Co-Occurring Disorders, Best Practices and Adolescents Webcast Thursday June 26, 2008 11:00 AM – 12:30 PM Dial-in Number: (866) 633-8010 Conference

Co-Occurring Disorders, Best Co-Occurring Disorders, Best Practices and Adolescents Practices and Adolescents

WebcastWebcastThursday June 26, 2008 Thursday June 26, 2008 11:00 AM – 12:30 PM 11:00 AM – 12:30 PM

Dial-in Number: (866) 633-8010 Dial-in Number: (866) 633-8010

Conference Code: 4449499285Conference Code: 4449499285

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Co-Occurring Disorders, Best Co-Occurring Disorders, Best Practice and AdolescentsPractice and Adolescents

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Co-Occurring DisordersCo-Occurring DisordersBest Practices and AdolescentBest Practices and Adolescent

Mary Jane Alumbaugh, Ph.DMary Jane Alumbaugh, Ph.D

““Double Trouble - Early”Double Trouble - Early”

Main PointsMain Points

• Section One: Co-Occurring Mental Health and Substance Use Disorders in Section One: Co-Occurring Mental Health and Substance Use Disorders in Adolescents: ResearchAdolescents: Research

• Section Two: Systems Issues - Parallel Treatment Systems-Colliding CulturesSection Two: Systems Issues - Parallel Treatment Systems-Colliding Cultures• Section Three: Assessment and Treatment of Co-Occurring DisordersSection Three: Assessment and Treatment of Co-Occurring Disorders• Section Four: Evidence Based Mental Health Treatments for Adolescents with Co-Section Four: Evidence Based Mental Health Treatments for Adolescents with Co-

Occurring DisordersOccurring Disorders• Section Five: RecommendationsSection Five: Recommendations

Section One:Section One:Co-Occurring Mental Health Co-Occurring Mental Health

and Substance Use and Substance Use Disorders in Adolescents: Disorders in Adolescents:

The ResearchThe Research

IntroductionIntroduction

The research tells us the majority of youth The research tells us the majority of youth referred for substance abuse treatment have at referred for substance abuse treatment have at least one co-occurring mental health disorder least one co-occurring mental health disorder (COD), a DSM-IV-TR mental health disorder and (COD), a DSM-IV-TR mental health disorder and a substance use disorder (SUD).(Turner, a substance use disorder (SUD).(Turner, Muck,et al, 2004)Muck,et al, 2004)

ResearchResearch• Adolescents with substance use disorders are at a six Adolescents with substance use disorders are at a six

times risk of having a co-occurring psychiatric disorder times risk of having a co-occurring psychiatric disorder (Dennis, 2004)(Dennis, 2004)

• Co-Occurring disorders are associated with poorer Co-Occurring disorders are associated with poorer treatment outcomes, both physical and psychological treatment outcomes, both physical and psychological when either disorder is not treated (Riggs, 2003)when either disorder is not treated (Riggs, 2003)

• Drug abuse changes the brain chemistry of developing Drug abuse changes the brain chemistry of developing brains. (Degenhar &Hall, 2006,Smit 2004) brains. (Degenhar &Hall, 2006,Smit 2004)

• Psychiatric symptoms often precede the SUDPsychiatric symptoms often precede the SUD

Incidence of Co-occurring Incidence of Co-occurring Disorders in System of Care Disorders in System of Care Adolescents Adolescents (Turner, Muck, Muck et al, 2004)(Turner, Muck, Muck et al, 2004)

• CSAT Sites 74% of youth with SUD also had a co-CSAT Sites 74% of youth with SUD also had a co-occurring mental health disorderoccurring mental health disorder

• SOC Sites 21.7% had five or more presenting SOC Sites 21.7% had five or more presenting problems; at least one of which was a SUD (Turner, problems; at least one of which was a SUD (Turner, Muck, 2004)Muck, 2004)

Co-Occurring Disorders Co-Occurring Disorders CategoriesCategories

• Co-occurring disorders in adolescents are usually categorized Co-occurring disorders in adolescents are usually categorized into internalizing and externalizing disorders. These should be into internalizing and externalizing disorders. These should be the focus of treatment for the mental health interventions.the focus of treatment for the mental health interventions.

• Internalizing disorders–symptoms of anxiety, fear, shyness, low self esteem, sadness, depression (6%)

• Externalizing disorders —symptoms of non compliance, aggression, attention problems, destructiveness, impulsivity, hyperactivity, and antisocial behavior (18-35%)

• Both types of disorder (38-65%)

Co-Occurring Disorders Co-Occurring Disorders CategoriesCategories

• Disruptive disorders and mood disorders are associated with earlier onset of use of substances and increased substance use disorders

• Trauma/victimization in youth with SUD range from 25% for males to 75% of females (Kanner, 2004, Dennis, 2004)

Gender DifferencesGender DifferencesGirlsGirls

• Conduct disorder associated with SUD in both girls Conduct disorder associated with SUD in both girls and boys, but girls with this combination had the and boys, but girls with this combination had the highest Child Behavior Checklist Scores for highest Child Behavior Checklist Scores for delinquencydelinquency

