19 Therapeutic Approaches | Addiction Counselor Exam Review Podcast

19  Therapeutic Approaches | Addiction Counselor Exam Review Podcast

Welcome to the addiction counselor exam
review. This presentation is part of the addiction counselor certification
training. Go to https://www.ALLCEUs.com/certificate – tracks to learn more about
our specialty certificates starting at 149 dollars.Hey there everybody and
welcome to this episode of addiction counselor exam review. Today we’re going
to be talking about therapeutic approaches among some other things we’re
going to review different therapeutic approaches including cognitive
behavioral and motivational enhancement contingency management and
trauma-informed care we’ll talk about types of treatment including individual
group and family and we’ll look at into the benefits and drawbacks of each and
then we’ll also look at culturally appropriate strategies methods for
family engagement how to do crisis intervention and some techniques for
relapse prevention so we’re going to cover a lot in this our therapeutic
approaches refer to basically how you approach solving a problem behavioral
and cognitive behavioral approaches are grounded in social learning theories and
principles of operant conditioning now when you think operant conditioning I
want you to think back to Pavlov’s dog he heard a bell ring he would start to
salivate so a lot of what we talked about with triggers revolves around
operant conditioning because something in the environment a lot of times will
trigger cravings for a substance or a behavior emphasis is on functional
analysis of behaviors to understand within the context of their antecedents
and consequences why they happen and antecedents are what happens before so
what types of things happen leading up to this use and what are the
consequences of this use that are supporting or rewarding continued use
because when people are using yes there are some drawbacks but there
are some benefits too so we want to look at what are some of those benefits in
addition to what triggered it in order to understand what is maintaining this
addiction cognitive behavioral approaches and behavioral also provides
skills training through which people recognize the situations or states in
which they’re most vulnerable some situations could be a bar or your
relatives house or whatever and States could be if you’re depressed or if
you’re anxious or if you’re overtired different conditions that basically make
you more vulnerable to use this thing and then you learn how to avoid those
situations or deal with them if you if they’re unavoidable and finally
behavioral and cognitive behavioral approaches use a range of behavioral and
cognitive strategies to help people cope effectively with situations that can’t
be avoided so if you can’t avoid going to your families for the holidays but
you know that’s a huge trigger you would talk with your therapist or you would
identify ahead of time cognitive strategies and things you could do
behavioral strategies in order to reduce the likelihood that you would relapse so
for example avoiding the liquor cabinet you know stay away from that part of the
house you may want to stay away from certain people that happen to trigger
you may they may trigger anger or anxiety or shame that makes you want to
use that causes those cravings so you would look at identifying some of those
triggers and ways to cope with them you would look at developing an emergency
plan so if those cravings got too strong what do you need to do cognitive
behavior therapy is based on the idea that feelings and behaviors are caused
by thoughts and you know kind of vice-versa all three of these impact one
another when we have negative thoughts we tend to see the negative in things
and we tend to feel bad which can make us physically hurt feel bad feel
depressed feel energy less fatigued so and when we’re fatigued we tend to not
see as much happy stuff and we tend to be a little bit
more negative so all of these can impact each other and it’s important in that
cognitive triad is what they call it to recognize that all three of these things
impact it cognitive behavior therapy says that people may not be able to
change their circumstances but they can change how they think about them and
therefore change how they feel and behave so take a job you hate you know
we’ve all had one of them you may hate that job but if you keep thinking this
is the worst job ever I hate my life I can’t do this anymore then your feelings
are going to center around hopelessness helplessness anger resentment all that
unpleasant negative stuff and your behaviors may seek to help you eliminate those feelings
through engaging in addictive behaviors or your behaviors may not be good at
work you know there are a lot of different things but if you change your
way of thinking about it and say okay this job really sucks I don’t like it
but it’s paying the bills for right now and there are a few people at the job
that I like that’s a bonus and I can get through this you know until I can find
another job and I do have options for looking for another job
so that gives you hope and empowerment and you recognize that yes this is not
an ideal situation but it is not as oppressive as when you were stuck in
your anger and resentment just going grumbling under your breath about how
miserable you were so that’s one of the approaches that cognitive behavioral
uses the goal of cognitive behavioral therapies is to teach the person to
recognize situations in which they’re most likely to use now we can’t possibly
create a relapse strategy for every single situation you’ll ever encounter
so you need to generalize and recognize situations in which the person is more
likely to use so under stressful situations I had one client that I
worked with who you know was a pretty heavy user of marijuana and alcohol but
he would not use in front of his children so you know that’s kind of
taking it to the other side when would you not use but we integrated that into
his treatment plan so during those times of day like right after work when he
really had some cravings to use because it was a long stressful day he would go
home and go out and play ball with his son so those cravings went away because
he wasn’t going to use them so CBT or cognitive behavioral therapy encourages
people to avoid circumstances in which they’re most likely to use and identify
alternate behaviors and alternate things to do contingency management therapy
uses motivational incentives to facilitate behavior change and has
improved treatment retention and abstinent rates and contingency
management can be anything from drug courts where or if you go
through and you stay clean you stay out of jail and you won’t have X and so
charge on your record or you get to keep your kids or will close your case you
know that’s a contingency and then there are also shorter contingency management
