willing to
explore a 12-step sort of approach ei is a good activity for them they have their
own literature they have their own books the meetings are not nearly as plentiful
as there are aana meetings around but
they’re always open to people starting new meetings so if you’re interested in
learning more about it maybe starting a meeting at your facility that could be
an avenue that you go down okay so how can you use a spiritual model with
clients who don’t believe in a higher power and for me it comes down to
working with them to define what spirituality means to them and in what
way they think spirituality or lack thereof or spiritual roadblocks are
contributing to their unhappiness right now and so we get into a much more
abstract conversation about what’s going on and talking about what does recovery
look like and if you’re recovering spiritually if you were a coverage
spirit spiritually what would be different what do you need to enhance
are we talking virtues or what behaviors and we kind of pick that apart for a
little while to develop their ultimate goal plan okay the psychological and
self-medication model says that addiction and mental health issues
result from deficits in learning thinking or emotion regulation so this
is the stuff we were all taught in grad school treatments can be ranged from
behavioral self-control to individual and group counseling to pharmacotherapy
I mean we’re not opposed to helping people figure out what may need to be
addressed and advocate for them or encourage them to advocate for
themselves with their physicians in order to access pharmacotherapy that
might help them so the goals will start with behavioral self-control training
behavioral self-control is you know think back basic behaviorism strengthen
internal mechanisms so increased self-awareness of what’s going on what
you need what your triggers are or your stimuli and establish external controls
so you can implement coping skills help people start learning how to set goals
so they have something out there that they see I need to accomplish this this
week or this this month or whatever it is and they have this external plan
that’s helping them monitor and shape their behavior you can use behavioral
contracting so for example what would you contract for with somebody who has
major depression who has difficulty getting out of bed we may contract for
having the person get up by a certain time each day and you put in rewards for
achieving that and if they don’t achieve it then we want to look at you know what
what’s going on what happened there but each day just like with standard
behavioral interventions if they do what they’re supposed to do or trying to do
we need to make sure that it’s rewarding so if they do get out of bed at whatever
time you you identify we need to make sure they have access to
some sort of rewards trigger management so encouraging people to be aware of
what their triggers are I’ve told you before one of my four as far as mental
health mood triggers is the commercials for the ASPCA and I was at the gym the
other day and I looked up and they had this poor little shivering dog in in the
video and it just broke my heart I was like okay no not even watching that but
what are people’s triggers for their mental health stuff it could be a
meeting that they have to go to at work it could be a person it could be a place
but helping them identify what those triggers are and figuring out how to
work with and or through them functional analysis of the behaviors not the
diagnosis so if somebody has symptoms of depression they meet the criteria for
major depression whatever you want to say all right we’re not going to look at
what is the function of depression well depression looks different for different
people what is the function of not being able to get out of bed not feeling you
know they just don’t want to get out of bed in the morning that’s the behavior
so what’s motivating that well they may not be sleeping well they may feel
fatigued and exhausted okay let’s look at what’s causing that because then we
can figure out something to address the underlying issue that’s causing the
targeted behavior the behavior you want to eliminate so conducting those
functional analyses if somebody stress eats okay
so that’s a specific behavior so what purpose does it serve and what else
could you put in its place to satisfy it this need instead of stress eating
relapse prevention so we want to look at relapse prevention strategies for both
mental health and addiction and they’re basically going to be the same good
sleep good nutrition good social support mindfulness relaxation and recreation
you know regularly I won’t say every day because some people just they work too
jobs have six kids can’t do it okay that’s fine but we want to make sure
that these people are living or trying to live a happy healthy life so that’s
what relapse prevention is is helping the person prevent those conditions
prevent it stuff that caused the neurochemical imbalances that led to
their depression which may have led to their unhelpful thinking so you know
wherever the unhelpful thinking came in the process you know it doesn’t really
matter we end up needing to treat or address everything but realizing that
relapse prevention means preventing those conditions from occurring again
just like when there’s a hurricane there’s a certain set of conditions that
have to happen for hurricane to form well there’s a certain set of conditions
for each person that need to kind of occur for them to have a recurrence of
their major depressive episode in most cases like 99% of the cases so we want
to know what those are so we can try to prevent them and we don’t want to know
what those are and what the symptoms are of the beginning of an episode so people
can intervene early if they notice you know what I’m starting to feel kind of
wonky then they can start saying I need to back off maybe I need to take this
weekend off and rest and relax because I’m starting to get burned out and I’m
starting to feel blue and I really don’t want to go into a whole depressive
episode that’s relapse prevention so preventing an early intervention
dialectical behavior therapy came as a response to people who weren’t doing
well with traditional cognitive behavioral clients in traditional
cognitive behavioral often and traditional therapy often