• Caregivers report more of both internalizing and Caregivers report more of both internalizing and externalizing disorders among girls (83%) than boys externalizing disorders among girls (83%) than boys (41%)(41%)

• Girls are over represented in groups with poor Girls are over represented in groups with poor outcomesoutcomes

Gender DifferencesGender DifferencesGirlsGirls

• Females had higher rates of co-occurring disorders Females had higher rates of co-occurring disorders and were more likely to have suffered physical/sexual and were more likely to have suffered physical/sexual abuseabuse

• Females report significantly higher level of drug Females report significantly higher level of drug dependence vs. abuse, (72% vs 43%) in boysdependence vs. abuse, (72% vs 43%) in boys

Gender DifferencesGender Differences

BoysBoys• Present more often with disruptive disorders Present more often with disruptive disorders

(ODD/CD/ADD)(ODD/CD/ADD)

• COD referrals are more often made in juvenile justice COD referrals are more often made in juvenile justice settings (80%) settings (80%)

• In juvenile justice settings 75% of males and 50% of all In juvenile justice settings 75% of males and 50% of all females have a co-occurring disorderfemales have a co-occurring disorder

Section Two:Section Two:

Systems Issues - Parallel Systems Issues - Parallel Treatment Systems and Treatment Systems and

Colliding CulturesColliding Cultures

Systems IssuesSystems IssuesCulture clashCulture clash

Different philosophies in mental health and substance Different philosophies in mental health and substance abuse treatment have resulted in the development of abuse treatment have resulted in the development of parallel but not intersecting treatment systems with parallel but not intersecting treatment systems with different funding streams, mandates and treatments. different funding streams, mandates and treatments. Co-Occurring disorders are at the nexus of this culture Co-Occurring disorders are at the nexus of this culture clashclash

Clinical DifferencesClinical Differences

Mental Health TreatmentMental Health Treatment The fundamental approach to clinical education has The fundamental approach to clinical education has not changed appreciably since 1910 (ICM 2000). not changed appreciably since 1910 (ICM 2000). Substance use disorders often are not seen as part of Substance use disorders often are not seen as part of the “care mandate.”the “care mandate.” • Medical model • Emphasis on licensure• Emphasis on minimal self disclosure. • Often treatment can not begin until abstinence is

obtained


Mental Health TreatmentMental Health Treatment • Reluctance to medicate individuals with a

substance use disorder• Psychological treatments offered but with no

substance abuse treatment component• Clinicians often not cross trained in SUD• Individuals with SUD often minimize or not

disclose the mental health disorder


Substance Abuse TreatmentSubstance Abuse Treatment

Based on a peer relationship modelBased on a peer relationship model• Licensure not necessary (changing)• Treatment provider often a recovering individual• Willing to disclose substance abuse history• Often reluctance to allow any medication of any

kind


Substance Abuse TreatmentSubstance Abuse Treatment• Treatment often ignores mental health problems

and focuses on substance abuse• Providers often not cross trained in mental health

treatments• Individuals with substance use disorders often do

not disclose the mental health disorder

Section Three:Section Three:

Assessment and Treatment Assessment and Treatment of Co-Occurring Disorders: of Co-Occurring Disorders:

Integrating CulturesIntegrating Cultures

Assessment and Treatment for Assessment and Treatment for Co-Occurring DisordersCo-Occurring Disorders

The process of screening, assessment, and The process of screening, assessment, and treatment planning should be an integrated treatment planning should be an integrated approach that addresses the substance abuse approach that addresses the substance abuse and mental health disorders, each in the context and mental health disorders, each in the context of the other and neither should be considered of the other and neither should be considered primary. Expect co-occurring disorders as primary. Expect co-occurring disorders as incidence is higher than realized in adolescents. incidence is higher than realized in adolescents. (Myers, Brown, & Ott 1995)(Myers, Brown, & Ott 1995)

Assessment and Treatment of Assessment and Treatment of Co-Occurring DisordersCo-Occurring DisordersAssessment:Assessment:

• Comprehensive biopsychosocial assessment• Assess for substance use disorder using a brief

screening tool in ALL adolescents entering system• Follow up with a comprehensive substance use

disorder assessment for adolescents who present with a co-morbid substance abuse disorder

• Assess for trauma/victimization

Assessment and Treatment of Assessment and Treatment of Co-Occurring DisordersCo-Occurring Disorders

Treatment:Treatment:– Incorporate empirically based treatments for co-occurring

disorders into routine practice– Target most common co-morbidities i.e. Depression, ADHD,

PTSD, CD, Trauma/Victimization– Medication has a place in treating co-morbid disorders,

particularly the internalizing disorders

Assessment and Treatment for Assessment and Treatment for Co-Occurring DisordersCo-Occurring DisordersSubstance use assessment should Substance use assessment should

include:include:• Onset, progression, patterns of use,

frequency, tolerance/withdrawal, triggers.• Assessment for patterns of use of multiple

drugs• Consequences of drug usage• Motivation for treatment • Family history regarding substance use

including extended family

Assessment InstrumentsAssessment Instruments

Screening Instruments:Screening Instruments:• Adolescent Alcohol Involvement Scale• Adolescent Drug Involvement Scale(ADIS)• Problem Oriented Screening Instrument for

Teenagers (POSIT)• Global Appraisal of Individual Needs Short Version—

(GSS) Sample attached.


