substance abuse: assessment and intervention

1. Substance Abuse: Assessment and Intervention Liz Coccia, Ed.D., LCDC, AAC

3. It is my understanding that all of you are familiar with the ASAM placement criteria and with Motivational interviewing, but if you could give me just a little more background that would be helpfulIt is my understanding that all of you are familiar with the ASAM placement criteria and with Motivational interviewing, but if you could give me just a little more background that would be helpful

5. This is what I have planned, and we can add to it those things that you mentionedThis is what I have planned, and we can add to it those things that you mentioned

9. Defining substance abuse and dependence Simple definitions: Abuse: intentional overuse in cases of celebration, anxiety, despair, or ignorance Dependence: impaired control over drug use probably caused by a dysfunction in the brain�s �pleasure pathway� DSM-IV-TR definitions Abuse Dependence

10. DSM-IV-TR Substance use disorders - defined The DSM-V will be out in a few years (2012?) and is looking to change these definitions and criteria. One point that Dr Erikson makes in his work is that we have over-used the term �addiction� to include all sorts of things � �crackberries�, TV, internet, etc. when a clearer term would be impulse control disorders or obsessive-compulsive disorders. The DSM-V will be out in a few years (2012?) and is looking to change these definitions and criteria. One point that Dr Erikson makes in his work is that we have over-used the term �addiction� to include all sorts of things � �crackberries�, TV, internet, etc. when a clearer term would be impulse control disorders or obsessive-compulsive disorders.

11. Addiction as a disease Current science indicates that major site of addicting drugs is in the Medial Forebrain Bundle (MFB) Neurotransmitters involved in addiction are: Dopamine, serotonin, endorphins, GABA, glutamate, norepinephrine and acetylcholine Now that we�ve defined addiction according to the standards, let�s talk about what is generally considered the cause of addiction. While we talk about addiction as a spectrum disorder, with many causes and pathways to recovery, the science in this area has supported that one primary explanation for addiction is that it is a brain disorder � a chronic, relapsing condition caused by malfunctioning brain chemistry. How many of you have had the opportunity to hear Dr. Carl Erikson speak on this? The following slides are really just a brief summary of his work in this area. This area (MFB aka mesolimbic dopamine system or MDS) of the brain contains numerous parts, including the nucleus accumens and the amygdala. This part of the brain is more �primitive� and is not controlled by the cerebral cortex (judgment and reasoning) Dr Erikson refers to dependence as a dysregulation of the MDS. Now that we�ve defined addiction according to the standards, let�s talk about what is generally considered the cause of addiction. While we talk about addiction as a spectrum disorder, with many causes and pathways to recovery, the science in this area has supported that one primary explanation for addiction is that it is a brain disorder � a chronic, relapsing condition caused by malfunctioning brain chemistry. How many of you have had the opportunity to hear Dr. Carl Erikson speak on this? The following slides are really just a brief summary of his work in this area. This area (MFB aka mesolimbic dopamine system or MDS) of the brain contains numerous parts, including the nucleus accumens and the amygdala. This part of the brain is more �primitive� and is not controlled by the cerebral cortex (judgment and reasoning) Dr Erikson refers to dependence as a dysregulation of the MDS.

12. Addiction as a disease Psychoactive substances typically act in the �pleasure centers� by: Mimicking neurotransmitters Stimulating the release of neurotransmitters Blocking the re-uptake of neurotransmitters Changing the action potential (speed at which messages are transmitted) As these changes take place in the reward center of the brain, other brain structures are effected causing the drug using behavior to become �hard wired� into the brain. Some drugs have higher addiction potential because of hwo well they �fit� into the receptor sites and whether they are agonists to natural neurotransmitters. As these changes take place in the reward center of the brain, other brain structures are effected causing the drug using behavior to become �hard wired� into the brain. Some drugs have higher addiction potential because of hwo well they �fit� into the receptor sites and whether they are agonists to natural neurotransmitters.

13. Drugs and Neurotransmitters Dopamine � amphetamines, cocaine, ETOH Serotonin � LSD, ETOH GAGA � benzo�s and ETOH Endorphins � opiods, ETOH Glutamate � ETOH AcH � nicotine, ETOH ENCB � marijuana, ETOH What the research suggests is that some people have certain vulnerabilities/dysregulations related to neurotransmitters and their drug of choice is what �connects� the best to correct the dysregulation. ENCB is endocannabinoin. So when people say they �need� a drug, they mean that in a physiological sense. What causes dysregulation is not resolved � genetic vulnerability, exposure to a drug, environmental factors are all considered possibilities. What the research suggests is that some people have certain vulnerabilities/dysregulations related to neurotransmitters and their drug of choice is what �connects� the best to correct the dysregulation. ENCB is endocannabinoin. So when people say they �need� a drug, they mean that in a physiological sense. What causes dysregulation is not resolved � genetic vulnerability, exposure to a drug, environmental factors are all considered possibilities.

