Module 7 Treatment Knowledge - UI Health Care science, education and ... Self-Monitoring Feedback Form ... Module 7 Module 7 –– Treatment Knowledge Module 8 – Referral,

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Unifying science, education and service to transform lives

Toolbox Training: A Substance Abuse Educational Series 2 of 40 For Mental Health Professionals First Edition

Module 7 – Treatment Knowledge

Goals and Objectives Listed below are the goals and objectives of the module and the corresponding TAP 21 competencies.

Module 7 Goals and Objectives

SAMHSA CSAT TAP 21 Competencies

Treatment Knowledge Goal: Introduce treatment and recovery models from a co-occurring specific perspective to include counseling theory, techniques, and relapse prevention perspectives. Objectives: 1. Define Evidence Based, Consensus

Based, and Best Practice; 2. Discuss the impact of the therapeutic

relationship and treatment alliance; 3. Develop co-occurring skills in best

practices implementation to include: Behavioral, Cognitive Behavioral, Cue Exposure, Contingency Management, Coping Skills, Cognitive Restructuring, Relapse Prevention, Motivational Interviewing, Stages of Change, and Pharmacological Therapy.

Transdisciplinary Foundations (TF) B. Treatment Knowledge

1. Describe the philosophies, practices, policies, and outcomes of the most generally accepted and scientifically supported models of treatment, recovery, relapse prevention, and continuing care for addiction and other substance-related problems. 2. Recognize the importance of family, social networks, and community systems in the treatment and recovery process. 3. Understand the importance of research and outcome data and their application in clinical practice. 4. Understand the value of an interdisciplinary approach to addiction treatment.

C. Application to Practice 1. Understand the established diagnostic criteria for substance use disorders and describe treatment modalities and placement criteria within the continuum of care. 2. Describe a variety of helping strategies for reducing the negative effects of substance use, abuse, and dependence. 3. Tailor helping strategies and treatment modalities to the client’s stage of dependence, change, or recovery. 4. Provide treatment services appropriate to the personal and cultural identity and language of the client. 5. Adapt practice to the range of treatment settings and modalities. 6. Be familiar with medical and pharmacological resources in the treatment of substance use disorders. 7. Understand the variety of insurance and health maintenance options available and the importance of helping clients access those benefits. 8. Recognize that crisis may indicate an underlying substance use disorder and may be a window of opportunity for change. 9. Understand the need for and the use of methods for measuring treatment outcome.



Module 7 – Treatment Knowledge Pre-session Assignment

All participants to read: Bednar, S.G. (2003). Substance Abuse and Woman Abuse—A Proposal for Integrated

Treatment. Federal Probation, 67, 52-58.

Be prepared to reflect on and discuss this article at the training session. Elective article: Walton-Moss, & B., McCaul, M.E. (2006). Factors Associated with Lifetime History of Drug

Treatment Among Substance Dependent Women. Addictive Behaviors, 31, 243-253.



Module 7 – Treatment Knowledge Agenda

ADDICTION COUNSELOR TRAINING SERIES

Treatment Knowledge

AGENDA

14-Nov-07 8:30 AM registration 9:00 AM Treatment Knowledge 10:30 AM break 10:45 AM Treatment Knowledge noon lunch 1:00 AM Treatment Knowledge

2:15 AM Referral, Service Coordination, and Documentation

3:30 AM break


4:30 AM close 15-Nov-07 8:30 AM registration


11:00 AM break

11:15 AM Professional Readiness: Attitudes and Values

noon lunch

1:00 PM Professional Readiness: Attitudes and Values

2:45 PM break


4:30 PM close



Module 7: Handout – A Review Module 4, 5, and 6 Clinical Evaluation: Screening, Assessment and Treatment Planning

Fill-in-the-Blank



Module 7: Handout – B Review Module 4, 5, and 6 Clinical Evaluation: Screening, Assessment and Treatment Planning



Module 7: Handout – C Review Module 4, 5, and 6 Clinical Evaluation: Screening, Assessment and Treatment Planning



Module 7 – Handout 1 Group Exercise:

Self-Monitoring Feedback Form

Example completed Self-Monitoring Feedback Form: Day Time What Who Where Thoughts Feelings Consequences

Sat 10:00 am

Beer Alone Bar I’m worthless

Sad Jail

Sun 9:30 am

Wine Alone Kitchen I hate people

telling me what to do.

Sad My family went to the park without

me.

For Exercise:

Divide into pairs.

Choose one person to role play a client in recovery. Consider modeling a client you have worked with ensuring confidentiality.

The alternate person will role play the clinician.

Client: take a few minutes to complete the Self-Monitoring Feedback Form on the next page. This form would have been discussed with the client in the previous session and completed as homework.

Initiate a face-to-face session reviewing the Self-Monitoring Feedback Form as a guide for discussion.



Module 7 – Handout 1 (continued)


Day

Time

What

Who

Where

Thoughts

Feelings

Consequences



Module 7 – Handout 2 Group Exercise:

Primary Locus of Care by Severity

Individually, write a short example from your therapeutic experiences of “one” of the four quadrants from the “Primary Locus of Care by Severity”

You will have ten minutes to complete this portion of the exercise.

In small groups of three share your example and discuss whether you believe your client was appropriate placed defending your assessment.