General Checklists:General Checklists:• Achenbach YSR

• Revised Behavior Problem Checklist.

• Youth Outcome Questionnaire YOQ

• Youth Outcome Questionnaire Self Report YOQ- SR


Substance Use Disorder InterviewsSubstance Use Disorder Interviews::• Adolescent Diagnostic Interview (ADI)• Diagnostic Interview for Children and Adolescents

(DICA)

Comprehensive Assessment Instruments:Comprehensive Assessment Instruments:• Comprehensive Adolescent Severity Inventory

(CASI)• The American Drug and Alcohol Survey (ADAS

classroom use)• Personal Experience Inventory (PEI)• Substance Abuse Subtle Screening Inventory--

SASSI

Section Four:Section Four:

Evidence Based Mental Evidence Based Mental Health Treatments for Health Treatments for Adolescents with Co-Adolescents with Co-Occurring DisordersOccurring Disorders

Evidenced Based TreatmentEvidenced Based Treatment

• “…“…the integration of the best research evidence the integration of the best research evidence with with clinical expertiseclinical expertise and and patient (consumer) patient (consumer) values”values”

• Based on the definition used in “Crossing the Based on the definition used in “Crossing the Quality Chasm: A New Health System for the Quality Chasm: A New Health System for the 21st Century” (2001), by the Institute of 21st Century” (2001), by the Institute of MedicineMedicine

Evidenced Based Mental Evidenced Based Mental Health TreatmentsHealth Treatments

• Evidenced Based TreatmentsEvidenced Based Treatments::• Hold promise for improving outcomes• Have different levels of support• Target specific populations/specific outcomes• Implemented with fidelity to ensure outcomes• Implementation/fidelity/model adherence: A robust

process• Practitioner is responsible for engagement

Evidenced Based Treatments Evidenced Based Treatments for Co-Occurring Disordersfor Co-Occurring Disorders

• Family Treatments Family Treatments • Cognitive Behavioral TreatmentsCognitive Behavioral Treatments• Parenting ProgramsParenting Programs• Substance Abuse TreatmentSubstance Abuse Treatment• Out of Home PlacementOut of Home Placement

Evidenced Based Mental Health Evidenced Based Mental Health Treatments that have Treatments that have demonstrated success with Co-demonstrated success with Co-Occurring DisordersOccurring Disorders

• Adolescent Transitions ProgramAdolescent Transitions Program• Aggression Replacement Treatment (ART)Aggression Replacement Treatment (ART)• Brief Strategic Family Therapy (BFST)Brief Strategic Family Therapy (BFST)• Family Behavior Therapy (FBT)Family Behavior Therapy (FBT)• Functional Family Therapy (FFT)Functional Family Therapy (FFT)

Evidence-Based Mental Health Evidence-Based Mental Health Programs that have demonstrated Programs that have demonstrated Success with Co-Occurring Success with Co-Occurring DisordersDisorders

• Motivational InterviewingMotivational Interviewing• Multidimensional Family Therapy (MDFT)Multidimensional Family Therapy (MDFT)• Multidimensional Treatment Foster Care Multidimensional Treatment Foster Care (MTFC)(MTFC)• Multisystemic Therapy (MST)Multisystemic Therapy (MST)• Seeking SafetySeeking Safety• Strengthening FamiliesStrengthening Families• Integrated Co-Occurring Treatment (ICT) Integrated Co-Occurring Treatment (ICT)

Common Characteristics of Common Characteristics of Family TherapiesFamily Therapies

• Family change is necessary for child successFamily change is necessary for child success• Multidimensional approach Multidimensional approach

• Individual, Family, Peers, School/Other Institutions, Community

• Time Limited Brief – 1mo. to 1 yr.Time Limited Brief – 1mo. to 1 yr.• Targeted-Problem FocusedTargeted-Problem Focused• Effect child by impacting family interactions & structureEffect child by impacting family interactions & structure• Present focused & pragmaticPresent focused & pragmatic

Common Characteristics of Common Characteristics of Family TherapiesFamily Therapies

• Utilize other empirically supported approachesUtilize other empirically supported approaches• Sequenced treatment – i.e. Phases/StagesSequenced treatment – i.e. Phases/Stages

• Engagement Strategies - Increasing hope-decreasing negativity

• Change – Practical, logical, research support,• Generalization – Family empowerment, linkage,

relapse prevention • Flexible Delivery – Home, Office, School, Community-Flexible Delivery – Home, Office, School, Community-

based. based. • Individualized – Tailored - FlexibleIndividualized – Tailored - Flexible• 20-25 years of iterative research development 20-25 years of iterative research development