14. Epidemiological estimates Drugs users who developed dependencies bases on 1992-1998 studies: Nicotine � 32% Heroin � 23% Cocaine � 17% - crack 20% Stimulants � 11% Alcohol � 15% Cannabis � 9% Sedatives � 9% Analgesics � 9% Psychedelics � 5% Inhalants � 4% Anthony et al 1994; Chen & Anthony 2003; Hughes et al 2006 Not everyone who uses a drug develops a dependence. Some people abuse drugs and may have severe patterns of abuse where they are heavily into drug seeking behavior, but they do not develop impaired control; they can stop. Not everyone who uses a drug develops a dependence. Some people abuse drugs and may have severe patterns of abuse where they are heavily into drug seeking behavior, but they do not develop impaired control; they can stop.

15. Addiction as a disease Basic components of disease model Addiction is primary � it is the main problem, not secondary to something else. It is progressive - there are signs and symptoms of addiction Permanent � once addicted to a drug, always addicted and to all drugs, not just the drug of choice. If not stopped, the disease will be fatal. Disease is marked by impaired (loss of) control, preoccupation, adverse consequences, and denial. Recovery requires life long abstinence and active participation in recovery groups. The disease is part psychological, physical, social and spiritual. Must treat all aspects for recovery. Px3 We say that addiction meets the standards of a disease because we have characteristics symptoms � these are (have them name some) � loss of control, unpredictability, preoccupation, adverse consequences and denial. There is a cause � and now we are narrowing in on the neurochemistry of the disease; and a course of progression which for the addict is that it gets progressively worse unless treated. We say that addiction is Primary, Progressive and Permanent. We typically compare addiction to diabetes � we have symptoms of diabetes, a cause or causes, and of course we all know that if left untreated diabetes causes death. We say that addiction meets the standards of a disease because we have characteristics symptoms � these are (have them name some) � loss of control, unpredictability, preoccupation, adverse consequences and denial. There is a cause � and now we are narrowing in on the neurochemistry of the disease; and a course of progression which for the addict is that it gets progressively worse unless treated. We say that addiction is Primary, Progressive and Permanent. We typically compare addiction to diabetes � we have symptoms of diabetes, a cause or causes, and of course we all know that if left untreated diabetes causes death.

16. Co-occurring Disorders Although we talk about addiction as primary, that is not to say that those with co-occurring disorders should be left untreated until the substance abuse has been treated. We have come a long way in the last 20 years in learning about the challenges of those with co-existing mental health disorders. There are those with SA disorders and no mental health issues; those with SA disorders with mental health issues caused by their drug use (particularly true with amphetamines and hallucinogens). There are those with psychiatric disorders with no SA issues; and those who abuse substances because of their psychiatric disorder. The intersection represents those who have two distinct disorders and must be treated simultaneously.Although we talk about addiction as primary, that is not to say that those with co-occurring disorders should be left untreated until the substance abuse has been treated. We have come a long way in the last 20 years in learning about the challenges of those with co-existing mental health disorders. There are those with SA disorders and no mental health issues; those with SA disorders with mental health issues caused by their drug use (particularly true with amphetamines and hallucinogens). There are those with psychiatric disorders with no SA issues; and those who abuse substances because of their psychiatric disorder. The intersection represents those who have two distinct disorders and must be treated simultaneously.

17. Co-occurring Disorders Prevalence of co-occurring disorders � 4.2 million adults have a mental health and substance abuse disorder 20% of people w/ SA disorders have at least 1 mood disorder 18% have at least 1 anxiety disorder 29% of people with alcohol use disorder and 48% of people with drug use disorder have at least 1 personality disorder Source: John Newport, PhD, Treating Co-occurring disorders. Counselor Magazine, Feb. 08 The figures may vary somewhat depending on the source, but the general conclusion is that we have a significant number of adults who have both a subtance abuse and a mental health disorder and need simultanious treatment. Source: John Newport, PhD, Treating Co-occurring disorders. Counselor Magazine, Feb. 08 The figures may vary somewhat depending on the source, but the general conclusion is that we have a significant number of adults who have both a subtance abuse and a mental health disorder and need simultanious treatment.