things when I ran the adolescent clinic if the youth did what they were supposed
to do throughout the day they earned points every time they got a positive
hash mark and they could cash in those points for video game time or sleep time
or other things that they wouldn’t necessarily have we also had a rewards
closet so they could save up their points and we had like junk food and a
variety of different things that teenage boys would find rewarding in that
rewards closet that they could purchase with the tokens that they earned from
being you know doing the next right thing motivational enhancement
approaches are client-centered and they initiate behavior change by helping
people look at all of the reasons that they use and all of the drawbacks to
both staying the same and to changing it helps people really understand how they
think and how they feel about that situation and harness internal
motivation it says you know I can’t make you change so I if you want to change
I’m gonna help you figure out reasons that you want to change and deal with
all those apprehensions you have about changing that’s my job but first you
have to want to change and we want to help people identify discrepancies for
example between their goals and their current behaviors so they want to be a
lawyer one client I worked with was a in college and he wanted to be a lawyer but
he was actively using some pretty hardcore drugs and you know you can’t
have a felony criminal record and become a lawyer in most states so we started
looking that at that and I said ok you’re telling me you want to be a
lawyer so you know that may mean that you need to give up using these protect
types of drugs you know there are certain legal drugs and I’m not gonna
tell him what he can and can’t do but it was important for him to give up the LSD
and the GHB and those things that he was using so that’s another avenue that you
can pursue with motivational enhancement for many clients that I’ve worked with
who are involuntary their whole goal is to get off papers get off probation get
off parole be done with me be done with the system so to speak okay so that’s
your motivation you cannot do that get off papers and continue to use at the
same time so during this period while you’re under state monitoring you know
let me help you figure out how you can meet the courts requirements so you can
meet your goals and then you can do whatever the heck you want you know am i
telling them to go back to using no but I’m also not telling them that you know
once you do this then you won’t ever use again make us for a lot of them the idea
of never being able to use again was way too overwhelming so we just started with
let’s do it for this short period and I felt in my heart that for a lot of them
if they stopped using for three months or so and got through that post-acute
withdrawal phase a lot of them would find that they had developed other
behaviors and other skills and other support systems and they didn’t have the
desire to go back to use that’s what I felt in my heart so you know I felt good
about helping them work towards a mutually agreeable goal because they’re
motivated to do that and traumaspecific approaches now this can kind of overlap
with cognitive behavioral and everything else trauma specific models are taken to
account the fact that many people have been traumatized and many people’s
symptoms and behaviors are a result or a reaction from that trauma they may be
trying to self-medicate PTSD they may be trying to help themselves deal with
anxiety that surrounds you know being in strange places or
whatever it is but there are there may be certain things in their present that
remind them of the trauma that can trigger the urge to use there also may
be things about the program and about recovery that can trigger their urge to
use one of the biggest triggers for a lot of people if they go into a 12-step
program is the talking about surrender and surrender is terribly frightening to
people who have been traumatized or victimized because that means
relinquishing all control and yes theoretically you’re relinquishing all
control to your higher power but in their mind they’re like well when I
didn’t have control before and I was victimized where was my higher power so
they may not trust their higher power so it’s really important to use a
trauma-informed approach when working with people who are in recovery from
anything because the statistics indicate that the majority of people have
experienced some traumas in their life trauma specific models are an essential
part of treatment because misidentified or misdiagnosed trauma symptoms
interfere with help-seeking and hamper engagement and treatment leading to
early drop out and make relapse more likely if you’re putting people for
example in co-educational therapy groups and they have been raped or molested by
somebody of the opposite gender that could be a trigger they may not be
willing to feel vulnerable in front of somebody who reminds them of their
abuser so we need to take all these things into consideration the primary
goal of trauma specific services are focused on directly the impact of trauma on people’s lives
and facilitating recovery from that trauma so we want to look and we want to
say this thing happened whatever it was you know you were in Hurricane Katrina
you were raped you were a victim of a home invasion robbery whatever it was
that happened and that was awful how is that impacting you in the present in
what ways are you still reminded of it in what ways does it trigger your
anxiety or PTSD and how can we help you deal with that so you’re not struggling
with that on a daily basis and how can we prevent re-traumatizing you what
types of things in our program might trigger those stress reactions as well
and again if somebody’s been raped if they are being examined by your
physician who happens to be someone of the opposite gender and they may feel
vulnerable that could be another triggering event now you may only have a
male physician to examine females or females to examine males or whatever and
you can’t avoid it so the question is what do you do and having a nurse in the
room or a female in the room can be helpful there are a lot of other things
a lot of it revolves around the doctor’s bedside manner you can overcome a lot
with a an understanding physician the addictions in trauma recovery
integration model or atrium is one approach a trauma specific approach that
can be used seeking safety is another one and you can buy the seeking safety
manual on Amazon I highly recommend it I had a couple of clinicians who used that
as the backbone of their intensive outpatient programs and we had just
absolutely fabulous results with the women reporting improvements in a lot of
different symptoms not only drug use but also anxiety depression anger you know
