Effective Interventions at the Bridge Programme Paul Clifford and Cynthia Young Director and Programme Coordinator Auck

1. Effective Interventions at the Bridge Programme Paul Clifford and Cynthia Young Director and Programme Coordinator Auckland Bridge Programme

2. History The Salvation Army involved in Alcohol work since late 1800’s – early 1900’s. Commitment under the Habitual Drunkards Act 1906. Despatched to Rotoroa Island. Introduction of various methods of treatment over many years. Questions in early – mid 1990’s regarding effectiveness of what we were doing – and is it the best methodology for long term sobriety.

3. Community Reinforcement Approach seen as having a 30+ year history with solid base of research supporting effectiveness. “Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach” Robert Meyers and Jane Ellen Smith (1995) CRA incorporated in to the Bridge Model of Treatment in 2003. Small group of Managers visit Life Link Training Institute Santa Fe, New Mexico. Followed by visit of Life Link Staff (Ray (Ande Anderson) to undertake a training regime for all Bridge staff commencing October 2005. Modified and improved for NZ Culture over intervening time.

4. CRA evidence based Evidence - Based Treatment – numerous studies have demonstrated that clients who received CRA fared much better than did those who received traditional treatments. CRA clients were almost completely abstinent in 1 year follow up, had more days of employment and greater social stability. Family involvement further increased the successful outcomes and the difference.

5. If punishment worked there would be no alcoholics! Negative approaches has been shown to be ineffective eg confrontation or aversion therapies CRA takes a different approach based on providing incentives to stop drinking Client, therapist and significant others work together to change the drinker’s lifestyle so that abstinence is more rewarding than drinking.

7. Spirituality Recovery Church (twice weekly) Spiritual Awareness (weekly group) Introduction to The Salvation Army (at entry to programme) Spirit Lifter (daily) Opportunities for one to one sessions with Recovery Church Staff Time off to attend other Churches or faith groups

8. CRA Approach Integrates several treatment components: building motivation to quit drinking, helping initiate sobriety, analyzing drinking patterns, increasing positive reinforcement, learning new coping behaviours and involving significant others in the recovery process.

9. Client’s timeline – Stage 1 Initial contact Appointment for Assessment Start attending pre-entry groups and using CRA tools eg exploring clients motivation for change, F.A.Using and Nonusing, L.S.S., Wkly Goals, Wheel of Change Supportive and empathetic, building hope and trust, identify and enhance positive reinforcers Entry to 8 week programme (Residential or day client) within 6 – 2 weeks (usually 4 weeks)

10. Stage 2 and Stage 3 Given a Monday date for entry to stage 2 as either day or residential client Welcomed and taken through admission process Settle in for 8 week programme Successfully complete on a Tuesday Commit to attending Stage 3 After Care Average engagement 8 weeks in Stage 3 Overall Treatment period is 5 months

11. Overview of CRA components CRA assessment using tools 8 week programme (Sobriety Sampling) Treatment Plan (Case Goals) Behavioural Skills Training (Groups) Employment Plus (Job Counselling) Social and Recreational Counselling Relationship Counselling Relapse Prevention Medication use (Antabuse, Naltrexone)

12. Use of CRA Tools Client’s interaction with forms and CRA tools: What Got Me Here Life Satisfaction Scale Weekly Goals Functional Analysis Relationship Resources Post Treatment Plans

13. Life Satisfaction Scale 1. AOD Use / Sobriety Job / Education Finance / Accommodation Social Life Personal Habits 6. Family / Relationships 7. Legal Issues 8. Emotional Life 9. Communication 10. General Happiness (11. Spirituality)

15. Use of Life Satisfaction Scale Simple and easy way to monitor client’s progress Highlights mental health problems Used at least 2-3 times throughout programme First step in identifying treatment goals Post treatment part of evaluation

16. Life Satisfaction Scale: Initial, Start and towards end of programme

17. “Weekly” goals Drawn from area with low – moderate score on Life Satisfaction Scale Client encouraged to choose area where they are likely to succeed Goals stated in positive and concise way Specific, measurable, achievable, realistic and in a time frame (SMART) Added to throughout programme

18. Format of ‘My Weekly Goals’ Name: Date: Area: Goal: In order to achieve this I: The assistance I would like from others is: Time frame for achievement of goal:

19. Ranking of Weekly Goals

20. Functional Analysis Identifies triggers and clarifies outcome Internal and external triggers Short term and long term consequences Useful in individualizing treatment With alternative non using behaviours Identifies past, current and potential reinforcers Acts as a reinforcer itself

21. Group Curriculum 8 week cycle of 11 curriculum groups Weekly entry and exit of clients Clients in group size 21 – 32 (average 28) Designed for range of learning styles Skills training in Communication, Problem Solving, Cognitive Behavioural Therapy, Relapse Prevention, and Exploring Recovery using creative media

22. Group Curriculum Communication/Social Skills Body Language Styles How to be Assertive Listening Skills Managing Feelings Managing Conflict Boundaries 1 Boundaries 2 Problem Solving/Goal Setting SWOT Goals –Vision and SMART Brainstorming/Mind Mapping Forward Thinking IDEAL DOIT Time Management Managing Stress

23. Group Curriculum Supporting Sobriety Social Networks Drink/Drug Refusal Positive Reinforcers Cravings Back up Plans Heading for Relapse Cross Addiction Functional Analysis Using/NonUsing Cognitive Restructuring Thinking Mistakes Self Defeating Beliefs CBT Thought Record Five Part Model Defense Mechanisms Self Talk Crisis Survival

24. Group Curriculum

25. Format of Self Directed Learning What is your present level of skill? How is this working for you? What would you like to be able to do? What do you need to change? How and when will you do that? What will be the benefits?