Family Therapy Family Therapy Brief Strategic Family TherapyBrief Strategic Family Therapy(BSFT)(BSFT)

• Targets child/adolescents 8-17 years exhibiting, or at risk Targets child/adolescents 8-17 years exhibiting, or at risk of behavior problems including substance abuseof behavior problems including substance abuse

• Improve Child’s Behavior by Improving Family Improve Child’s Behavior by Improving Family InteractionsInteractions

Brief Strategic Family Therapy Brief Strategic Family Therapy

OutcomesOutcomes• 42% Reduction Behavior Problems42% Reduction Behavior Problems• 75% Reduction Marijuana use75% Reduction Marijuana use• 58% Reduction Association with Antisocial Peers58% Reduction Association with Antisocial Peers• 75% Client Retention75% Client Retention• Reduces RecidivismReduces Recidivism• Improves Family RelationshipsImproves Family Relationships

Brief Strategic Family TherapyBrief Strategic Family Therapy

• Severe Conduct Disorder and Substance Abuse 24-30 Severe Conduct Disorder and Substance Abuse 24-30 SessionsSessions

• Jose Szapocznik PhD - Spanish Family Guidance Jose Szapocznik PhD - Spanish Family Guidance Center, Center for Family Studies, University of MiamiCenter, Center for Family Studies, University of Miami

Family therapyFamily therapyFamily Behavior Therapy (FBT)Family Behavior Therapy (FBT)

Outpatient behavioral treatment aimed at reducing drug Outpatient behavioral treatment aimed at reducing drug and alcohol use in adults and youth along with common and alcohol use in adults and youth along with common co-occurring problem behaviors such as depression, co-occurring problem behaviors such as depression, family discord, school and work attendance, and family discord, school and work attendance, and conducts problems in youth.conducts problems in youth.

• Participants attend sessions with parent/guardianParticipants attend sessions with parent/guardian

Family Behavior TherapyFamily Behavior Therapy• 90 min. weekly sessions gradually decrease to 60 min. 90 min. weekly sessions gradually decrease to 60 min.

monthly with participants progress in therapymonthly with participants progress in therapy• Behavioral contracting to establish an environment that Behavioral contracting to establish an environment that

facilitates reinforcement for performance of behaviors that are facilitates reinforcement for performance of behaviors that are associated with abstinence from drugsassociated with abstinence from drugs

• Implementation of skill-based interventions to assist in Implementation of skill-based interventions to assist in spending less time with individuals and situations that involve spending less time with individuals and situations that involve drug use and other problem behaviors.drug use and other problem behaviors.

• Skills training to assist in decreasing urges to use drugs and Skills training to assist in decreasing urges to use drugs and other impulsive behavior problemsother impulsive behavior problems

• Communication skills training to assist in establishing social Communication skills training to assist in establishing social relationships with others who do not use substances and relationships with others who do not use substances and effectively avoiding substance abusers.effectively avoiding substance abusers.

Family Behavior TherapyFamily Behavior Therapy

• PopulationsPopulations• Adolescents ages 13 to 17Adolescents ages 13 to 17• Young adults ages 18 to 25Young adults ages 18 to 25• Adults ages 26 to 55Adults ages 26 to 55• Male and FemaleMale and Female

• Races: White, Black or African American, Hispanic or Races: White, Black or African American, Hispanic or

Latino, Race/ethnicity unspecifiedLatino, Race/ethnicity unspecified..


• Decreases illicit drug useDecreases illicit drug use• Decreases frequency of alcohol useDecreases frequency of alcohol use• Improves quality of Family relationshipsImproves quality of Family relationships• Reduces symptoms of DepressionReduces symptoms of Depression• Reduces symptoms of Conduct DisorderReduces symptoms of Conduct Disorder• Improves School / Employment attendanceImproves School / Employment attendance


• Bradley Donohue, Ph.D. Associate ProfessorBradley Donohue, Ph.D. Associate Professor• University of Nevada, Las VegasUniversity of Nevada, Las Vegas

– E-mail: [email protected]


Family TherapyFamily TherapyFunctional Family Therapy Functional Family Therapy (FFT)(FFT)

• Targets Youth 11-18 yrs at risk/ presenting behavior Targets Youth 11-18 yrs at risk/ presenting behavior problems, substance abuse, conduct disorderproblems, substance abuse, conduct disorder

• Demonstrates strong outcomesDemonstrates strong outcomes• Reduces recidivism from 25-60%• Reduction in violent behavior• Reduces siblings’ entry into high risk behaviors

Functional Family TherapyFunctional Family Therapy

• Low drop out from treatmentLow drop out from treatment

• Reduces family conflictReduces family conflict

• Improves family communicationImproves family communication

• Improves parentingImproves parenting


• Therapist assumes responsibility for Treatment Therapist assumes responsibility for Treatment Phases Phases