across the board there were improvements in symptoms and trauma recovery and
empowerment model is another approach that you can use couples and family approaches again they
can be used with cognitive behavioral behavioral which are the identified best
practices for working with addictions but there is some there’s a lot of
emotional stuff and there’s a lot of social stuff that goes on so we need to
look at how do we apply these things you know if you’re going to use cognitive
behavioral for example do you use it in group do you use it in couples and
families do you use it an individual or all of the above how do you do that
you want to make sure that the approach you’re using is trauma-informed so
you’re looking out for those triggers no matter what the setting whether it’s
individual group or family the defining feature of couples and families
treatment is that they’re treated treating substance abuse in the context
of the family and the social system recognizing that when we talk about
addictions for the most part it is very rare to have a single identified patient
and nobody else contributes and nobody else is affected you know I’ve never
seen it it it could happen but I’ve never seen it so we want to recognize
the fact that this individual something triggered their use you know it could
have been lack of social support it could have been some genetic
vulnerabilities it could have been a lot of things we don’t exactly know what
causes addiction but it also could have come in part from social factors so we
want to look at that and as that person began to use how did their behavior
impact the family a lot of times when people come to treatment they’ve
alienated the majority of their family the majority of their family has already
thrown their hands up and gone I don’t know what to do anymore I’ve tried
everything I don’t know how to help you anymore and they’ve had to institute
tough love so to speak so families if we want this person to have a good strong
sober saying social support system we need to integrate the family in
treatment and the family can be anybody that the client defines his family it
doesn’t have to be mom dad brother etc and anybody the person considers family
can be part of this treatment so the prevailing models and we’re not going to
go through them right now I do have some videos on our YouTube channel at all
CEUs comm slash YouTube that goes over some of the family approaches but brief
strategic Family Therapy structural or strategic Family Therapy
multi-dimensional Family Therapy multi-systemic family therapy behavioral
and cognitive behavioral family therapy and solution-focused brief therapy so I
will do another review on the different types of family therapy and like I said
I do have some videos on the YouTube channel but it’s important to understand
that there are six prevailing models of couples and Family Therapy that you may
need to be aware of for your exam and you know know how to integrate it when
you’re working with clients to bring them into treatment not every approach
is culturally appropriate for every person which brings us to culturally
appropriate strategies to areas of concern with regard to cultural
competence and addiction counseling are the competence of the individual
practitioner how much do we know about the culture that our clients come from
and I do want to put this big you know red flashing warning thing here don’t
assume that if your client is of a particular ethnicity will say Asian that
they adhere a Orab scribe to all or any Asian values we want to know what Asian
values are and that gives us a launch pad so we can start asking we want to
understand the difference between Asian culture and American culture so we can
ask the person you know does this fit for you if you’ve got somebody who’s
Asian American and they’ve been here for you know six generations they’re
probably going to be a lot more acculturated to American culture but
again you don’t want to assume so we want to look at that because culture
impacts what people feel comfortable talking about what they feel caused the
prob how involved they want their family to
be whether they feel that this issue mental health substance abuse has
brought irrevocable shame to their family there’s a lot of issues that come
up in culture it also impacts the type of treatment whether they’re wanting to
see a an MD type physician or maybe a spiritual healer or a cultural leader in
order to address some of their issues so we do need to be aware of that it
doesn’t mean they’re going to want it but we need to know what’s culturally
sensitive and ask you know would you like when I have somebody come over you
know switching gears a little bit when I have somebody come over who’s diabetic
you know I don’t know what they can eat I don’t know a lot about diabetes so if
I’m preparing a meal I ask them ahead of time
what works for you what can you eat what is what do you like to eat in order to
make sure that I’m being sensitive to their individualized needs culture and
the second thing is the cultural appropriateness of the specific
intervention strategies some cultures you know my grandmother for example you
know white Catholic elderly woman but the elderly part is the cold part of the
culture that was really crucial in addressing treatment issues because when
she was raised back in the 1920s you didn’t talk about your stuff in a group
full of people you didn’t air your dirty laundry you put on a happy face and you
just dealt with it and you dealt with it behind closed doors so putting her in
group therapy it would have been highly inappropriate and she wouldn’t have
gotten much out of it most likely so we do want to consider the appropriateness
of the intervention if you’ve got someone who is atheist and they are
adamantly opposed any reference to a higher power
well let’s not put him in a 12-step program because that’s just going to you
know they’re gonna smack into a wall there and their personal values
and their approach to life may conflict so we need to look at what might work
better for them such as smart recovery rational recovery something like that so
we do want to make sure that the interventions we’re using are culturally
appropriate and that we are aware of what is culturally potentially
culturally appropriate and then we talk to the client and identify what’s
appropriate for them culturally appropriate treatment can include the
language used the format of the program the goals set for events and specific
program activities so some cultures complete abstinence is not a goal you
know because alcohol or whatever is integral into their culture for some
cultures medication assisted therapy is not okay so we want to be aware of that
for some cultures having someone in residential treatment may not be
acceptable or because they believe the whole family should be involved in the