unintentionally reward ineffective treatment while punishing therapists for
effective therapy with a lot of clients when we start digging when we start
pushing buttons when we start helping them move through those stuck points it
hurts and they don’t like it so in certain circumstances among certain
groups of people they symptoms escalate so much that the
therapist has to back off every time they start to get to a point the client
either discharges or rapidly escalates or decompensates so cognitive behavioral
wasn’t helping to deal with the distress that was caused by pushing on those
buttons and dealing with those old wounds the sheer volume and severity of
problems presented by clients makes it impossible to use the standard cognitive
behavioral format in many cases because they would be doing ABC worksheets until
doomsday so we need to help them figure out how to moderate some of this
distress and how to figure out what the root causes are clients found the focus
on change inherent to CBT in validating because cognitive behavioral was often
saying again this is your problem is caused by unhelpful cognitions and
behaviors that’s what you need to change let’s you know it’s very practical very
pragmatic but clients who are struggling and who are extremely emotionally raw
often felt very invalidated so the overriding themes in DBT our
mindfulness using that wise mind getting out of the emotional reactive mind
distress tolerance sometimes life is going to be unpleasant and you can’t
necessarily make it stop so what do you do how can you address it emotion
regulation and interpersonal effectiveness and problem solving a lot
of people who have emotional dysregulation have difficulty managing
those emotions and not going from 0 to 240 and 1.2 seconds they’ve had
struggles with interpersonal relationships a lot of people with
borderline personality disorder characteristics also struggle with
relationships because of their lack of internal sense of self their need for
external validation so more interpersonal effectiveness skills need
to be taught but they also need to be able to regulate their emotions and
their distress another model that you might not be familiar with but has a lot
of really awesome units for straight-up mental health is the matrix model for
stimulant use now if you’re going to use it as an evidence-based practice
obviously you’re using it with stimulant abusers but this manual for the matrix
model provides you with worksheets I mean it’s it’s a clinicians manual for
identifying triggers body chemistry and recovery thinking feeling and doing work
in recovery guilt and shame sex and recovery truthfulness trust being smart
not strong talking about asking for help so there are a lot of really awesome
things that you can get some ideas off of to do group if nothing else the goals
of the matrix model are to learn about issues critical to addiction and relapse
receive direction and support from a trained therapist and become familiar
with self-help programs not just 12-step but that can include celebrate recovery
and some of those others the therapist functions simultaneously as teacher and
coach fostering a positive encouraging relationship so a lot of this is
psycho-educational like I said it a lot of the groups are applicable to people
who don’t have any addiction issues at all
motivational inherent enhancement therapy is unique because it usually
only consists of three to five sessions period and a story it’s used to help
resolve ambivalence about treatment and abstinence or change whatever the change
may be and that can be relationship issues or whatever the therapy consists
of initial and assessment battery because you want to get an understanding
of what’s going on in this person’s life so you can provide them feedback
followed by two to four individual sessions with the therapists and they’re
not usually weekly they’re spaced out where you develop goals and you empower
the person to make Changez on their own the first treatment
you want to provide feedback about the initial assessment place the
responsibility for change directly on the shoulders of that person saying you
know what you got this but I can’t do it for you I am here to advise as much as I
can but ultimately if you’re going to change it’s the balls in your court
so we want to elicit self motivational state statements identifying the reasons
they want to do it and examples of how they’ve succeeded in the past so self
motivation and self-efficacy we want to strengthen motivation and build a plan
for change so this is still the first session it’s a long one we provide
advice such as coping strategies for high-risk situations then we provide a
menu of options so here’s some advice about you know different directions you
could go here’s a menu of options for different types of treatment different
books you could read you know these are things I think would help you here’s a
laundry list now let’s figure out what looks good to you we want to provide
empathy and enhance self efficacy so feedback responsibility advice menu
of options empathy and self-efficacy in the subsequent sessions the therapist
monitors change reviews the change strategies being used and encourages
change you’re the cheerleader at that point so this is very behavioral in
nature and motivational in nature and puts a whole lot of responsibility on
the person which means it’s really good for some people who are really high
functioning and really motivated family behavior therapy I really like it’s
demonstrates positive results in both adults and adolescents it addresses not
only substance use and mental health problems but other co-occurring issues
because it’s family behavior therapy not identified patient behavior therapy so
we’re looking at a whole family going alright what’s going on here it can
start addressing conduct disorders child mistreatment family console
unemployment you know the range of things goes on we figure out what are
the weak links if you will or the trigger points in this family that are
causing the identified behaviors what they want to get rid of and how can we
help them meet those goals it involves the patient along with at least one
significant other such as a cohabitating partner or a parent so it doesn’t have
to be the whole family ideally it is everybody living in that household but
it requires at least one other person FBT combines behavioral contracting with