18. Co-occurring disorders Drugs most commonly abused by those with mental illness are alcohol, marijuana and cocaine. Prescription drugs are also commonly abused. Males aged 18-44 have highest incidence of drug abuse. Treatment issues are more complicated and people with dual disorders are more likely to have histories of violence and end up in criminal justice system Unfortunately our treatment for this population � male drug abusers with psychiatric disorders � has not kept up with demand and many of these individuals end up in our jails and prisons. Unfortunately our treatment for this population � male drug abusers with psychiatric disorders � has not kept up with demand and many of these individuals end up in our jails and prisons.

19. Recap What have we said so far Let�s just recap for a moment � askk audience to summarize what we�ve said about addiction as disease and co-occurring disorders.Let�s just recap for a moment � askk audience to summarize what we�ve said about addiction as disease and co-occurring disorders.

20. Trends in Substance Use Prescription drug abuse Heroin Methamphetamine Baby-boomers Let�s talk next about some of the trends n substance use � what are we seeing as particular problem areas?Let�s talk next about some of the trends n substance use � what are we seeing as particular problem areas?

21. Prescription Drug Abuse Non medical use of prescription drugs has increased from 5.4% in 2002 to 6.4% in 2006 Prescription pain medication (Vicodin and Oxycontin) account for greatest abuse According to epidemiological studies, 50 million Americans are experiencing chronic pain at any given time One explanation is the greater acceptance of opiod medication for non cancer pain and a rise in patients reporting chronic pain (40% increase between 1996-2006) related to sedentary lifestyles and aging population; and that 95% of individuals treated for chronic pain are being seen by primary care physicians and not specialists. So we have 2 populations � those who divert prescription medication for the sole purpose of the psychoactive effect and those who use the medication for medical purposes but develop an addiction.One explanation is the greater acceptance of opiod medication for non cancer pain and a rise in patients reporting chronic pain (40% increase between 1996-2006) related to sedentary lifestyles and aging population; and that 95% of individuals treated for chronic pain are being seen by primary care physicians and not specialists. So we have 2 populations � those who divert prescription medication for the sole purpose of the psychoactive effect and those who use the medication for medical purposes but develop an addiction.

22. Heroin Increase in percentage of people who inhale heroin Proportion of inhalers who are Hispanic grew from 26%-69% (1996-2007) Average age of inhalers has decreased from 30 to 27 Time between first use and seeking treatment is 7 years compared to 15 years for injectors We are also seeing an increase in heroin use thanks to the marketing skills of heroin producers � to keep competative to cocaine, heroin producers started increasing the purity of their product to allow for snorting. People who snort aren�t �junkies� � there is less stigma than for needle users. But, the damage done by snorting is significant and causes unique health problems from those who inject. Those entering treatment, admissions rose from 4% in 1996 to 20% in 2007 of heroin admission for those who inhaleWe are also seeing an increase in heroin use thanks to the marketing skills of heroin producers � to keep competative to cocaine, heroin producers started increasing the purity of their product to allow for snorting. People who snort aren�t �junkies� � there is less stigma than for needle users. But, the damage done by snorting is significant and causes unique health problems from those who inject. Those entering treatment, admissions rose from 4% in 1996 to 20% in 2007 of heroin admission for those who inhale

23. �Cheese� Heroin Mixture of Tylenol PM and heroin � in Texas, Dallas area reports highest problem Users are younger � Dallas reports range from 12-19 with average age of 16 High use reported among Hispanic males This drug has only come to light in the last few years and seems to be geographically specific. It gets its nickname �cheese� because it resembles parmasean cheese and the market for users is much younger. This drug has only come to light in the last few years and seems to be geographically specific. It gets its nickname �cheese� because it resembles parmasean cheese and the market for users is much younger.

24. Methamphetamine Meth half-life is 8-12 hours (compared to 1-2 hr for cocaine) Paranoia lasts 7-14 days (compared to cocaine 4-8 hr following drug cessation) Higher incidence of psychosis than with any other stimulant and neurotoxicity is greater Meth continues to be one of the most popular stimulants of abuse with a 6% rise in treatment admission from 2000-2007 (5% - 11%). It is also one of the few drugs that is used more by women than men. The purity of the drug has dropped. �Smurfing� � breaking open pseudoepedrine products is on the rise in Texas. Meth continues to be one of the most popular stimulants of abuse with a 6% rise in treatment admission from 2000-2007 (5% - 11%). It is also one of the few drugs that is used more by women than men. The purity of the drug has dropped. �Smurfing� � breaking open pseudoepedrine products is on the rise in Texas.