treatment process the whole way through so there are a lot of different things
that we need to consider and risk and protective factors may not be relevant
for all cultural groups most of the risk and protective factors that we know
about we’ve looked at either white American or black American individuals
we really haven’t gotten a really good sample of multicultural risk and
protective factors and for example you know going back to
those some cultures that really value interdependence instead of independence
they are going to feel it’s gonna be a greater risk factor if there is
disharmony in the family than it is for people who are more independent
potentially so the impact of these various risk factors we’ve identified
can be different based on cultural values programs and practices that have
been tested and found effective with one cultural group can be modified to fit
other cultural groups most of the time but you need to actually step back and
look at it before you start implementing it you don’t want to implement on the
fly and go oh let’s just tweak this here and tweak that there that doesn’t work
you need to look at it and go what parts of this do not work for this particular
cultural group and what can we do differently to get them from point A to
point B modifications can take two forms cultural accommodation which modifies
the way the practices are delivered so that can be utilized with a particular
culture or community so cultures that don’t feel comfortable sharing their
stuff in front of strangers may prefer more individualized activities or may
prefer online activities where they’re able to maintain more anonymity cultural
adaptation involves reviewing and changing the structure of the program or
practice to more appropriately fit the needs and preferences of the particular
cultural group or community so is you know in some treatment programs maybe a
goal is to integrate the nuclear family and in some cultures the nuclear family
is not necessarily that important so we want to look and see what goals
does this program have and what goals does this individual have
you and family counseling you know I talked
earlier about the fact that there are multiple types of family counseling and
it’s important to incorporate this because the effects of substance use
disorders go beyond the nuclear family feelings of abandonment fear anger
embarrassment or guilt happen for everybody in the family the person with
the addiction as well as their loved ones these issues are gonna have to be
dealt with family counseling requires knowledge
about the effects of family interactions on the substance use disorder and the
impact of the substance use disorder on family interactions so I remind you of
the family roles in the addictive family the hero the scapegoat the mascot the
enabler the lost child you know those are common in an addicted family and
there’s a reason that that pattern exists because those are often reactions
to substance use so we do want to look at that and the family therapist needs
to understand be able to identify those roles why people have chosen those roles
and help people shed that particular skin in order to become you know feel
empowered and happy family counseling assists members in identifying and
interrupting harmful interaction patterns such as passive aggressive
behavior escape goading name-calling and presents opportunities for members to
focus on their own goals and issues and create a healthier system where
everybody can support each other in growth instead of being afraid of
abandonment and holding on for dear life and keeping secrets the first step
though is to engage the family a change in any part of the system will bring
about changes to other parts of the system and that’s important to recognize
so when you have a person in residential treatment that’s great
that’s lovely because they can focus on that I love residential treatment for
the first 90 days when possible gets them through post acute withdrawal
allows them to start learning about their own thoughts and
patterns and developing some skills but if they’re in with you for 90 days and
they’re making these transformations from caterpillar to butterfly their
family may not recognize them when they get out you know the family’s not
involved so we need to get the family involved in this metamorphosis process
so everybody is on on the same footing so when John’s having a bad day after he
gets out of treatment his wife doesn’t automatically assume that he’s going to
relapse because now he’s got these new skills so she’s not making assumptions
on the based on the John she knew three months ago she’s making assumptions
based on the John that exists now family counselling and addiction treatment has
two main purposes to use family strengths and resources to help find or
develop ways to live without substances of abuse so what are these strengths and
resources compassion caring willingness financial there are there are a lot of
resources that we can look at you can throw the all of those resources at
people and they can fall flat because we need to know first why is the person
with the addiction using once we identify that then we can identify what
strengths and resources they need to bolster their recovery and we can figure
out which ones the family has and that’s the great place to start and we can say
okay you’ve got a really supportive family member over here and you’ve got a
good place that you know you can go live with your Uncle Tom
over in in Jersey and and get away from your dealer and and other people that
may trigger you for a while and you know we can look at the strengths that exist
and build on those and family Kansa counseling also ameliorates the impact
of addiction on both the client and family because family counseling helps
families understand why the person with the addiction developed it as much as
possible and see their recovery process and be able to be proud and inspired by
that recovery process they’re able to deal with all those issues of rain
anger and resentment and abandonment and all that stuff they’re able to deal with
it in counseling so it’s not this negative undercurrent that’s out there
they’re able to get it out deal with it so they’re starting fresh so to speak
and I always go back to that analogy of the caterpillar turning into a butterfly
caterpillars eat far different things than butterflies do caterpillars look
far different than butterflies do caterpillars move different than
butterflies do same thing with clients that you know they come in and they have
an addiction they come out and they are in recovery it’s a whole different
ballgame the person using substances is regarded as a subsystem within the
family every person is their own subsystem so we need to look at how does
this subsystem interact and I want you to think of a big factory you know if a
big factory or the electric electric grid for the United States you know
