Henry Schmidt III, Ph.D. Cory Redman John Bolla, MA, CDP Washington State Juvenile Rehabilitation Administration CODIAC

1. Treatment of Substance Abuse and Co-occurring Disorders in JRA’s Integrated Treatment Model Henry Schmidt III, Ph.D. Cory Redman John Bolla, MA, CDP Washington State Juvenile Rehabilitation Administration CODIAC Co-occurring Disorders Conference Yakima, Washington October 1-2, 2007

2. Substance Abuse Treatment and JRA’sIntegrated Treatment Model (ITM) • All youth receive treatment throughout JRA supervision • Targets are identified based on treatment model • DBT for residential • FFPS for parole • Substance abuse treatment fits within the broader ITM context • Skill-building across multiple domains • Improve family functioning

3. Treatment in a Nutshell • Clear behavioral targeting • Engage and motivate, elicit commitment • Assess controlling variables for client’s use • Reinforcers • Cues/contexts of use • Behavioral sequences (urges lead to plans…) • Statistical risk factors (e.g., mental illness, family use) • Modeling, Coaching and Reinforcing of skills • Contingency Management • Troubleshooting, Relapse Prevention

4. Treatment for Co-Occurring Disorders • Mental health diagnosis less important than symptoms • Psychiatric care as required • Increase client understanding of MH issues and recognition as possible risk factors for target behaviors • MH behavior may be a risk factor for a target behavior • ‘Solutions’ for MH risk factors are selected, learned and practiced • Solutions are tailored to match client interests, current skills, broad ability

5. Program Development • Assessment of client needs • EBPs for adolescents, juv justice population • Reviewed treatment expert recommendations • Fit with EBP treatment modalities currently in use (DBT; FFP; FIT) • Identification of treatment assumptions, modes • Adaptation and creation of treatment materials

6. JRA Substance Abuse Treatment: Program Elements • Screening and Assessment • Prevention • Pre-Treatment • Treatment • Aftercare

7. Substance Abuse Screen/Assessment • Screens • Global Appraisal of Individual Needs (GAIN – SS) • Substance Abuse Screen (SAS) • Client History Review (structured interview) • Assessments • Biopsychosocial Diagnostic ASAM Assessment • Acute Intoxication and/or Withdrawal Potential • Biomedical Conditions and Complications • Emotional/Behavioral Conditions and Complications • Treatment Acceptance/Resistance • Relapse/Continued Use Potential • Recovery Environment • Behavior Analysis

8. Intervention Decision Process • Screen • Assessment • Assignment to Treatment Level • Assignment to Aftercare • Transition to Parole Services

9. Prevention

10. Goals of Prevention • A comprehensive prevention curriculum for all youth not needing substance abuse treatment. • Practice strategies for rejecting drugs and alcohol. • To emphasize that use of tobacco, alcohol, and drugs are not the norm among teenagers. • Help youth to develop greater self-worth, self-efficacy, and self-confidence. • Enable youth to effectively cope with anxiety, depression, anger, shame, guilt, fear, etc. • Link prevention activities within the home, schools, and community.

11. Elements of Prevention • Pschoeducation re: • Harmful effects of drugs and alcohol (including nicotine) • Peer norms for use • Risk factors for use • Skill Building • Refusal skills • ‘Reasons to not use’ – strengthen commitment and abstinence/moderation beliefs and expectancies

12. Pre-Treatment

13. Goals of Pre-Treatment • Prepare youth for substance abuse treatment. • Introduce preliminary education and information about substance abuse. • Identify individual’s risk and protective factors, triggers and cues, patterns of use, and functions and drivers. • Increase desire to engage in treatment.

14. Elements of Pre-Treatment • Orientation to treatment • Assess stage of change • Increase motivation and engagement toward participation in pre-treatment and treatment • Obtain commitment to explore and understand personal substance abuse

15. Treatment

16. Goals of Treatment • Decrease: • substance abuse. • physical discomfort from abstaining. • urges and cravings to use drugs. • apparently irrelevant behaviors. • keeping options to use drugs open. • capitulating to use drugs. • Increase community reinforcement of “clear mind” behaviors.