• Engagement• Motivation• Assessment• Change behavior• Generalize


• Average duration of service is 3-4 monthsAverage duration of service is 3-4 months• 8-30 sessions of direct service

• Full time therapist will serve 12-15 families at one timeFull time therapist will serve 12-15 families at one time• Site certification and trainingSite certification and training

• James Alexander PhD – University of UtahJames Alexander PhD – University of Utah

Family TherapyFamily TherapyIntegrated Co-Occurring Treatment Integrated Co-Occurring Treatment Model (ICT)Model (ICT)

• Four main areas of focusFour main areas of focus• Basic needs and safety• Individual functioning• The family system• Community connections and supports

• Integrated Co-Occurring Treatment Model is a home Integrated Co-Occurring Treatment Model is a home based intervention using system of care service philosophy based intervention using system of care service philosophy but adapted to youth with co-occurring disorders.but adapted to youth with co-occurring disorders.

• Integrated treatment approach a Integrated treatment approach a singlesingle provider provider addresses both the mental and the substance abuse needs addresses both the mental and the substance abuse needs of the adolescent.of the adolescent.

Integrated Co-occurring Integrated Co-occurring TreatmentTreatmentICTICT

• ICT utilizes a stage wise approach, (engagement, ICT utilizes a stage wise approach, (engagement, persuasion, active treatment and relapse prevention) persuasion, active treatment and relapse prevention)

• Uses motivational interviewing to facilitate readiness for Uses motivational interviewing to facilitate readiness for change. The provider also assesses the family’s change. The provider also assesses the family’s readiness and stage of change, as well as the readiness and stage of change, as well as the community’s readiness to receive the youth into the community’s readiness to receive the youth into the community. community.

• Intensive service delivery is consistent with philosophy of Intensive service delivery is consistent with philosophy of home-based interventionhome-based intervention

• Flexible work hours to meet on call availability 24/7Flexible work hours to meet on call availability 24/7

Integrated Treatment for Co-Integrated Treatment for Co-Occurring DisordersOccurring Disorders

• Time limited 4 to 6 monthsTime limited 4 to 6 months• Small case loadsSmall case loads• Collaborative relationships with other child/family serving Collaborative relationships with other child/family serving

systemssystems• Advocacy and system navigationAdvocacy and system navigation• Comprehensive mix of treatment/case managementComprehensive mix of treatment/case management• Provision of services where youth and family live and Provision of services where youth and family live and

functionfunction• Helen K. Cleminshaw , Richard Shepler : Center for Helen K. Cleminshaw , Richard Shepler : Center for

Family Studies , The University of Akron. Family Studies , The University of Akron.

Family TherapyFamily TherapyMultidimensional Family TherapyMultidimensional Family TherapyMDFTMDFT

• Targets Adolescents (11-18 years) with drug and Targets Adolescents (11-18 years) with drug and behavior problems. behavior problems.

• Outcomes include improvements in: Outcomes include improvements in: • Rates of drug Use {42%-70% abstinent at follow-

up} • Behavior Problems• School Performance• Family Functioning

Multidimensional Family TherapyMultidimensional Family Therapy• School Improvement School Improvement

• Attend/Passing grades:

– 43% MDFT - 17% Family Group Therapy - 7% Group Tx

• Improves Family Functioning Improves Family Functioning

• Less conflict/More cohesion

• Prevention OutcomesPrevention Outcomes

• Improves MH SymptomsImproves MH Symptoms

• 30-80% reductions Depression, Anxiety, Conduct

• Stronger outcomes w/Co-Occurring conditions compared to CBT

• Lower Recidivism & Association w/Delinquent PeersLower Recidivism & Association w/Delinquent Peers

• Superior outcomes to Family Group Therapy, Peer Superior outcomes to Family Group Therapy, Peer Group Therapy, and Residential TreatmentGroup Therapy, and Residential Treatment

• Superior outcomes to Residential Treatment for Superior outcomes to Residential Treatment for Adolescents with Co-Occuring Conditions at 1 yr follow Adolescents with Co-Occuring Conditions at 1 yr follow upup

• Howard Liddle PhD – University of MiamiHoward Liddle PhD – University of Miami

Multidimensional Family TherapyMultidimensional Family Therapy

Family Therapy Family Therapy Multisystemic Therapy (MST)Multisystemic Therapy (MST)

A family and community-based treatment for adolescents A family and community-based treatment for adolescents presenting serious antisocial behavior and who are at presenting serious antisocial behavior and who are at imminent risk of out-of-home placement. imminent risk of out-of-home placement.

Wraparound approachWraparound approach

Multisystemic TherapyMultisystemic TherapyIntensive Family / Community Based TreatmentIntensive Family / Community Based Treatment

• Targets chronic, violent, or substance abusing offenders at high risk of out of home placements, and their families

• Outcomes: » Decrease in Substance Use and

Psychiatric Symptoms» 25-70% Reduction Arrest Rates» 47-64% Reduction Out of Home Placement » Improves Family Functioning» Improved School Performance

Multisystemic TherapyMultisystemic Therapy

• Interventions aim to : Interventions aim to : • Improve Caregiver discipline practices• Enhance family affective relationships• Decrease association with deviant peers• Increase association with prosocial peers• Improve school/vocational performance• Prosocial recreational outlets• Develop indigenous support network – family, friends,

neighbors, etc.