there are lots of grids here and there in each substation has its own grids and
its own backups so each person is sort of a substation now what happens if they
go offline or what happens if they’re producing too much electricity or or
whatever so we want to recognize that each person in the family is a subsystem
that impacts the entire system the familial relationships within each
subsystem are the point of therapeutic interest and intervention so you have
John here and you know he’s his own subsystem and you want to see how he
interacts with mom that’s one interaction and how he interacts with
dad and sister and brother okay you’re understanding how he interfaces with
these other subsystems out there but then you also want to look at how does
mom interface with brother you know you’re gonna start looking at the family
dynamics because if mom shows favoritism towards brother and disparages John then
we see where there might be a disconnect in this the energy of this system
goals of family counseling include helping families become more aware of
their own needs you know what do you need in order to be happy and healthy
and functional what are your stressors what is
triggering substance use behavior what is triggering you know difficulties in
this family system you know it can be things like poverty sickness
you know if sickness is one of those things then maybe we need to help them
access medical care if their living environment is not a safe one maybe we
need to help them do that but we need to help them identify what needs do you
have that are preventing you from being happy and healthy and if any one of
those subsystems in the system is unhealthy mentally or physically then
it’s going to impact the rest of the system so we need to help everybody
achieve health and wellness family counseling provides gen genuine enduring
healing for family members it works to shift power to the parental figures in a
family if that’s appropriate you know if you’re dealing with all adults then that
may not be as appropriate but I’ve worked with a lot of families where the
eight-year-old is tucking in mom who’s passed out on the couch and there’s and
making sure that his little sister gets on the bus in the morning that’s a lot
for an eight-year-old to handle so family counseling redistributes power as
it quote should be it improves communication among family members
helping them learn how to assertively communicate and see the other people it
enables them to learn how to hear without being defensive it helps the
family make interpersonal intrapersonal and environmental changes and it keeps
substance abuse and mental health issues from moving from one generation to the
other so if we can break these patterns and make the system healthier then is
probably going to produce healthier products codependency refers to people
who are in a close relationship with the addicted individual and are over
involved with the other person and the other person’s problematic behaviors
such as using sometimes to their own detriment so a lot of times people who
are enablers or codependent are really invested in covering up for the
behaviors of the person with the addiction enabling is when the
codependent person unintentionally or intentionally helps an addict to
continue in their addiction by repeatedly putting out little fires for
the addicted person you know they just want to make sure that nobody sees the
problem and paint a happy picture so they’re gonna cover up and they’re
following around cleaning up this person’s messes well what does that
communicate to the person with the addiction it communicates there are no
consequences for their behavior so they might as well go ahead and do what they
want addiction treatment programs that involve family generally use family
interventions that differ from those used by family counselors or therapists
because we generally in a lot of treatment programs we don’t have a
licensed Marriage and Family Therapist so we use certain techniques but we’re
not implementing you know agency-wide strategic brief family therapy or
something an intervention refers to confrontations that a group of family
and friends have with the person in order to convey the impact of the
substance use and urge them to enter treatment so what kind of treatment do
we have I said we talk about you know different types and levels individual
counseling and some of the benefits of individual counseling is a lot of the
privacy and you’re able to elicit really strong emotions because you’re focused
on that person for the whole hour you’ve got more flexible pacing with
individual counseling with groups you tend to want to stay on a certain pace
make sure everybody’s making progress but with individual counseling you know
you can drop back two or three steps if it seems like you’ve gone too far and go
okay let’s slow our roll a little bit and see you know what we need to do
differently or what did we miss it’s individualized to the client and
often involves brief intervention now you can have individual counseling
that goes on for months or you know even years if you’re going in two years
I’m sensing a dependency really clients often are ready to take a break after
about six months usually brief interventions often use cognitive
behavioral or motivational approaches they’re typically three to six sessions
and they’re generally effective their approach provides feedback to clients
about what we see in the assessment we just were kind of tactfully blunt you
know this is the information that I’ve got and this is where you tell me you
want to be these are your goals I’m wondering how I can help you deal with
the discrepancies it pays places the responsibility for change on the client
shoulders we can’t make them change it says if you’re if you’re ready I’ll be
here we can provide by provide advice about what they may want to do and a
menu of options so if I say you know my advice is that you enter treatment now
there are these all these different kinds of treatments that you can enter
into and we can talk about what you might be willing to do we provide
empathy because change is hard and this is scary you hear about people who you
know are in recovery and they relapse and relapse repeatedly and it seems like
it’s you know a no-win situation so we want to provide empathy to how scary
this process is and we want to encourage self efficacy encourage that can-do
attitude they don’t have to relax they don’t have to do anything what is it
that they want to do and how can I help you do that how can I be a support to
you so this is remember what we call the frames process group counseling is one
of the most effective approaches to treating substance use disorders though
because clients learn about themselves by interacting with others they get peer
support from one another you can help a lot of clients at once it reinforces