17. Dialectical Behavior Therapy(DBT) • Developed by Marsha Linehan and colleagues, for • Chronically suicidal women meeting criteria for Borderline Personality Disorder • Manualized, one-year outpatient treatment model • Successful in working with difficult-to-engage, difficult-to-treat populations

18. DBT Adaptations • Substance Abuse • Linehan et al. (1999) • Adolescents • Outpatient, Rathus & Miller (2002) • Inpatient, Katz et al. (2004) • Residential settings • Inpatient psychiatric, Swenson et al. (2001) • Forensic inpatient - McAnn, Ball, Ivanoff (2000) • Washington State JRA – Trupin et al. (2002) • Other Disorders: Batterers, couples

19. Why DBT and Adolescent Substance Use? • Behavioral Dyscontrol • Truancy, criminality, substance use, self-injury • Emotional Dyscontrol • Low-skilled in identifying and regulating emotions • Cognitive Rigidity (developmental) • b/w thinking, oppositional, rule-governed morals • Interpersonal Issues • Socially isolated or shifting groups, deviant peers, etc. • Issues of Self (developmental) • Unstable sense of self, low self-esteem

20. Basics of DBT JRA’s Residential Treatment

21. DBT Modes of Treatment • Individual Therapy • Group Skills Training • Telephone Contact • Therapist Consultation Group • Pharmacotherapy (as needed)

22. Functions of Comprehensive CBT • Enhance Client Motivation • Acquire Skills • Generalize Skills • Structure Environment for Treatment • Enhance Therapist Motivation and Skills

23. Important Elements DIALECTICS - Balance of Acceptance v. Change BEHAVIORAL ASSUMPTIONS • Clients are doing the best that they can • Maladaptive behavior occurs because • Lack of skills to do otherwise • History of it being reinforced • Strong contextual risk factors Thus, the behavior makes sense in context

24. DBT Treatment Hierarchy DECREASE • Suicidal, Self-Injurious Behavior • Treatment-Interfering Behavior • Quality-of-Life Interfering Behavior Behaviors are targeted sequentially Only one or two targets at a time DBT-S • Substance use is top quality-of-life interfering target

25. New Concepts for DBT-SUD

26. ‘Dialectical Abstinence’ Relapse Prevention Absolute Abstinence

27. DBT-SUD Path to Clear Mind Decrease Substance Abuse Decrease Urges and Cravings to use Drugs Decrease Apparently Unimportant Behaviors Decrease ‘Keeping Options to Use Drugs Open’ Decrease Capitulating to Use Drugs Increase Community Reinforcement & ‘Clear Mind’ Behaviors CLEAR MIND

28. Strong Emphasis on Attachment Strategies for Clients • DBT already successful at retaining difficult-to-treat clients (BPD) • Increased emphasis on engaging clients • Increase positive contact outside of session • Post cards, birthday and special occasion cards • Increasing non-demanding contact during first 3 months • Daily telephone check-in, exchange of messages • Conducting therapy ‘in vivo’ • Altering session length (non mood-dependent) • Supportive friends and family network meetings

29. Attachment strategies for patients • Finding ‘lost’ clients • Clients are ‘dropping off’ until formally out of treatment • Often drop off when lapsing, relapsing • Therapist task is to ‘find’ client who is not responding to phone calls • Social network mapping – all relevant networks • Where gone in the past? What places does s/he frequent? • Orient clients to ‘getting found’ ahead of time

30. Working with Mandated Clients Also requires a large emphasis on Engaging and Motivating • Cannot expect client to show up wanting to change • Many clients ignore negative impact of lifestyle • Confrontation not effective • Caution against settling for compliance over participation

31. JRA’s Residential DBT-SUD Model • Individual sessions with case manager • Skill acquisition groups • Skill generalization groups • Milieu intervention • Family skills groups • Staff meetings • Psychopharmacology (for MH, not SUD)

32. JRA Residential Tx. Hierarchy • Engage and Motivate – ALWAYS! • Suicidal/Self-injurious Behavior • Aggressive Behavior • Escape Behavior • Treatment-interfering Behavior • Quality-of-life-interfering Behavior • Substance Abuse, Dependence • Criminal Behavior, Gang Involvement, Truancy, etc.