Multisystemic TherapyMultisystemic Therapy

• SAMHSA’s National Registry of Evidence-based SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP) Programs and Practices (NREPP)

• Scott W. Henggeler, Ph.D.Scott W. Henggeler, Ph.D.• Dept of Psychiatry and Behavioral SciencesDept of Psychiatry and Behavioral Sciences• Medical University of South CarolinaMedical University of South Carolina• E-mail: E-mail: [email protected]@musc.edu


Characteristics of Cognitive Characteristics of Cognitive Behavioral TreatmentsBehavioral Treatments

• Cognitive Behavioral Therapy is a general term for treatments Cognitive Behavioral Therapy is a general term for treatments based on the premise that thoughts influence behavior. based on the premise that thoughts influence behavior.

• CBT is briefer and time-limited. • It is highly instructive in nature and makes use of

homework. • The fundamental premise is that people can learn to

think differently and act on that learning. • CBT is structured and directive.

• Many of the treatments listed use both family therapy Many of the treatments listed use both family therapy techniques and CBT or other techniquestechniques and CBT or other techniques

Cognitive BehavioralCognitive BehavioralAggression Replacement Training Aggression Replacement Training (ART)(ART) • Assumes aggression is related to Assumes aggression is related to

• Weak or absent personal, interpersonal and social-cognitive skills for pro-social behavior

• Impulsive and over reliance on aggressive means to meet daily needs

• More egocentric and concrete moral reasoning• Consists of three coordinated componentsConsists of three coordinated components

• Skillstreaming - Anger control training - Moral reasoning Arnold Goldstein, Eva Feindler

Cognitive Behavioral Therapy:Cognitive Behavioral Therapy:ART-Anger Control TrainingART-Anger Control Training

Eva Feindler PhDEva Feindler PhD • Teaches youth alternatives to aggression• An emotion oriented component• Involves modeling, guided practice, performance feedback, and

homework• Youth are taught to respond to provocations

– Triggers– Cues– Reducers– Reminders– Use of appropriate skillstreaming alternatives– Self evaluation

Cognitive Behavioral Therapy:Cognitive Behavioral Therapy:ART - SkillstreamingART - Skillstreaming

Barry Goldstein PhDBarry Goldstein PhD• Procedures to enhance pro-social skill levels• Small group instruction• 50 pro-social skills• Modeling “expert” use of the behaviors• Guided opportunities to practice and role-play• Provided performance feedback; praise, re-

instruction and feedback• Transfer training; encouraged to practice and use in

real world situations

Cognitive Behavioral Therapy:Cognitive Behavioral Therapy:ART - Moral Reasoning TrainingART - Moral Reasoning Training

• Group discussion of moral dilemmasGroup discussion of moral dilemmas• Group rulesGroup rules• Group processGroup process

– Introduce the problem situation– Cultivate mature morality– Remediate moral development delays– Consolidate mature morality

Cognitive Behavioral Cognitive Behavioral Seeking SafetySeeking Safety

• A present-focused treatment for clients with a history of A present-focused treatment for clients with a history of trauma and substance abuse. The treatment was trauma and substance abuse. The treatment was designed for flexible use: group or individual format, designed for flexible use: group or individual format, male and female clients, and a variety of settings. (i.e., male and female clients, and a variety of settings. (i.e., outpatient, inpatient residential). outpatient, inpatient residential).

• Treatment and intervention focuses on coping skills and Treatment and intervention focuses on coping skills and psychoeducation and has five key principles.psychoeducation and has five key principles.

Seeking Safety PopulationSeeking Safety Population

• Adolescents ages 13-17Adolescents ages 13-17• Young adults ages 18-25Young adults ages 18-25• Adults ages 26-55Adults ages 26-55• Male and FemaleMale and Female• Races: American Indian/Alaska Native, Asian American, Races: American Indian/Alaska Native, Asian American,

Black or African American, Hispanic or Latino, Black or African American, Hispanic or Latino, Race/ethnicity unspecified, White.Race/ethnicity unspecified, White.