self discipline and inspires hope because they’re seeing those same people
come back time after time and they’re all staying
clean and it’s like okay we’re doing good here and they can communicate quite
honestly having done individual and group counseling I can tell you group
counseling in many ways is a little bit easier because you’ve got eight other
pairs of eyes watching each person so things that you as a clinician may miss
which we do miss things other people may pick up on those nuances and call them
out so that’s a beauty of group therapy is it’s everybody’s trying to help one
another and themselves there are different types of groups that you can
use psycho-educational groups provide information about psychological issues
and coping and all that stuff skills development groups help people develop
skills so they can have a happier healthier life employment skills job
skills life skills cognitive behavioral groups help people
change the way they think about a situation support groups provide support
interpersonal process groups help people work with each other to enhance their
interpersonal skills and to learn more about themselves because generally we
develop a microcosm of our outside life in the group so in this interpersonal
group people start learning more about themselves and how they treat other
people relapse prevention groups self-explanatory
cultural focus groups involve bringing people that are of a particular culture
and are embracing that culture together so we can provide culturally sensitive
treatment an art therapy is another great group that can be used as well as
specific issue groups such as groups for depression self-esteem and trauma
recovery in addition you know we’re getting all
these layers here in addition to the approach you choose whether it’s
cognitive behavioral or solution-focused or motivational and then the setting you
choose whether it’s individual group or family and making sure that any
interventions you choose are trauma-informed and cultural culturally
appropriate we also need to look at medication not everybody wants meds some
people do and medication can be beneficial for some clients so who is
often benefits from medications clients who face health risks as part of
withdrawal so thinking about especially your alcohol in your benzos you know
this can be life-threatening so medication can help clients who will not
quit using because of withdrawal this is where methadone buprenorphine and
suboxone can be helpful and some of your nicotine replacement drugs clients who
have tried everything else but keep returning to treatment and continue to
relapse that tells me there’s probably a co-occurring issue somewhere that we’re
missing so clients may benefit from either drugs that will prevent them from
getting the benefit from the drugs like antabuse
or naloxone or looking at something that may help
address their mental health issues which are a trigger for their use such as
depression or anxiety clients who believe they’re unable to quit using on
their own may benefit from medication and this is one of the reasons that
nicotine replacement drugs are so effective clients who feel overwhelmed
by cravings clients who believe that medication will help them engage or
benefit from psychosocial treatment and this one’s really true if you’ve got a
client in there who is just miserable from cravings and they feel like they’ve
got the worst flu ever they’re not getting a daggone thing you’re saying so
if they’re able to take the edge off that then they’re going to be able to
function and focus a little bit better if they’re clinically depressed they’re
not going to give a rat’s patootie about anything you’ve got to say most likely
and they’re gonna have a hard time concentrating so if they start taking
some psychotropic medications to deal with their mental health issue that may
help them benefit more from psychosocial treatment and clients without medical
addiction or family history risks associated with medication may benefit
so basically this is a laundry list of pretty much every client can benefit if
there’s some way that the medication can help them even if they start on a mental
health medication it doesn’t mean they have to take it forever it can be one of
those where they take it for six months or a year while they’re getting clean
helping their body get healthier and developing the new skills and tools they
need to deal with life on life’s terms crisis is a situation in which there’s a
risk of harm to the client unless intervention occurs and it’s important
to remember that a relapse can be a crisis so we want to look at what can we
do and how can we identify crises crises can be emotional or physical you know a
heart attack is a physical crisis depression is an emotional crisis and
crisis has five components and probably need to know these for your tests a
stressful traumatic event a vulnerable or unbalanced situation a
precipitating factor you know what caused this
the act of crisis state based on the person’s perception now some people may
perceive the this one situation as not a big deal whereas other people it may
feel like the end of the world so we need to look at what’s causing that
crisis state and what’s the person’s perception of it and a resolution of the
crisis remember that a stressful event alone
does not constitute a crisis crisis is determined by the individuals view of
the event their personality and temperament their life experiences their
current physical state if they’re intoxicated or withdrawing or in pain
it’s going to impact them differently than if they are physically well rested
nourished and healthy and varying degrees of stress and coping skills and
their response to the situation so I mean even think about yourself on any
given day you may respond better or poorly to a situation based on how
rested you are how whether you feel healthy or sick and how much social
support you have so we need to really recognize that crises can differ a
crisis represents a time of danger and opportunity it’s another thing you
probably need to remember the danger is the person could go further into crisis
and become suicidal or homicidal the opportunity is the fact that people when
they’re in crisis need that crisis to stop you know that it’s an untenable
thing to maintain so it’s an opportunity for them to get motivated to make
certain changes in their life that maybe they weren’t motivated to make before
all models of crisis intervention involve making sure the person is safe
stabilized helps them process the crisis event and encourages them to draw
conclusions from the process that they can integrate into their life as a
learning experience so what triggered it you know what was what triggered the
event what was the event how did I respond to the event how could I prevent
something like this in the future and if something like this in the future
