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Chapter Ten:

Chapter Ten:. Treatment Techniques and Approaches. points to consider. Individual counseling Group work Working with families Self-help Spiritual counseling Meditation Behavioral therapy Pharmacotherapy. Coordinates the whole of treatment

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Chapter Ten:

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  1. Chapter Ten: Treatment Techniques and Approaches

  2. points to consider • Individual counseling • Group work • Working with families • Self-help • Spiritual counseling • Meditation • Behavioral therapy • Pharmacotherapy

  3. Coordinates the whole of treatment Based on therapeutic relationship Education Promotes client self-assessment Provides a picture of client’s situation individual counseling

  4. therapeutic relationship Not based on liking Entails — • Being respectful • Being knowledgeable • Sharing expertise in appropriate fashion • Ability to foresee possibilities client can’t • Providing support and hope

  5. case management • Assessing variety of needs • Liaison with other agencies • Functioning as client’s advocate • Record keeping

  6. group work Common in substance abuse treatment Clinical opportunities • to try on new behaviors • for positive peer pressure • to explore self in relationship to others • to see oneself through others’ eyes

  7. types of groups • Psycho-educational • Support groups • Problem-solving groups • Activity groups

  8. groupfunctions • Initiating • Elaborating, clarifying • Facilitating • Expressing group feeling • Giving feedback • Seeking feedback

  9. working with families • Relatively new • Addresses needs of family members • “Family” a broad concept • Different types of family treatment • for family member’s issues • to engage alcoholic in treatment • as part of alcoholism treatment

  10. Johnson family intervention • Introduced by Vernon Johnson • No longer need to wait for alcoholic to “hit bottom” • Not equal “attack” • Family members share examples of negative incidents

  11. Johnson family intervention (cont.) • Requires preparation of family • Family sees negative behavior as inconsistent with alcoholic’s values • Family express belief that drinking represents disease • Few formal studies one study: many families elect not to proceed; if do, 75% alcoholics enter treatment

  12. other family interventions Community Reinforcement and Family Training (CRAFFT) • Uses cognitive-behavioral method • Family members trained to use technique • Manual-guided therapy • Study: two-thirds enter treatment

  13. family work within alcohol treatment • Family component common in treatment • Part of assessment process • Different formats • couples therapy • family groups • educational programs

  14. tips for working with families • Interactions versus content • Teach communication skills • Be alert for scapegoating • Stress acceptance of other’s rights to own feelings • Teach problem-solving skills

  15. common issues for family • Practical concerns • Realistic expectations for treatment • Need to have patient hear their “story” • Need to deal with issues in manageable chunks • How to involve children • Fear of relapse

  16. children in the family • Often believe problems are their fault • Include in family meetings • Children define own level of involvement

  17. children in the family (cont.) • If a serious illness, tell children plans for their care • If possible child abuse/neglect, referral required • Use special child-oriented programs • Respect children’s defenses

  18. the family in recovery • Recovery can bring stress • Family tasks during recovery • strengthen generational boundaries • resume age- and sex-appropriate roles • Re-definition of roles • Dealing with “lost” time

  19. divorce or separation • Divorce and separation common • Some enter treatment estranged; for others divorce occurs post-treatment • Need to deal with “what is”

  20. self-help for family members • Al-Anon • best known • for family members • originally AA Auxiliary • application of AA constructs • Alateen • Important to distinguish from formal treatment

  21. AlcoholicsAnonymous Founded in 1935 • Condition then considered medically hopeless • Bill Wilson on business trip to Akron OH • Had urge to drink • Sought out another alcoholic, Bob Smith, MD

  22. AlcoholicsAnonymous (cont.) • Based on one alcoholic helping another • Spiritual but not religious • 1939, wrote Alcoholics Anonymous • sets forth steps had taken to become and stay sober • known as “12 steps”

  23. Alcoholics Anonymous (cont.) • Little formal organization • organized around 12 traditions • AA activity involves • attendance at meetings • informal contacts • reading literature • “working” the steps

  24. Referral to AA • Introduction via treatment programs • Promote sufficient exposure to AA • No formal referral mechanism

  25. Via AA member, 36% Treatment facility, 40% Family, 25% Legal system, 14% Counseling agency or health care provider, 15% Employer or co-worker, 5% Routes to AA 2001, Membership SurveyNB. Could identify 2 factors