25. Methamphetamine WHO estimates that meth is most widely used illicit drug in the world (except for marijuana) with 26 million regular users (heroin at 16 million; 14 million cocaine) Research suggests that relapse rates are higher and treatment needs to be longer than for other substances

26. Baby Boomers By 2020, 50% of US population will be 55+ Illicit drug use by people in their 50s has increased by 63% with greater reports of heroin and cocaine 60% who enter treatment are on some type of psychotropic medication Finally, I would just like to address an interesting shift that has recently been reported in the literature. While traditionally we see older adults with alcohol or prescription drug addiction, the baby boomers are showing up in treatment with illicit drug use. Many report feeling a loss of purpose in their life and having difficulty adjusting to increasing health problems � can�t believe they can get old. Attitude toward treatment is better than for traditional older adults and are more open to mental health services and support groupsFinally, I would just like to address an interesting shift that has recently been reported in the literature. While traditionally we see older adults with alcohol or prescription drug addiction, the baby boomers are showing up in treatment with illicit drug use. Many report feeling a loss of purpose in their life and having difficulty adjusting to increasing health problems � can�t believe they can get old. Attitude toward treatment is better than for traditional older adults and are more open to mental health services and support groups

27. Break Let�s take 15 minutes

28. Assessment and Motivational Interviewing SAMHSA refers to the MI Assessment �Sandwich� Top �slice� involves building rapport and using OARS to elicit discussion of client�s perception of problem Open-ended questions Affirmations Reflective listening Summaries As I said in the beginning, we�re not going to cover any particular assessment instruments. It is my understanding that there are some you already use as part of the organization. What I want to focus on instead are more global framework for engaging the client and gathering information. Given the prevalence of SA disorders, an assessment starts with the first contact. From the first point of contact the MI skills are important. During opening discussion you are gathering the reason for the call, the client�s perception of the problem and getting some idea as to the client�s initial readiness for change and the types of resistance you might meet. Open ended questions � what would you like to talk about; what changes would you like to see in your life; Affirmations � I can hear that you really care for your family; it sounds like you have a good idea of what is causing some difficulties; Reflective listening responds with the essence of what the client said or what you think the client meant; Summaries let you track what has been said and your understanding and helps structure the session around the important issues. Gives you an opportunity to emphasize certain elements and move you alongAs I said in the beginning, we�re not going to cover any particular assessment instruments. It is my understanding that there are some you already use as part of the organization. What I want to focus on instead are more global framework for engaging the client and gathering information. Given the prevalence of SA disorders, an assessment starts with the first contact. From the first point of contact the MI skills are important. During opening discussion you are gathering the reason for the call, the client�s perception of the problem and getting some idea as to the client�s initial readiness for change and the types of resistance you might meet. Open ended questions � what would you like to talk about; what changes would you like to see in your life; Affirmations � I can hear that you really care for your family; it sounds like you have a good idea of what is causing some difficulties; Reflective listening responds with the essence of what the client said or what you think the client meant; Summaries let you track what has been said and your understanding and helps structure the session around the important issues. Gives you an opportunity to emphasize certain elements and move you along

29. Assessment and MI �Middle� of the sandwich � this is gathering the details of the substance use H F A A L T T A B L U D M T P Once you have a general idea of the client�s perception of the problem, now you need to gather the details of the substance use to determine whether medical intervention or specialized care is necessary. Here is where we are looking for signs and symptoms of SA disorders. You may use a standardized instrument (ASI, SASSI, etc) but I want to give you just a generic information gathering version if you are not at the point of using an instrument. I like the HALT BUMP FATAL DT because it is easy to remember, but of course there are many others available. H � do you use to get high; A �alone; L � look forward; t � tolerance; B � blackouts; U � unplanned ways; M � medicinal reasons (anxious, stressed, etc) P � protect your supply. F � family history; A � AA, 12-step group; T � thoughts about being dependent; A � attempts/thoughts of suicide; D � DWI/legal trouble; T � tranquilizer/medication to control use. Substance use history, legal, medical, educational/employment, family/social, psychological/emotional, socioeconomic/cultural factors and use of community resources. We talk about assessing strengths, weaknesses, problems and needs.Once you have a general idea of the client�s perception of the problem, now you need to gather the details of the substance use to determine whether medical intervention or specialized care is necessary. Here is where we are looking for signs and symptoms of SA disorders. You may use a standardized instrument (ASI, SASSI, etc) but I want to give you just a generic information gathering version if you are not at the point of using an instrument. I like the HALT BUMP FATAL DT because it is easy to remember, but of course there are many others available. H � do you use to get high; A �alone; L � look forward; t � tolerance; B � blackouts; U � unplanned ways; M � medicinal reasons (anxious, stressed, etc) P � protect your supply. F � family history; A � AA, 12-step group; T � thoughts about being dependent; A � attempts/thoughts of suicide; D � DWI/legal trouble; T � tranquilizer/medication to control use. Substance use history, legal, medical, educational/employment, family/social, psychological/emotional, socioeconomic/cultural factors and use of community resources. We talk about assessing strengths, weaknesses, problems and needs.