Seeking SafetySeeking Safety

OutcomesOutcomes• Reduces Substance abuseReduces Substance abuse

• Improved trauma-related symptomsImproved trauma-related symptoms

• Improved psychopathologyImproved psychopathology

• Increased treatment retentionIncreased treatment retention

Seeking Safety Seeking Safety

• SAMHSA’s National Registry of Evidence-based SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP) Programs and Practices (NREPP)

• Lisa M. Najavits, Ph.D.Lisa M. Najavits, Ph.D.– Director, Treatment Innovations– Professor of Psychiatry, Boston University School of

Medicine– Lecturer, Harvard Medical School

• E-mail: [email protected]


Parenting ProgramParenting ProgramAdolescent Transitions ProgramAdolescent Transitions Program

• Outcomes Outcomes – Reduces Negative Parent/Child Interaction– Decreases Antisocial Behavior at School– Reduces Smoking at 1 Year Follow Up

Adolescent Transitions ProgramAdolescent Transitions Program

• School-based Universal, Selected, IndicatedSchool-based Universal, Selected, Indicated

• Twelve Group and Four Family MeetingsTwelve Group and Four Family Meetings

• Social Learning Theory – Skill Development Social Learning Theory – Skill Development

Parent TrainingParent TrainingAdolescent Transitions ProgramAdolescent Transitions Program

• Outcomes Outcomes • Reduces Negative Parent/Child Interaction• Decreases Antisocial Behavior at School• Reduces Smoking at 1 Yr Follow Up

• Thomas Dishion PhD, Kate Kavanaugh PhD – University of OregonThomas Dishion PhD, Kate Kavanaugh PhD – University of Oregon

• Parenting ProgramParenting Program• Targets high-risk children 6-12 yrs / parentsTargets high-risk children 6-12 yrs / parents• Created for children of parents with AODCreated for children of parents with AOD• Improves Parenting Skills, Child Social Behavior, and Improves Parenting Skills, Child Social Behavior, and

Family RelationshipsFamily Relationships• Decreases Parent/Child Substance Use, Child Decreases Parent/Child Substance Use, Child

Behavior Problems, Parent/Child DepressionBehavior Problems, Parent/Child Depression• Up to 2-year longitudinalUp to 2-year longitudinal

Parenting ProgramsParenting ProgramsStrengthening Families ProgramStrengthening Families Program

Parenting ProgramParenting ProgramStrengthening Families ProgramStrengthening Families Program

• Adapted: African American, Asian/Pacific Islander, Adapted: African American, Asian/Pacific Islander, Hispanic, Native American, Rural FamiliesHispanic, Native American, Rural Families

• Adapted to 10-14 year olds ( V.Molgaard) Adapted to 10-14 year olds ( V.Molgaard) • Three Part Curriculum – Parenting Skills, Child Skills, Three Part Curriculum – Parenting Skills, Child Skills,

Family Life Skills – 14 sessionsFamily Life Skills – 14 sessions• Separate Parent and Child Groups Separate Parent and Child Groups • Combined Parent and Child GroupCombined Parent and Child Group• Karol Kumpfer PhD – University of UtahKarol Kumpfer PhD – University of Utah

Substance AbuseSubstance AbuseTreatment Motivational Enhancement Treatment Motivational Enhancement Therapy and Cognitive Behavioral Therapy Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users: 5 or 7 for Adolescent Cannabis Users: 5 or 7 Sessions,Sessions,

• Substance abuse treatment protocol tested with Substance abuse treatment protocol tested with Cannibis abusers but can be used with other SUD. Cannibis abusers but can be used with other SUD.

• These brief treatments can be transposed easily to These brief treatments can be transposed easily to the mental health setting.the mental health setting.

Substance Abuse TreatmentSubstance Abuse Treatment

• Manualized treatment protocolsManualized treatment protocols• Five or seven sessions Five or seven sessions • Combines motivational enhancement and cognitive Combines motivational enhancement and cognitive

behavioral treatment.behavioral treatment.• Sampl, S., & Kadden, R. (Free)Sampl, S., & Kadden, R. (Free)• Cannabis Youth Treatment SeriesCannabis Youth Treatment Series• SAMSHASAMSHA

Substance Abuse Treatment Substance Abuse Treatment Motivational InterviewingMotivational Interviewing • Engagement in Treatment -- Readiness for Change Engagement in Treatment -- Readiness for Change • Based on a theory of stages of change. Motivational Interviewing is Based on a theory of stages of change. Motivational Interviewing is

a directive, client centered counseling style for eliciting behavior a directive, client centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. It is change by helping clients to explore and resolve ambivalence. It is focused and goal directed. focused and goal directed. – Stage One—Pre-contemplation Stage—Not thinking about

making a change– Stage Two- Contemplation State- Unsure about what to do—

often want to change, but want to stay the same– Stage Three- Action Stage—People begin to implement their

“change plans”– State Four- Maintenance Stage-People try to sustain the

changes.

Out of Home CareOut of Home CareMultidimensional Treatment Multidimensional Treatment Foster CareFoster Care

• Targets Adolescents with Delinquency and their Targets Adolescents with Delinquency and their Families. Families.