happens what skills and tools have I realized that I have that I can use to
deal with it the best way to handle a crisis is obviously to prevent it so
early assessment of clients for their potential for agitated or assaulted
behavior is essential and you know this kind of behavior can happen at any point
and I’ve had clients before who’ve been you know in treatment for three weeks
and doing fine and then they get a call from their lawyer and they find out that
there’s a warrant out for their arrest and all of a sudden they spiral
downwards very very rapidly so it’s important to keep your finger on the
pulse of what’s going on with your clients and early assessment isn’t just
at the beginning you are regularly assessing your client for any changes in
their status clients should be taught strategies aimed at helping them manage
their own behavior such as stress and anger prevention the violent and
aggressive behavior needs to start at admission so if you’ve got somebody
who’s agitated we need to get them on a behavior contract and/or see the doc
they may need some medication to help them rein it in a little bit it just
depends on the reason for their aggression we need to make sure that
they’re safe the other clients are safe and the staff is safe clients need to be
assessed and asked about past violent incidents whether they’ve ever been put
in seclusion or restraint and whether they’ve ever experienced abuse as a
child or an adult and remember abuse as a child or an adult is a traumatic
experience so if that person has been restrained or abused before and they
need to be restrained now that’s probably going to escalate the situation
so that’s that trauma-informed approach to crisis management so we need to know
these things when at the clinics I’ve worked at before
we’ve asked clients at the beginning if you become you know extremely upset what
things help and what things absolutely make it worse so we have it written down
in their chart and we know ahead of time that if you lay hands on them when
they’re angry it’s gonna get ugly it doesn’t mean that we necessarily won’t
but most of the time you know if you avoid some of their early identified
triggers they feel respected and they don’t feel as vulnerable one of the most
recommended intervention strategies is verbal crisis de-escalation which is
aimed at meeting the agitated person’s immediate
and calming the situation so let me hear what you need a lot of times a person in
crisis one of the first things they need is to be heard because they feel out of
control and they need to be heard and validated ok let’s do that another
immediate need is to get rid of the bystanders because the bystanders just
inflame the situation a third immediate need when people are
upset is often to enable them to move and a lot of times we want people to sit
down and calm down but think about when you are just like really revved up how
hard it is to sit down and be still so sometimes it’s better if you can and
if it’s safe to take the client to a place where they can walk around and
talk even if it’s just pacing in circles in a group room if it’s a safe
environment it may help them defuse some of that adrenaline and energy
steps in crisis intervention assess the severity of the crisis form a connection
demonstrating that you’re there with the client explore the problem focusing on
the client’s immediate situation using active listening and paraphrasing in
order to restore the person to his or her previous level of functioning you
know we’re not trying to get them to be you know cured we’re trying to get them
to where they were this morning before they got agitated deal with feelings and
emotions including not only the content of the material but also the underlying
feelings if they’re telling you that their attorney just called them and
they’ve got three warrants out for arrest and they’re looking at 15 years
of prison time and they’re telling you all this okay that’s content that’s you
know obvious content how do they feel about that
they’re probably devastated terrified you know let’s start looking at how are
they feeling you know what is what are the words that help describe their level
of agitation generate alternative solutions and summarize your
understanding of the situation develop an action plan which is very specific
regarding time people in crisis need some relief and need some hope if we say
you know okay at some point we need to do this and that the person’s not gonna
feel really reassured if we say okay in 30 minutes we will call your attorney
and then we will figure out when your court date is and you know bla bla bla
but you get immediate goals you develop some sort of sense of immediate relief
so you know maybe it calling the attorney is not going to do a whole lot
of good but we can call him and look at what are our options and maybe identify
some things that might mitigate the sentencing process and start working on
what they can do and what the client can do in order to improve their chances
they’ll stay out of jail and then develop a specific follow-up plan with a
lot of clients who were in crisis they may start to feel better and then they
get upset again so generally when I’ve worked in a
residential situation or even outpatient we have clients check in periodically
and it could be every hour it could be every four hours that way where we know
they’re still doing okay and as the time between the crisis incident and you know
now gets longer you know we can expand the window
for when they when they’re checking in so initially have them check in every
hour and then every four hours and then you know after a couple of days maybe
they only need to check in once a day but that gives you a chance to provide
early intervention if they should start decompensating again remember that
relapse is certainly a type of crisis you know this is when people see all of
their hard work going down the toilet and in many of their eyes what I want
them to remember is it’s not going down the toilet you know yes you made a
choice and it was an unfortunate choice but all those skills and tools you had
they didn’t just disappear you just chose not to use them so we need to
figure out why why was using more rewarding than the stuff you’ve been
learning in treatment what triggered this situation and what did we miss
because clearly life got the better of you right now so we need to figure out
how to prevent that from happening again elapsed or a recurrence of use is
thought to have a different cognitive and behavioral process different from
relapses so if somebody just uses once has elapsed generally that’s different
than if they go on a one or two week bender interventions designed to stop
elapsed may prevent a full-blown relapse remembering that lapses can actually
occur behaviorally too so if people start returning to that stink and
thinking we need to intervene even if they haven’t picked up yet they may be