30. Matching ASAM Client Placement Criteria Maslow�s Hierarchy of Needs Client factors + program factors = treatment referral With the information you gathered during the assessment, and using the ASAM Client Placement Criteria, you are now determining the next course of action. ASAM: acute intoxication and/or w/d complications; biomedical conditions or complications; emotional behavioral complications; treatment acceptance or resistance; relapse potential; recovery living environment. I also like to reference Maslow at this point because it is another good way to think about what to address first, second, etc. (don�t use slide, just talk about it if appropriate and time OK)With the information you gathered during the assessment, and using the ASAM Client Placement Criteria, you are now determining the next course of action. ASAM: acute intoxication and/or w/d complications; biomedical conditions or complications; emotional behavioral complications; treatment acceptance or resistance; relapse potential; recovery living environment. I also like to reference Maslow at this point because it is another good way to think about what to address first, second, etc. (don�t use slide, just talk about it if appropriate and time OK)

32. Assessment and MI Bottom �slice� of the sandwich focuses on strategies for eliciting change or managing resistance Focus on competencies and strengths Individualize treatment plan Shift away from labeling Partnerships for change Continuum of problems/continuum of care Now that you have determined the best course of action, how do you engage the client and move them towards that step? Depending on how long you�ve worked in the profession, you may remember the old style of confrontation to �break� through denial. We know now that is ineffective in helping someone with substance dependence make a change. The emphasis now is on focusing on competencies and strengths � we talk about using what the client brings to the table, enhancing self-efficacy. We want to look at the individual client�s needs and not try to stick them into a pre-determined treatment plan. What are the client�s strengths, weaknesses, problems and needs? There is no point in labeling, or forcing someone to �admit� to being alcoholic or a drug addict. People-first language � not �the diabetic� but the person with diabetes. The client needs to be an active participant in their treatment � what does the person want to accomplish � what does he/she see as the primary difficulty? That is why educating the person about the biological aspects of the drug and addiction has been emphasized so the person can make an educated decision about his/her health. We also realize that it is essential to intervene early and often � no longer say �oh, he�s in denial � he needs to keep using and come back when he hits bottom�. We need to re-define what is considered �success� � this is where harm reduction comes in � what outcomes improve the person�s overall functioning even if abstinence does not occur. We also must see addiction as a chronic relapsing disease. Just as with any relapsing disease we do not considered it a treatment failure if the person relapses; we also don�t give them a set limit of treatment and say �good luck�. Again, this is where matching treatment is important and creating an individualized plan � if someone has been through typical treatment multiple times, more specialized treatment approaches may be needed. We talk about addiction as a �spectrum� disorder and recovery is multifaceted � at different stages of recovery different therapeutic interventions may be needed. Now that you have determined the best course of action, how do you engage the client and move them towards that step? Depending on how long you�ve worked in the profession, you may remember the old style of confrontation to �break� through denial. We know now that is ineffective in helping someone with substance dependence make a change. The emphasis now is on focusing on competencies and strengths � we talk about using what the client brings to the table, enhancing self-efficacy. We want to look at the individual client�s needs and not try to stick them into a pre-determined treatment plan. What are the client�s strengths, weaknesses, problems and needs? There is no point in labeling, or forcing someone to �admit� to being alcoholic or a drug addict. People-first language � not �the diabetic� but the person with diabetes. The client needs to be an active participant in their treatment � what does the person want to accomplish � what does he/she see as the primary difficulty? That is why educating the person about the biological aspects of the drug and addiction has been emphasized so the person can make an educated decision about his/her health. We also realize that it is essential to intervene early and often � no longer say �oh, he�s in denial � he needs to keep using and come back when he hits bottom�. We need to re-define what is considered �success� � this is where harm reduction comes in � what outcomes improve the person�s overall functioning even if abstinence does not occur. We also must see addiction as a chronic relapsing disease. Just as with any relapsing disease we do not considered it a treatment failure if the person relapses; we also don�t give them a set limit of treatment and say �good luck�. Again, this is where matching treatment is important and creating an individualized plan � if someone has been through typical treatment multiple times, more specialized treatment approaches may be needed. We talk about addiction as a �spectrum� disorder and recovery is multifaceted � at different stages of recovery different therapeutic interventions may be needed.