contingency management so you set up a contract you agree to do these things if
you do there are certain rewards that you can get and they set up the rewards
therapists seek to engage families in applying the behavioral strategies
taught in sessions and acquiring new skills to improve the home environment
such as you know how do you deal with the toddler if you know there are
difficulties with child neglect or child maltreatment you know some education
about how to do that and okay when Sally starts asking why is this blue or why is
this green for the 700th time and you just want to pull your hair out what do
you do instead of losing your temper so basically providing these tools but
it’s set up in a contract with rewards for successful completion and it does in
contrast to the other things it looks at the family system it looks at the
environment and addresses biopsychosocial spiritually
environmentally the trigger points that may be prompting the behaviors you want
to eliminate seeking safety love this one is a present focus therapy for
trauma PTSD and addiction it is available as a book with guidance for
clients and clinicians and you can get it on Amazon and it can be done in
individual or group I had two clinicians where I used to work that used to run
this program or different instances of this program and the clients loved it
and did super super well as far as their their outcomes
the topics not going to go into huge depth you can look at it on Amazon but
they range from introduction to safety PTSD and taking it taking back your
power compassion creating meaning detaching from emotional pain and
grounding identifying red and green flags and self nurturing and again you
can conduct these in any order so your particular group may need a different
order and maybe you don’t work with people who have active substance use
issues so you can take that substance group kind of out of it because this is
really looking at PTSD recovery and creating safety the socio-cultural model
emphasizes the socialization process culture observational learning and
reinforcement of behaviors so somebody using this model is really going to look
at the social and family relationships and in substance abuse recovery we often
say that people need to change people places and things well that’s easy to
say but it is almost impossible to do for most people they’re going to go back
to that same environment out of which they came because that’s the only place
they have to go they don’t they can’t afford to go to a sober-living facility
that may charge $1500 a month or something so they’re going back home so
changing the culture that they live in they live in the same neighborhood you
know whatever that’s not so easy but we can help them develop skills and tools
to deal with the stressors in their family and social relationships in their
environment we can help them develop social competency and interpersonal
effectiveness playing on the observational learning if they see John
and he’s doing he’s he goes drinking when he’s had a bad day and it seems to
help him feel better and your client says well maybe I had a when I have a
bad day go out drinking we want to encourage him to think what are your
ultimate goals and is following what John does even though it looks like it
might help is that really going to help you is that going to be the solution
that you’re looking and encourage people to work within
their own cultural infrastructure to find a safe place you know what is it
that I can do where so I’m remaining true to my culture as I define it but
I’m also happy and healthy and all those sorts of things
relapse prevention is a really basic approach and it adopts strategy is
designed to help clients become aware of cues or triggers that make them more
likely to abuse substances or become symptomatic triggers and I’ve told you
before that um you know it can be holidays it can be seasons it can be
smells it can be there are a variety of things I know for me there are certain
smells that trigger really positive memories and certain smells that trigger
trauma and I’ve learned how to deal with those triggers through practice and
experience but it’s important for clients to be able to recount if they
have a smell for example that triggers a traumatic memory for them to be able to
stay in the present and not you know go back there wherever back there was so
relapse prevention helps people be a lot more cognizant of their environment and
more mindful one of the things that we don’t we don’t usually use the words
mindfulness and relapse prevention together but you can’t have one without
the other mindfulness helps clients identify when
they start feeling that queasy little feeling that pit of their stomach that
says this is not a good place for me to be or this is gonna be stressful so they
can address it early that early intervention and it helps them look
around and eliminate as many triggers as possible
so they can have positive things around if they’re say particular you know
billboard on their way to work that triggers them they can go a different
route if they see maybe they’re driving past the neighborhood where they used to
live with their expose and that just devastates them every time they drive by
it or it makes them really angry well maybe they can find a different
to work so monitoring and managing those triggers so they’re not intentionally
putting themselves in stressful or dangerous high-risk situations and
helping them develop alternative coping responses to those cues all right so you
have to drive by your old neighborhood you get enraged when you drive by there
and you’re thinking about what happened and I can’t stand it what can you do how
can you get out of that flurry of adrenaline and get yourself to a place
that’s more helpful for you for some people you know one thing I might
suggest for a client who has to do that is to think alright if they know ahead
of time they’re gonna have to drive by that place what can they do leading up
to it positive self-talk leading up to it and distraction techniques as they
pass it so maybe having their favorite song really loud on the radio or the
comedy channel on or something that can help so they get so they get past it or
if they have an unreasonable fear of bridges what can you do if you know
you’ve got to go over a bridge to get through it so it doesn’t throw you for
for a loop now obviously those are acute responses