  26. Other self-help groups • Other self-help groups • 12-step programs • modeled after AA • drugs other than alcohol • also for other behavioral disorders • Non-12-step programs • alternative to AA

  27. other 12-step programs Other 12-step programs • Narcotics Anonymous (NA) • Cocaine Anonymous (CA) • Nicotine Anonymous • Overeaters Anonymous (OA) • Gamblers Anonymous (GA)

  28. non-12-step programs • Reject ... • spiritual element • disease concept • view of individual as powerless • Emphasize ... • ability to make choices • capacity for change

  29. non-12-step programs • Women for Sobriety • Rational Recovery • Secular Organizations for Sobriety • S.M.A.R.T. Recovery (Self Management &Recovery Training) • Moderation Management

  30. Women for Sobriety • Founded in 1976 for women • Women then minority in AA • Emphasis on ability to make choices • Based on 13 principles • Principles share common features with cognitive therapy

  31. Rational Recovery • Founded in 1985 • Explicit alternative to AA • Emphasizes choice • Program organized around “addictive voice recognition” (AVR) • AVR similar to cognitive restructuring

  32. Moderation Management • Founded in 1994 • Abstinence not goal • Intended for “problem drinkers” • Explicit guidelines for moderate use

  33. spiritual counseling Potentially useful for those … • who have religious background • for whom guilt an issue • who need to revise spiritual views • who are struggling with spiritual aspects of AA

  34. spiritual domain • Spiritual domain of increasing interest in medicine • Religious involvement associated with fewer alcohol problems • Treatment outcome better for persons involved in AA

  35. meditation • Part of differing spiritual traditions • Used for stress reduction • Different types

  36. activities therapy • occupational therapy • recreational therapy • promotes social skills • use of leisure • fitness Includes —

  37. behavioral techniques • Underpin many treatment approaches • Based on learning theory Include — • Relaxation Therapy useful to deal with anxiety • Cognitive-Behavioral Therapy deals with automatic thoughts can defuse high-risk triggers

  38. behavioral techniques (cont) • Systematic Desensitization also useful to deal with anxiety • Life Skills Training • Record Keeping identify precursor to problem situations • Contingency Management more widely used rewards for desired behavior • Relapse Prevention

  39. relapse prevention: common elements • Use array of behavioral techniques • Identifying high-risk situations • Techniques to deal with craving • See relapse as process not event • Attending to cues and cravings • Addressing social pressures

  40. relapse prevention: common elements (cont.) • Creating a supportive network • Correcting errors in thinking • Skills to handle negative feelings • Balanced lifestyle

  41. pharmacotherapy • Some question use of medications • Use of medications buys time • Two major drugs alcohol treatment • Disulfiram • Anti-craving agents

  42. Disulfirampharmacotherapy • Discovered accidentally • Disulfiram blocks metabolism of alcohol • prevents breakdown of acetaldehyde • acetaldehyde toxic • basis for action not action on brain • Drinking while taking alcohol  • rapid heart beat, nausea, flushing weakness and dizziness

  43. Disulfiram (cont.)pharmacotherapy • Disulfiram use dissuades people from impulsive drinking • Disulfiram excreted slowly, remains in body for 4 to 5 days • Use as part of broader treatment effort • Cautions: • need to watch diet • liver function needs to be evaluated

  44. Anti-craving agents pharmacotherapy • Naltrexone first used in opiate treatment • Reduces craving in alcoholics • Earliest use with “treatment failures” • found fewer incidents of drinking • less alcohol if drink • less response to alcohol • Marketed as Revia®

  45. Anti-craving agents (cont.)pharmacotherapy • Acamprosate introduced in 2004 • Marketed as Camporal® • Reduces craving in alcoholics

  46. treatment matching • With array of treatments, which to use for whom? • Large study by NIAAA “Project MATCH” • Examined 3 different therapies • 12-step Facilitation • Cognitive-Behavioral Therapy • Motivational Enhancement • Question: Who does best in which treatment?

  47. treatment matching (cont.) • Project MATCH findings • virtually no difference in outcome • Four of 21 patient characteristics mattered • psychiatric illness • severity of dependence • level of anger • social support for abstinence

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