33. According to Prochaska and DiClemente (1982; 1986) behavioral change is a multi-step process; rather than a one-time event. Different stages of the change process include: Precontemplation: change is not considered Contemplation: change is being considered Preparation: some action steps toward change have occurred Action: active steps toward change are happening Maintenance: maintaining behavioral change until it becomes permanent Relapse: return to previous pattern of behavior Determining a client�s stage of change can help the counselor �fit� the treatment plan to the client�s readiness and needs. This may help prevent the client from rejecting all or parts of the treatment plan. According to Prochaska and DiClemente (1982; 1986) behavioral change is a multi-step process; rather than a one-time event. Different stages of the change process include: Precontemplation: change is not considered Contemplation: change is being considered Preparation: some action steps toward change have occurred Action: active steps toward change are happening Maintenance: maintaining behavioral change until it becomes permanent Relapse: return to previous pattern of behavior Determining a client�s stage of change can help the counselor �fit� the treatment plan to the client�s readiness and needs. This may help prevent the client from rejecting all or parts of the treatment plan.

34. Stages of change and appropriate MI strategies

35. Stages of Change and MI Strategies

36. Effective Catalysts for Change Consciousness raising � new information Self-reevaluation � feelings/thoughts related to problem behavior Self-liberation � choosing and committing to act; believing in ability to change Counter conditioning � strategies for coping such as relaxation, positive self-statements Stimulus control � avoiding high risk situations Increasing information about the problem � observation, interpretation, bibliotherapy. Especially helpful during pre-contemplation Self-evaluation � assessing how one feels/thinks about oneself with respect to the problem behaviors. Clarifying values, challenging beliefs or expectations. Especially helpful during contemplation Self-liberation � choosing and committing to act or believing in ability to change. Decision-making, commitment-enhancing techniques. Especially helpful from preparation on through maintenance. Counter conditioning � learning new coping strategies. Especially helpful during preparation and action Stimulus control � this is teaching relapse prevention, triggers. Especially helpful during preparation and action Increasing information about the problem � observation, interpretation, bibliotherapy. Especially helpful during pre-contemplation Self-evaluation � assessing how one feels/thinks about oneself with respect to the problem behaviors. Clarifying values, challenging beliefs or expectations. Especially helpful during contemplation Self-liberation � choosing and committing to act or believing in ability to change. Decision-making, commitment-enhancing techniques. Especially helpful from preparation on through maintenance. Counter conditioning � learning new coping strategies. Especially helpful during preparation and action Stimulus control � this is teaching relapse prevention, triggers. Especially helpful during preparation and action

37. Effective Catalysts for Change Reinforcement management � rewards for making changes * Helping relationships � support systems Emotional arousal and dramatic relief � e.g. - role playing, psychodrama Environmental reevaluation � how does problem behavior impact personal environment Social liberation � increasing alternatives for non problematic behavior Reinforcement � I put an * by this because it is getting more popular in some segments of treatment. Research is being done to show that contingency management interventions in the treatment of addictive disorders are effective when used in community-based treatment settings. While there is certainly critics of such programs (give people prizes for coming to counseling!) I think we will be hearing more about these programs being implemented. Within the MI model, we are looking at helping clients establish rewards for their progress. It can also mean covert reinforcement to encourage people in the change process. RM is most useful once the action phase is reached and in maintenance to help keep the new behaviors in place. Helping relationships � identify the support systems and create new peer groups. Preparation on. Emotional arousal and dramatic relief � involves experiencing and expressing feelings about one�s problems and solutions to them. Precontempaltion and contemplation. Environmental reevaluation � is the process of assessming how one�s problems affect the personal and physical environment. Pre and Contemplation and Maintenance stages Social liberation � this is getting outside of yourself � Adler�s social interest, AA�s 12th step. Reinforcement � I put an * by this because it is getting more popular in some segments of treatment. Research is being done to show that contingency management interventions in the treatment of addictive disorders are effective when used in community-based treatment settings. While there is certainly critics of such programs (give people prizes for coming to counseling!) I think we will be hearing more about these programs being implemented. Within the MI model, we are looking at helping clients establish rewards for their progress. It can also mean covert reinforcement to encourage people in the change process. RM is most useful once the action phase is reached and in maintenance to help keep the new behaviors in place. Helping relationships � identify the support systems and create new peer groups. Preparation on. Emotional arousal and dramatic relief � involves experiencing and expressing feelings about one�s problems and solutions to them. Precontempaltion and contemplation. Environmental reevaluation � is the process of assessming how one�s problems affect the personal and physical environment. Pre and Contemplation and Maintenance stages Social liberation � this is getting outside of yourself � Adler�s social interest, AA�s 12th step.