33. Engage and Motivate Clients • Know your client’s goals, strengths • Explore pro-social, community- or family-oriented values • Nonjudgmental exploration of issues around substance use • Orient to program – this is what we have to offer • Commit to work full-time to help client reach own goals (partnership, coach)

34. Engage and Motivate Clients • Distinguish between education and treatment • Elicit a commitment to treatment before beginning change strategies (Linehan; Miller & Rollnick) • Soft commitment is acceptable; ‘foot in the door’ • Problem-solve client wanting to quit • What would s/he find helpful? • What has worked in the past? • Label ‘not being motivated’ as normative, cyclical, problem to be solved – not moral failing

35. Structure Supports Engagement • Token economy • Level system tied to commitment, treatment participation and progress • Compelling reinforcers for clients to earn • Non-contingent staff warmth and encouragement • Peers are bought into the program • Low support for drug using, war stories (seen as unskillful, not goal-oriented) • Public recognition for accomplishing treatment goals

36. Relevant Assessment of Drug and Alcohol History • Statistical v. Idiographic Risk Factors • ASAM Biopsychosocial Assessment, Researched risk factors, Chain Analysis • Psychological Constructs v. Behavioral Descriptions • Understand in which situations the client used (topography – complete picture)

37. The Chain Analysis • Pick specific instances of different situations • Moment-by-moment narrative of events • Identify the controlling variables for use – • What problems did using solve? • What were prompts for using? What got the ball rolling? • What were vulnerabilities for using – made it more likely the youth would use? (External or internal contexts.) • Client and therapist both understand what drove substance use

38. Assess for Relapse – Plan for Success • Problem-solve future use – what is present in community environment that could lead to relapse? • What skills will be needed to address this? • What changes in environmental structure could be made to support treatment and long-term goal attainment? (‘Burning bridges’)

39. Skill Acquisition • Broad palette of skills • Skills are behaviorally specific. • Particular skills are focus for individualized treatment, needed to address specific elements of client’s risk for use. • Groups and individual work incorporate principles of learning • Modeling • Shaping • Reinforcement • Arbitrary vs. Natural • Staff speak the same language throughout program

40. Skill Generalization • Milieu program – all interactions are opportunities to drag out and strengthen skillful behavior, diminish unskillful behavior • Remind clients to take skills into all contexts • School • Family meeting • Interactions with peers • Recreation and work activities • Interactions with staff, etc. • Highlight positive outcomes of skill use (staff help youth to notice) • Encourage client self-reinforcement

41. Structuring the Environment • Visual cues to remind youth and staff of the treatment environment • Invite youth’s parents/significant others to participate • Youth report on progress in program (new skills, chains for use, relapse prevention plan) • Family meetings focus on what has been effective in eliciting commitment, maintaining motivation; what has ‘tripped up’ youth • Youth are taught to begin to structure their own environment, begin to display those skills • Community resources are identified, contacted and agree to participate with youth (mentors, programs, treatment)

42. Motivating Staff • Knowledge that leaders are developing/have vision for complete program • Confidence in skill level and knowledge of treatment director (or identified program specialist) • High-quality training, when needed (paced, relevant to expanding demands of job, etc.) • Examples of high-quality work (paperwork, video or live demonstration of clinical tasks) • Weekly staff consultation meeting focused on describing treatment, de-polarizing staff (and increasing flexibility)

43. Motivating Staff (2) • Advancement based on demonstration of skills • Managers are provided training to manage well • Focus on systematic skill development • Link learning skills to individual staff goals • Staff see results of their own treatment efforts • More skillful youth • Committed to long-term goals • Accomplishing important tasks • Understanding what drives own behavior • Building a support network • Preparing for success (relapse prevention plans)

44. JRA Community Aftercare • Functional Family Parole • Families’ needs are identified and discussed prior to the youth being released to the community on parole. • Youth and family with special needs (mental health, substance abuse, etc.) are assisted by the Parole Counselor in being linked to community based resources. • Families are contacted regularly and youth with substance abuse issues are monitored by random urinalysis.

45. Family Integrated Transitions (FIT) • EBP to transition juvenile offenders with the co-occurring disorders back into their community • Designed and implemented by Eric Trupin, Ph.D. and David Stewart, Ph.D., from the University of Washington. • To meet the needs of these high risk youth, several evidence-based programs were combined. Those are: • Multi-Systemic Therapy (MST) as the core treatment model, plus: • Dialectical Behavior Therapy (DBT) • Motivational Enhancement Therapy (MET) • Relapse Prevention/Community Reinforcement

46. FIT Target Population • Ages 11 to 17.5, with a substance abuse/dependency and mental health need • At least 2 months left on sentence • Residing in Snohomish, King, Thurston or Mason counties (JRA Regions 3, 4, and 6) with a family or stable placement • Sex offenders are NOT excluded from the target population

47. FIT Demonstrated Outcomes • 33% reduction in felony recidivism • FIT reduces recidivism from 40.6% to 27.0%. • Cost of Program: $8, 968 spent per youth • Benefit-cost ratio related to the reduction in crime is a savings of $3.15 for every dollar spent – or total of $19, 247 per youth in the FIT program