but enough stressors could potentially trigger a full-blown relapse of anxiety
or depressive major depressive symptoms medication assisted therapy which
allegedly is supposed to be becoming available at all treatment facilities
and I’ll wait to see that happen includes methadone suboxone vivitrol
antabuse and some SSRIs you’re selective serotonin reuptake inhibitors they’ve
been found to help with certain compulsive behaviors certain
antidepressants especially zoloft it’s been found to be really helpful with
people with bulimia so there is some evidence out there that SSRIs can help
with some compulsive behaviors in addition to mood issues vivitrol is
helpful for alcohol and opiate abuse antabuse is the thing that people take
then makes them throw up and really really sick actually it increases the
rate at which they get alcohol poisoning is technically what happens if they
drink so there’s a lot of different types of medication assisted therapy out
there it’s not necessarily meant to have somebody on it indefinitely
I help start a methadone clinic where I came from in Florida and our
psychiatrist really looked at it as an 18-month treatment program get people on
you know get them to the point where they’re not having cravings to use then
they had in methadone clinics you are required by the Food and Drug not food
and drug by the DEA there are all kinds of requirements for counseling that have
to take place in a methadone clinic not in the patient not in the doctor’s
offices where people go and get suboxone that’s generally just getting them
suboxone but in methadone clinics people have to undergo pretty intensive therapy
in addition to it and a lot of clinics will only maintain people on it unless
there is an overriding reason not to discharge them for about 18 months to
two years you have to present to the powers that be at the DEA or wherever
compelling reasons to keep somebody on methadone more than two years now some
of the people that I worked with that were veterans did have chronic pain they
had opiate addiction issues methadone was being used to help monitor manage
their pain you know there were some outstanding outliers or whatever but
understand that methadone really for the most part is not meant to be something
that people get on and stay on for the rest of their lives it’s not replacing
one addiction with another it’s supposed to help them get through that period
until their neurotransmitters can kick back in and they develop the skills they
can they need to develop to deal with life on life’s terms medication assisted
therapy for mental health issues are your SSRIs
SNR is your atypical antipsychotics your antipsychotics
some people need those obviously if somebody has a psychotic disorder or a
bipolar disorder they’re probably going to have to be on medication people with
a generalized anxiety and major depressive disorder and some of your
mood disorders may not have to be but it may help them get through until they
start getting some treatment traction harm reduction is the acceptance that
drug use and mental health issues are just a reality the goal is to prevent
harm caused by severe mental health issues you know not being able to get
out of bed losing your job relationship problems you can have a lot of problems
from mental health even if you don’t have an addiction when we talk about
these we talked about the for ELLs just to make it easier to remember
liver lover livelihood and law so we want to prevent health problems we want
to prevent relationship problems we want to keep people employed and keep them
from getting involved with the law interventions for harm reduction include
low threshold pharmacological interventions so like what we just
talked about if we’re talking about drugs needle exchange programs emphasis
on non injection routes of administration such as oral tablets and
even smoking and inhalation but injection int’l a ssin and smoking are
the three fastest ways to get high and three most potent so we want to steer
people away from those as much as possible lead more towards oral as as
needed and if you’ve got somebody on other medications you know for some sort
of mental health issue I know some of my clients who had psychotic disorders
would have injectable antipsychotics but we don’t want people ideally injecting
themselves every single day unless it’s inevitable but with the antipsychotics a
once a month injection of the of the antipsychotic would keep the person
going so they didn’t have to remember to take it so we want to look at harm
reduction what can we do to help this purse
an involvement of those with a history of use or distress in program
development so to develop a harm reduction program we need to ask people
who have the problem what is going to help you out what can minimize the
ancillary problems caused by this behavior condition or addiction
multidisciplinary psychotherapeutic interventions for co-occurring issues
medication assisted therapy for both addictive and mental health issues
wraparound services including legal and child care and social services to ensure
people have access to necessary resources to achieve their goals and
family therapy to improve the interpersonal environment of the person
now if you can get all those in the same facility awesome but these are all
things that we need to consider when we’re looking at providing a
comprehensive treatment program there are many approaches to dealing with
mental health and addiction issues since co-occurring issues are the expectation
not the exception it makes sense to be aware of strategies to address both or
all issues or at least where to find those evidence-based and promising
practices current trends and practices are steering clinicians to use more
individualized strengths-based biopsychosocial spiritual approaches are
there any questions you all right everybody you have an amazing
day I am going to be doing an extra little recording it’s not a CEU thing
but let’s see it’s one o’clock now in about 30 minutes I’m going to be doing
another recording in the same room on the recommendations that came out from
the opiate Commission thingy so if you’re interested in learning about it
you can tune in if you don’t want to that’s cool too it will be on the
YouTube channel on Saturday have a great weekend everybody if you enjoy this
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