38. Movie time! Let�s watch some clips and see if we can spot what the counselor is doing wrong! These are �a little� over the top but let�s look at the mistakes the counselor is making during these interviews.These are �a little� over the top but let�s look at the mistakes the counselor is making during these interviews.

39. What doesn�t work Labeling � attempting to get client to accept a label or diagnosis Shaming/blaming/criticizing Being the �expert� � telling someone what to do/lecturing Being in a hurry Arguing for change Claiming preeminence � I know what�s best OK, what did you see in the clipsOK, what did you see in the clips

40. When goals collide Do you - Give up? �� come back when you�re ready� Negotiate? Find a starting point of agreement Approximate? Look for a step in the right direction Refer? Find a better treatment match There are times when what you/your agency thinks is best for the client is not what the client thinks is best. Using the MI approach, you realize that you cannot impose your goals on your clients � you may get compliance if you have a �power over� relationship, but there will not be any significant change. There are times when what you/your agency thinks is best for the client is not what the client thinks is best. Using the MI approach, you realize that you cannot impose your goals on your clients � you may get compliance if you have a �power over� relationship, but there will not be any significant change.

41. Special cases Mandated clients Family members

42. Mandated clients � special considerations Interventions must be made at the appropriate stage of change, most often precontemplation Decontaminate the referral process � �I�m sorry you came into our services this way� Honor the anger and sense of dehumanization Avoid assumptions about the type of treatment needed Make clear that you will help the client with what he/she believes is important Clearly explain consent and confidentiality It is rare that a client with a substance disorder voluntarily enters treatment. Unlike many problems in which a person finds his/her self in an uncomfortable position and seeks assistance, the reinforcing power of the drugs and the denial defense mechanism keeps most addicts away from treatment until they are about to lose something of great importance. The greatest desire of someone with an addiction is to �gain control� over the drug to allow continued use but without the consequences. With the mandated client your job is to move the person from extrinsic to intrinsic motivation. Most of these client enter in the precontemplation stage and therefore it is counterproductive to use action-oriented interventions. It is rare that a client with a substance disorder voluntarily enters treatment. Unlike many problems in which a person finds his/her self in an uncomfortable position and seeks assistance, the reinforcing power of the drugs and the denial defense mechanism keeps most addicts away from treatment until they are about to lose something of great importance. The greatest desire of someone with an addiction is to �gain control� over the drug to allow continued use but without the consequences. With the mandated client your job is to move the person from extrinsic to intrinsic motivation. Most of these client enter in the precontemplation stage and therefore it is counterproductive to use action-oriented interventions.

43. Family members Assessing needs Safety first How long has this been a problem Why now What have they tried and how did that work Family members are often the ones who will make the first phone call for assistance. A spouse/partner/adult child will say �I just don�t know what do to about my loved one.� What they have difficulty grasping is that they are the client, not the addict and your job is to work with them, not the addict. This is the standard �put your own air mask on before assisting others�. Safety first � is there any history of violence or threat of violence? Is the person psychiatrically stable? How long has this been a problem � you can use the same criteria for an assessment with the substance abuser with the family member. What drugs/how often/how long/negative consequences What happened to bring the crisis to a head? Are there outside authorities involved at this point? What has been tried and how effective were those attempts? Any involvement in counseling or support groups (Alanon, CoAnon)? Family members experience stress related psychological and physical problems, financial difficulties and other negative consequences, but they also have a degree of denial about the severity. They want to believe if the addict would just get help, the family would be OK. Family members are often the ones who will make the first phone call for assistance. A spouse/partner/adult child will say �I just don�t know what do to about my loved one.� What they have difficulty grasping is that they are the client, not the addict and your job is to work with them, not the addict. This is the standard �put your own air mask on before assisting others�. Safety first � is there any history of violence or threat of violence? Is the person psychiatrically stable? How long has this been a problem � you can use the same criteria for an assessment with the substance abuser with the family member. What drugs/how often/how long/negative consequences What happened to bring the crisis to a head? Are there outside authorities involved at this point? What has been tried and how effective were those attempts? Any involvement in counseling or support groups (Alanon, CoAnon)? Family members experience stress related psychological and physical problems, financial difficulties and other negative consequences, but they also have a degree of denial about the severity. They want to believe if the addict would just get help, the family would be OK.