three months from picking up but if we see that they’re stopping following
their their recovery plan if they’re not taking good care of themselves if they
return to stink and thinking that is a relapse just waiting to happen
so we need to provide intervention oftentimes lapses occur in response to
an acute stressor so maybe they got fired and they just that was just too
overwhelming so they went and had a few drinks and then they felt really guilty
afterwards that’s different than a relapse that builds over time and
generally kicks off a series of future events lapsing back into use indicates
that treatment needs to be reinstated or adjusted or that another treatment needs
to be tried so you know let’s look at again what did we miss or what needs
we’re not getting fulfilled similar to drug and alcohol treatment treatment for
chronic illnesses are effective but require strict adherence to medical and
behavioral regimens clients with these diseases often do not comply with their
treatment and a lot of clients we work with have things like hepatitis
cirrhosis HIV chronic pain so we do need to make sure that they’re following
their treatment plan for all of their conditions three key points forming a
comprehensive view of relapse relapses are common and clients should understand
that they are likely to be vulnerable yet we all hit periods where we become
vulnerable to relapse merely mentioning the R word relapse will not cause a
client’s to relapse relapse is reasonably predictable when examining
general precipitance you know what things generally trigger
people to relapse stress anxiety catastrophic something
happened like a hurricane you know there are some pretty predictable things that
cause most people to hit a crisis point and can trigger a relapse but we also
want to look at people’s own personal triggers including social situations
whether they’re taking care of themselves or getting hungry angry
lonely and tired personal emotions and situations that can be danger zones and
need to be anticipated for some people you know you think anger anxiety
depression those are huge danger zones well they are
but for some people happiness if they feel like they’re getting too happy it
also could be a trigger for use because they’re afraid that you know that
happiness is going to end and then they’re going to screw up so they
self-sabotage we need to be aware of that relapses are preventable with the
use of self-monitoring and abstinence maintenance activities including AAA or
other self-help groups counselling involvement with the recovery community
religious congregation health club or fitness group or any lifestyle that is
inconsistent with use remember this for treatment planning when people are
getting out of treatment or if they’re in intensive outpatient they need
something to do the other hours of the day where they’re not in treatment so
they need to be involved in things that keep them in a safe situation relapse
prevention is an umbrella term encompassing most skills based
treatments that incorporate cognitive behavioral skills building and coping
responses the overall goal of relapse prevention is to help people create more
positive habits and positive changes in their lives in order to prevent relapse
and sustain their own recovery so positive habits include getting enough
sleep eating healthfully being mindful of their mood and their activities
engaging in social activities that they’re comfortable with for social
support relapse prevention therapy or RPT is a behavioral self-control program
that teaches clients to understand that relapse is a process it’s not just out
of the blue you know you look back and you see that a lot of things led up to
it identify and cope effectively with highest risk situations cope with urges
and cravings implement damage control procedures during a lapse to prevent a
full-blown relapse stay engaged in treatment
even after elapsed or a relapse and identify when and how to create a more
balanced lifestyle so it’s about creating a recovery lifestyle it’s
recovery is not something you do for six months and then you
recovered you want to embrace a recovery lifestyle cognitive techniques provide
clients with a way to reframe the habit change process as a learning experience
with errors and setbacks expected you may have lapses you may have relapses
you may have thought lapses or you know recurrence of your depression that’s
expected during this process we just need to communicate so we can help
clients identify these when they start happening early and provide as
intervention as early as possible behavioral techniques include the use of
lifestyle modifications such as meditation exercise and spiritual
practices to strengthen the clients overall coping capacity the C naps model
of relapse prevention therapy is also based on the belief that total
abstinence plus personality and lifestyle changes are essential for full
recovery and you can learn more about C naps if you just google it online there
are five components to the C naps process assessment warning sign
identification warning sign management recovery planning and relapse early
intervention training so they identify their warning signs they identify how to
manage them they create this great plan for a recovery lifestyle but then they
also have an emergency plan for intervening early if they see that
they’re starting to head down a bad path there are many approaches to treatment
including cognitive behavioral motivational trauma-informed relapse
prevention and family approaches these approaches can be applied in individual
group or family settings and counselors must constantly remain aware of the
impact of culture on choosing treatments and interventions family engagement is
crucial in the recovery process but family is who the client defines it as
it may not be blood relatives crisis has five components and what causes a crisis
can be different for each person but as clinicians we need to be aware of
the seven steps in Christ intervention most relapse prevention
theories address relapse triggers unpleasant emotions interpersonal
conflict and social pressure these triggers account for almost three
quarters of the relapses so these are those general factors that we were
talking about unpleasant emotions interpersonal conflict and social
pressure antecedents to relapse can be found with an ended within an individual
such as the person’s mood or coping style or may be triggered by
interpersonal events so we need to you know really talk to a person about what
triggered your prior relapses or what triggers your cravings and look at
individualizing their plan stay up-to-date with our current episodes of
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once you’re certified or licensed please remember to visit all CEUs for all of
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