• Alternative to Group Home Placement and IncarcerationAlternative to Group Home Placement and Incarceration

Evidence-based Practices – Out-of-Evidence-based Practices – Out-of-Home CareHome CareMultidimensional Treatment Foster CareMultidimensional Treatment Foster Care

OutcomesOutcomes• Fewer arrests (less than half the rate of the control Fewer arrests (less than half the rate of the control

group)group)• Fewer days incarceration and group home placementFewer days incarceration and group home placement• Greater completion of treatment - fewer AWOLsGreater completion of treatment - fewer AWOLs• Improved school performanceImproved school performance• Less hard drug useLess hard drug use• Improved emotional well beingImproved emotional well being

Evidence-based Practices – Out-of-Evidence-based Practices – Out-of-Home CareHome CareMultidimensional Treatment Foster CareMultidimensional Treatment Foster Care• Youth is placed in a Therapeutic Foster HomeYouth is placed in a Therapeutic Foster Home

– One youth per home– 24/7 support for foster parent and natural parents

• Youth receive weekly individual therapy with focus on Youth receive weekly individual therapy with focus on developing effective:developing effective:– Problem solving skills-Social skills-Emotional regulation

skills• Foster Parent and Team Meetings WeeklyFoster Parent and Team Meetings Weekly• Parent Daily Report – Child Behavior / Foster Parent StressParent Daily Report – Child Behavior / Foster Parent Stress• Parents attend weekly family therapy with focus on effective Parents attend weekly family therapy with focus on effective

parenting and family managementparenting and family management

Evidence-based Practices – Evidence-based Practices – Multidimensional Treatment Multidimensional Treatment Foster CareFoster Care

• Public school, with daily monitoring of attendance Public school, with daily monitoring of attendance and performanceand performance

• Strict Adherence to Roles: Foster Parent, Care Strict Adherence to Roles: Foster Parent, Care Manager, Individual Therapist, Family Therapist, Manager, Individual Therapist, Family Therapist, Skills Trainer, Recruiter/CallerSkills Trainer, Recruiter/Caller

• Patricia Chamberlain PhD – Oregon Social Learning Patricia Chamberlain PhD – Oregon Social Learning CenterCenter

Section Five:Section Five:

RecommendationsRecommendations

Recommendations Recommendations • Assessment format that includes standardized SUD Assessment format that includes standardized SUD

instruments, screening & comprehensive when instruments, screening & comprehensive when indicated:indicated:• GAIN-Short Form• Adolescent Diagnostic Interview (ADI)

• Family Treatment ProgramsFamily Treatment Programs• Integrated Community Treatment• Multidimensional Family Treatment• Multisystemic Therapy

• Preventive ProgramPreventive Program• Strengthening Families

RecommendationsRecommendations• Out of Home CareOut of Home Care

• Multidimensional Treatment Foster Care• Social Skills Training Social Skills Training

• Aggression Replacement Therapy• Substance Abuse Treatment Substance Abuse Treatment

• Motivational Interviewing• Motivational Enhancement and Cognitive

Behavioral Therapy (5 or 7 sessions)• Trauma Treatment TherapyTrauma Treatment Therapy

• Seeking Safety

Websites:Websites:• http://www.nida.nih.gov/http://www.nida.nih.gov/• www.kap.samhsa.gov The Cannabis Youth Treatment Protocolwww.kap.samhsa.gov The Cannabis Youth Treatment Protocol• http://coce.samhsa.gov/productshttp://coce.samhsa.gov/products• http://www.healthfinder.govhttp://www.healthfinder.gov• http://www.kap.samhsa.gov/products/manuals/tips/indexhttp://www.kap.samhsa.gov/products/manuals/tips/index• http://www.ndri.org/search/search.http://www.ndri.org/search/search.• http://www.ncmhjj.com/resource_kithttp://www.ncmhjj.com/resource_kit• http://mentalhealth.samhsa.gov/publications/allpubshttp://mentalhealth.samhsa.gov/publications/allpubs• http://www.ncbi.nlm.nih.gov/bookshttp://www.ncbi.nlm.nih.gov/books• http://www.vera.org/publications/publicationshttp://www.vera.org/publications/publications• http://www.motivationalinterview.org/http://www.motivationalinterview.org/• http://www.mid-attc.org/http://www.mid-attc.org/• http://http://www.seekingsaftey.orgwww.seekingsaftey.org • http://www.unlv.edu/centers/achievementhttp://www.unlv.edu/centers/achievement• http://http://www.fftinc.comwww.fftinc.com• http://www. Motivational.interview.orghttp://www. Motivational.interview.org

http://www.nida.nih.gov/

http://www.mid-attc.org/

http://www.seekingsaftey.org/

http://www.seekingsaftey.org/

http://www.unlv.edu/centers/achievement

http://www.fftinc.com/

Co-Occurring Disorders, Best Co-Occurring Disorders, Best Practice and AdolescentsPractice and Adolescents

• Please if you have any questions regarding this Please if you have any questions regarding this webcast please email webcast please email [email protected]@cimh.org

• To unmute your phones by pressing #6 once the To unmute your phones by pressing #6 once the training has ended. Thank you for your training has ended. Thank you for your participation.participation.

• All questions will be answered at the end, so All questions will be answered at the end, so please email Maria Lovato at please email Maria Lovato at [email protected]@cimh.org



The EndThe End

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Co-Occurring Disorders, Best Practices and Adolescents Webcast Thursday June 26, 2008 11:00 AM – 12:30 PM Dial-in Number: (866) 633-8010 Conference