26. Methods for Self Directed Learning Write out your thoughts, feelings and possible proactive action. WRITING - VISUAL Do some art work expressing all of the above ART - VISUAL Talk to a buddy and practice with role plays ACTION - EXPERIENTIAL Share what you have done with your Case Manager. VERBAL

27. Group Outcomes Monitoring degree of participation Explicit question at end of group eg how helpful on scale of 1-5 or verbal feedback about learning Facilitator debriefs with team Weekly opportunity for client to identify learning in one to one session and end of week group End of treatment – client satisfaction survey

28. Summary of Group Outcome Provides a course in Self Management – understanding self, building skills to manage self in a wide range of situations, identify values and direction, make positive choices, building confidence and self esteem, encouraging greater use of creativity and thinking before acting.

29. Application of CRA in 1:1 sessions One to one sessions are to facilitate and support 1. client’s interaction with CRA tools 2. learning and practicing of skills eg role play 3. actions to achieve these goals 4. access to resources such as Employment Plus, recreational/social opportunities, relationship and family sessions, developing spiritual resources 5. processing of issues

30. Dealing with past issues Client initiated and paced Process in one to one session Acknowledging issues Choice around process eg talking, art, writing Working towards acceptance or positive change Developing competence and confidence Action plan formulated Options and resources offered including use of other modalities such as T.A. May need external referral

31. Role of Case Manager? Empowering and encouraging the client as much as possible Facilitate process at client’s pace Asking questions that allow client to decide on their priorities and actions Offer suggestions and feedback within coaching framework Emphasis is on accessing and building resources Help client make choices and take responsibility Hold accountable via weekly review of progress

32. Involving Significant Others Helps support improvements in quality of family and recreational time Provides them with brief relationship counselling using CRA relationship resources Improves communication, restores hope Coaching to avoid enabling and increase positive reinforcement for sobriety Clarifies post treatment expectations

33. Relationship resources Using the CRA Relationship tools – Relationship Scale, Perfect Relationship Goals, Daily Reminder To Be Nice Tools made available for significant others Modified to include parent/child/sibling situations Family / Whanau sessions offered to clarify expectations

34. Recreation/Social Integrating new choices on daily basis Opportunities provided Art and Craft Gym on site Exercise eg walking up Mt Eden, Team sports Family/Whanau involvement Functional Analysis - Non Using Organised events eg Sports Day, Movie Free time and weekend leave

37. Graduation Post treatment Plan presented to staff and peers for feedback Certificate of achievement – signed by client as making a personal commitment to maintain recovery principles Satisfaction Survey acts as overview

38. Options After Leaving? After Care Groups Recovery Church Potential Re-Entry to Programme Participate in Post Treatment Evaluation Continue to make healthy and positive choices and be part of an alternative culture

39. Key Interventions Building a therapeutic relationship Using CRA tools Facilitating opportunities for learning Support engagement in groups Involve family where possible Support work on emerging issues Clinical review process midway Assist with post treatment plans

40. Multilayered experience with One to one session Psycho-educational groups Being part of Therapeutic Community with residential and day clients of both genders Family AA/NA Spiritual awareness and practice Other services eg Medical, Dental, Budgeting, Quit Smoking Coach

42. How do we evaluate treatment? Client satisfaction surveys and complaints 99.9% would return if they needed help and would recommend programme to others Retention figures for past 4 years show that about 2/3’s of clients successfully complete the programme (64%) 500/782 8% return to repeat the programme - most of these 66% have graduated previously and graduate again, others 20% succeed this time around

43. Repeaters generally do better Second time around there is a deeper level of engagement, better focus and stronger commitment to making changes Clients appreciate the consistency of the programme - structure, content and delivery They acknowledge a need for help and put their faith in what is offered at The Bridge

44. What do clients like? Feeling safe, accepted and cared for Accepting that they have a problem and they are not alone with this Being heard, developing hope for the future Health improving, Enjoying learning about self Clear headed, more cheerful, family atmosphere Having fun with staff and clients Spiritual awakening, Forgiving self and others

45. What do staff like? Witnessing positive transformation Agent of change in creative caring process catalyzing learning Role model within community Opportunities to make a difference through kind encouraging interactions Privilege of facilitating client’s process

46. Follow on studies Pilot study (2007) showed 72% of clients were still abstinent 6-12 months after completing stage 2. Consent forms are collected at point of exit and follow up will occur at 3, 6, + 12 mths This will eventually provide a comprehensive database of how clients get on post treatment

47. What is the process for change? Input from staff, client feedback, other Bridge Programmes, professional development and training, planning days Important to keep fine tuning… relaxation, recreation, developing healthy communities, more emphasis on spirituality?

48. Clients most likely to succeed? Hard to predict but important factors seem to be ……Point of readiness for change and a successful spiritual awakening - those who have taken the opportunity to develop a spiritual faith report “This is what has been missing in my life” Staying connected to Recovery Church opens new possibilities with many ex-clients coming regularly and taking on roles eg music, testimonies, readings, and become part of The S.A.