44. Stages of change and the family Precontemplation � User just has to stop using Contemplation � Maybe they don�t really have a problem but we really need to do something Preparation � Family is actively looking for solutions Action � Steps taken to bring about change Maintenance � Family adjusts to life without the substance and re-structures itself with user in recovery Families go through the same stages of change � precontemplation � defenses are high � excuses, protecting mixed with anger at why can�t they just use like other people? Therapist should offer support for any positive change; provide education Contemplation � tension is high in family. Provide education about addiction and use the tension to create movement toward change. Preparation � bibliotherapy, support groups are helpful Action � Contracts for new behavior; intervention, therapist must reinforce decision to hold to behavioral changes. Maintenance � may seem like an easy time but for the family to adjust to having a clean and sober family member may be difficult. Anger over continued attendance at support group meetings, redistribution of family responsibilities. Families go through the same stages of change � precontemplation � defenses are high � excuses, protecting mixed with anger at why can�t they just use like other people? Therapist should offer support for any positive change; provide education Contemplation � tension is high in family. Provide education about addiction and use the tension to create movement toward change. Preparation � bibliotherapy, support groups are helpful Action � Contracts for new behavior; intervention, therapist must reinforce decision to hold to behavioral changes. Maintenance � may seem like an easy time but for the family to adjust to having a clean and sober family member may be difficult. Anger over continued attendance at support group meetings, redistribution of family responsibilities.

45. OK, let�s recap again � we�ve said fitting mi strategies into stages, special cases. Also consider Maslow when looking at what to address first. OK, let�s recap again � we�ve said fitting mi strategies into stages, special cases. Also consider Maslow when looking at what to address first.

46. Referral Support groups Beyond 12-step groups are other types of programs such as Secular Sobriety (SOS), SMART Recovery, Women for Sobriety, Rational Recovery and Moderation Management, Good Chemistry Harm Reduction Programs Methadone maintenance Suboxone or other medication I�m not going to give you any specifics of referral sources as I�m sure you have an excellent data base. But I did want to mention a few aspects of treatment options. Pharmaceutical interventions for addiction are growing. We have more options for opiate addiction with buprenorphine and the 2002 legislation that allows doctors to treat with this drug if they are trained. Cocaine and other stimulants have few options although they are experimenting with a variety of drugs. Alcohol has a growing number � naltrexone, acamprosate. There is now a naltrexone injection for extended release called vivitrol Not much medication for bezo, pot, LSD, ecstasy or people with multiple drug use. I�m not going to give you any specifics of referral sources as I�m sure you have an excellent data base. But I did want to mention a few aspects of treatment options. Pharmaceutical interventions for addiction are growing. We have more options for opiate addiction with buprenorphine and the 2002 legislation that allows doctors to treat with this drug if they are trained. Cocaine and other stimulants have few options although they are experimenting with a variety of drugs. Alcohol has a growing number � naltrexone, acamprosate. There is now a naltrexone injection for extended release called vivitrol Not much medication for bezo, pot, LSD, ecstasy or people with multiple drug use.

47. Referrals Treatment programs Traditional programs Therapeutic community models Contingency management models Cue exposure (for relapse prevention) Holistic models TC�s emphasize peer support and accountability. �Right living� As I mentioned earlier, CM models are gaining more popularity and have been researched by SAMHSA and shown to be effective. They first determine the target outcome and criteria for success, then design incentive programs to reinforce behavior change. CM models use the basics of operant conditioning with choosing the reinforcer, and establishing the magnitude, frequency and timing of the incentive. Cue exposure uses classical conditioning to create extinction of the triggers. Holistic models � accupuncture, biofeedback, spiritual enhancement, meditation, nutrition. What is the best fit for your client at this point in time?TC�s emphasize peer support and accountability. �Right living� As I mentioned earlier, CM models are gaining more popularity and have been researched by SAMHSA and shown to be effective. They first determine the target outcome and criteria for success, then design incentive programs to reinforce behavior change. CM models use the basics of operant conditioning with choosing the reinforcer, and establishing the magnitude, frequency and timing of the incentive. Cue exposure uses classical conditioning to create extinction of the triggers. Holistic models � accupuncture, biofeedback, spiritual enhancement, meditation, nutrition. What is the best fit for your client at this point in time?

48. Practice Worksheet #1 � with a partner, identify examples of high level skills and low level skills Role play and observation using Worksheet #2

49. Questions Further information: ecoccia@austincc.edu; 223-3207

50. Additional information The following is not a complete list of references but will give you a starting place: www.utexas.edu/research/asrec Enhancing Motivation for Change in Substance Abuse Treatment; TIP 35; SAMHSA www.samhsa.gov American Society of Addiction Medicine (1996) Patient Placement Criteria for the Treatment of Substance-related Disorders, 2nd edition. Chevy Chase, MD, ASAM SAAS Update; State Association of Addiction Services Update, Vol. V, No. 12. September, 2007 Dual Diagnosis: Substance Abuse and Mental Illness; NAMI; http://www.nami.org