Overcoming Addictions: Skills Training for People with Schizophrenia

1. Overcoming Addictions: Skills Training for People with Schizophrenia Thad A. Eckman, Ph.D. Program Director, Dual Diagnosis Treatment Program, West Los Angeles VA Medical Center and Associate Professor of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine

2. Schizophrenia and Addiction • Common comorbidity • Creates special problems for: • patients • clinicians • health care systems • social service agencies

3. Special Problems • Diagnostic uncertainty • Poorly integrated treatment • High drop-out (and drop-in) rate • Disability income facilitates drug use • Encumbered by serious learning deficits

4. Comprehensive Dual Diagnosis Treatment Program • Single clinical team treats both disorders in a single setting • Acute inpatient care, day treatment and outpatient clinic • Incentive Program (modified token economy) • Assertive case management • Twice weekly urine tests • Representative payees for money management • Skills training

5. Behavioral Skills Training Modules • Symptom Management • Medication Management • Successful Living • Recreation for Leisure • Basic Conversation Skills • Social Problem Solving • Friendship and Intimacy • Workplace Fundamentals • Substance Abuse Management

6. Substance AbuseManagement Module (SAMM) • Purpose • To stop addiction from interfering with treatment and rehabilitation of serious mental illness

7. Target Population • Severely addicted people with severe mental disorders • Substance dependence causing: • frequent hospitalizations • poor outpatient attendance

8. SAMM Development • Tried standard cognitive-behavioral drug relapse prevention strategies with groups of schizophrenic patients. • Selected those most readily accepted and understood. • Adapted these using a skills training methods originally developed to teach social and independent living skills to schizophrenics.

9. Lessons from Development • “Talk doesn’t cook rice.” Severely mentally ill individuals suffer • Significant deficits in verbal learning ability • Conceptual disorganization • Deficits in executive function • Focus on Skills • One size fits most • Keep it simple

10. Module Theme How to say no to drugs and yes to healthy pleasures.

11. How to Avoid Drugs:7 Recommendations • Seek healthy pleasures Do things that are fun and healthy. • Avoid high risk situations Don’t get into situations where you can’t say no. • Escape high risk situations If someone offers drugs, say no. • Control damage from a slip If you slip, quit early.

12. Additional Recommendations • Understand how you learned to use drugs. • Know why you decided to quit. • Carry an emergency card.

13. Relapse Prevention U-turn Healthy Pleasures Escape Quit Early Warning Sign High Risk Situation Slip Full Blown Relapse 20

14. Learning principles Triggers, craving Damage Control / Harm reduction Abstinence Violation Effect High Risk Situations Warning Signs U-turns Healthy Habits Healthy Pleasures Support Persons Pros and Cons of drugs Money management Concepts

15. Nine Specific Skills How to: • Quit before a slip becomes a relapse • Report a slip • Refuse drugs from an aggressive dealer • Refuse drugs from a friend • Enlist a support person • Get an appointment with a busy person • Discuss symptoms and side-effects with a psychiatrist • Negotiate with a payee • Get someone to join you in a healthy pleasure

16. Refusing Drugs Offered by a Friend 1. Make eye contact. Use a firm, sincere voice tone. Say you're not interested. 2. Use the broken record technique. Repeat yourself. 3. Level with the person. Tell them that drugs were causing you problems and it's better for you to leave them alone. 4. Suggest an alternative. Request to do something other than use drugs. 5. Tell the other person how you feel about being pressured. 6. Leave the situation. Tell the person that you are serious about not using.

17. Reporting Symptoms and Side Effects 1. Greet your doctor politely. Make eye contact and use a pleasant tone of voice. 2. Describe the symptom or side effect specifically. 3. Say how long you’ve had the symptom or side effect. 4. Describe the severity or your problem by explaining how it interferes with your daily activities. 5. Ask directly for your doctor’s help. 6. Repeat the doctor’s instructions. 7. Ask how long it will take to get relief. 8. Thank the doctor for assistance.

18. Three Types of Group Sessions • Basic training • engagement in treatment • terms and concepts • Skills training • how to avoid drugs • how to approach healthy pleasures • Practice • how to apply skills to real-life situations

19. Timing of Sessions Skills Training Basics Practice • Basic Training -- 3 per week x 3 weeks (9 total) • Skills Training -- 3 per week x 9 weeks (27 total) • Practice Groups -- twice weekly throughout

20. Learning Activities • Introduction • Video question and answer • Role play • Resource management • Outcome problems • In vivo exercises • Homework

21. Rationale for Learning Activities • People who have severe mental disorders have trouble with: • attention • planning • impulse control • Learning activities work by: • repeating material in different ways • participants practice skills in various environments • offering increased opportunities to reinforce new skills

22. Basic Training: Rationale • Engages patients despite poor attendance. • Lays the groundwork for skills training by • motivating participants • identifying and personalizing the benefits of abstinence • providing basic terms and concepts

23. Getting High = Your brain’s own feel good chemicals = Addicting Drugs 12

24. Your Brain Adjusts To Drugs Your brain cuts down on its production of natural feel good chemicals 13

25. Withdrawal When the drug is gone, there’s not enough of your brain’s own feel good chemicals 14

26. Conditioned Craving • Pavlov’s Dogs Meat Mouth Waters Meat + Bell Mouth Waters Bell Mouth Waters • Addiction Drug Craving Drug + Trigger Craving Trigger Craving 15

27. Using Drugs and AlcoholAdvantages vs. Disadvantages 16

28. Basic Training: Structure • Eight stand-alone sessions • Continuous loop • Emergency card plus basic concepts

29. Basic Training:Stand-Alone Sessions • Patients can drop in and out • Learn something useful • especially how to return to treatment • Doesn’t disrupt the progress of other patients

30. Basic Training:Continuous Loop • Graduate after eight sessions • like video loop at a museum • Poorer attendance => more sessions are repeated • Slower learners can repeat the loop

31. Basic Training: Products • Emergency card • reminders of negative consequences • advantages of not using • reminders of coping strategies • phone numbers of support people • Recognize critical concepts • damage control, high risk situations, warning signs, u-turns, healthy habits and healthy pleasures

32. Skills Training: Rationale • Talk doesn’t cook rice -- Chinese proverb • Each patient learns all skills • Skills tailored to each patient

33. Skills Training: Structure • 27 forty-five minute sessions • Session Format • use core concept to explain need for skill • develop specific scenes for each patient • conduct role play (easy version) • constructive feedback • repeat role-play (with obstacle) • assign homework

34. Practice: Rationale • Real life => high relevance • Real time => high drama • Attention grabbing => better learning

35. Practice: Structure • All stages of treatment • Series of questions • about prior week • about next week • High-risk situations (recent or anticipated)

36. Practice: Structure (cont.) • Choose one or two situations • Illustrate how to manage the risk • Much group participation and role play • Homework assignments

37. Schedule of Groups • Basic Training • 3 times weekly until all eight sessions attended and test passed • Skills Training • 3 times weekly for 27 sessions total • Practice Sessions • twice weekly, throughout the module

38. Nine Specific Skills How to: • Quit before a slip becomes a relapse • Report a slip • Refuse drugs from an aggressive dealer • Refuse drugs from a friend • Enlist a support person • Get an appointment with a busy person • Discuss symptoms and side-effects with a psychiatrist • Negotiate with a payee • Get someone to join you in a healthy pleasure

39. How to Do Skills Training • Each of the nine skills has: • Overview of the session • Detailed step-by-step instructions • Sample therapist script • Video segment that models the skill

40. How to do Skills Training • Introduce the goal of the module • Say No to drugs and Yes to healthy pleasure • Introduce the session goal • E.g., To learn how to refuse drugs offered by a dealer • Check for assimilation • Make sure participants can repeat the goals • Identify benefits of achieving the goal

41. How to do Skills Training • Review module terms and concepts related to the skill to be learned • What is a high risk situation? • Any situation that make it really hard not to use. • What do I mean by Damage Control • To reduce the harm; to get out as soon as possible.

42. How to do Skills Training • Develop the skill steps • Brainstorm with group members • Write suggestions on blank flip chart • Shape responses • After group has developed their list, show them prepared flip chart • Reinforce their ability to generate skill steps

43. How to do Skills Training • Video illustration • Introduce video • Critique model’s performance • Elicit suggestions for improvement

44. How to do Skills Training • Set up role-play scenario • Select group member • Set up role-play • Think of real situation; set the scene; elicit specific details • Who, where, what was participant thinking and feeling • Review roles • Review steps on flip-chart

45. Model Skills • Showing works better than telling • Before you model a sequence, tell patients what they will be expected to do and what to watch for (refer to flip-chart) • If possible, have a patient who already possesses the requisite skill demonstrate

46. Conduct Role-plays • Behavioral rehearsal is key • Brief scenes enacted by patients • Very active - get out of your seats • Instruct and guide • prompt specific behaviors • model responses • provide corrective feedback

47. Cue Responses /Shape Behavior • Prompt participant during exercise • Stay near • Whisper what to say in his ear • Cue him with gestures • Shape behaviors • Repeated rehearsal; shape successive approximations • Provide constructive feedback

48. Assess Performance • Assets: effective behaviors • Deficits: desirable behaviors missing from repertoire • Excesses: behaviors that are overbearing, intrusive, flamboyant or aggressive

49. How to do Skills Training • Review Role-play • Ask role-player what was most effective • Elicit positive feedback from group members • Ask co-trainer for feedback • Summarize effective behaviors, elicit group applause • Provide Corrective Feedback • Repeat role-play

50. Give Feedback:Positive and Specific • Always praise efforts as soon as a scene ends. (Even if a scene was grossly deficient) • State remarks in specific behavioral terms: • “That was terrific. You looked him right in the eye and firmed up your voice when you told him you didn’t want any drugs” (as opposed to “That was good”).