Module 7 – Handout 2 (continued) Group Exercise:


High

Sev

erity

Low Severity High Severity

A lco

hol a

nd o t

her d

rug a

buse

Mental Illness

High

Sev

erity


A lco

hol a

nd o t

her d

rug a

buse

Mental Illness



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Unifying science, education and service to transform livesUnifying science, education and service to transform lives

Toolbox Training: Toolbox Training: A Substance Abuse Educational Series for A Substance Abuse Educational Series for Mental Health ProfessionalsMental Health Professionals

Module 7 Module 7 –– Treatment KnowledgeTreatment KnowledgeModule 8 Module 8 –– Referral, Service coordination and Documentation Referral, Service coordination and Documentation Module 9 Module 9 –– Professional Readiness/Attitudes and ValuesProfessional Readiness/Attitudes and Values

November 14-15, 2007

Content guided : Candace Peters, MA, CADC

2007 SeriesSeptember 12-13October 17-18November 14-15December 12-13

Toolbox Training: A Substance Abuse Educational Series Module 7 – Treatment Knowledge Module 8 – Referral, Service coordination and Documentation Referral Module 9 – Professional Readiness/Attitudes and Values November 14-15, 2007 Content guided by: Candace Peters, MA, CADC

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Prairielands ATTC Toolbox Training: A Substance Abuse Series for Mental Health Professionals -- October 17-18, 2007

Welcome

Anne Helene Skinstad, PhD– Project Director

Candace Peters, MA, CADC– Director of Training

Ros Hayslett– Projects Coordinator

Duane Mackey, EdD– Native American Initiative Regional Coordinator

Peter Nathan, PhD– Faculty Consultant, University of Iowa

Ken Winters, PhD– Faculty Consultant, University of Minnesota

Welcome Prairielands Addiction Technology Transfer Center

Anne Helene Skinstad, PhD Project Director Candace Peters, MA, CADC Director of Training

Ros Hayslett Projects Coordinator

Duane Mackey, EdD Native American Initiative Regional Coordinator Peter Nathan, PhD Faculty Consultant Ken Winters, PhD Faculty Consultant



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Announcements & Logistics

Logistics

Announcements: – Sign-in beginning of first day and sign-out end of second day– Lunch will be served at noon– Self-care

Course Expectations: Interactive participation– Small group discussion– Role play– Large group discussion– Journal article review– Module review exercises

Evaluation Forms– GPRA: Consent, Pre, Customer Survey, Follow-up– Iowa Consortium on Mental Health Evaluation

Announcements & Logistics

Logistics Announcements: Complete forms at beginning of session

Sign-in Consent ATTC National Pre-Event Form

Complete forms at end of session Sign-out ATTC Network Customer Survey—Training IA Consortium Evaluation

Participants will receive “Follow-up” survey within 30 days of session completion

ATTC Network Customer Survey—Training Follow-up

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Prairielands ATTC Toolbox Training Module 3 Clinical Eval: Screening

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This Series is Designed To:Prepare participants for the certification examinationEnhance knowledge for existing addiction counselorsImprove overall counselor competence and treatment outcomeIntroduce Technical Assistance Publication (TAP) #21

LimitationsThis Training Series is designed as a broad overview.Previous education or training is necessary in order to pass the certification exam.Each module covers a wide range of concerns issues.Some topics are addressed only briefly.You are responsible to seek additional preparatory help if necessary.

Series Design This Series is Designed To:

Enhance participant co-occurring substance abuse and mental health knowledge

Enhance knowledge for existing addiction counselors

Improve overall counselor competence and treatment outcome

Introduce Technical Assistance Publication (TAP) #21 Introduce the National Institute on Drug Abuse’s

(NIDA) Principles of Drug Addiction Treatment: A Research-Based Guide

Limitations

This Training Series is designed as a broad overview. Previous education or training is necessary Each module covers a wide range of topics and

some topics are addressed only briefly. You are responsible to seek additional preparatory

help if necessary.



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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge

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Module Series

1. The Addiction Complex Simplified2. Basic Counseling Skills 3. Professional and Ethical Responsibilities4. Clinical Evaluation: Screening 5. Clinical Evaluation: Assessment 6. Clinical Evaluation: Treatment Planning 7. Treatment Knowledge 8. Referral, Service Coordination, and Documentation 9. Professional Readiness: Attitudes and Values 10. Counseling Families, Partners, & Significant Others 11. Group Counseling 12. Client, Family, and Community Education

Toolbox Training Module Series

1. The Addiction Complex Simplified: A New Understanding

2. Basic Counseling Skills 3. Professional and Ethical Responsibilities

4. Clinical Evaluation: Screening 5. Clinical Evaluation: Assessment 6. Clinical Evaluation: Treatment Planning

7. Treatment Knowledge 8. Referral, Service Coordination, and

Documentation 9. Professional Readiness: Attitudes and Values

10. Group Counseling 11. Counseling Families, Couples, and Significant

Others 12. Client, Family, and Community Education

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Prairelands ATTC Toolbox Training Module 4 Clinical Eval: Assessment

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Message from SAMHSAEvery day, countless lives are enriched or saved

because of the work carried out by addiction counselors.

In a myriad of settings, competent, well-trained counselors form the relationships and carry out the strategies that help their clients move from life-threatening addiction to life-affirming recovery…

We can state with certainty that thousands of addiction counselors accomplish their missions with distinction.

Message from SAMHSA Every day, countless lives are enriched or saved

because of the work carried out by addiction counselors.

In a myriad of settings, competent, well-trained counselors form the relationships and carry out the strategies that help their clients move from life-threatening addiction to life-affirming recovery…

We can state with certainty that thousands of addiction counselors accomplish their missions with distinction.



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Today’s Presenter’s Anne Helene Skinstad, PhD Project Director, Prairielands ATTCFaculty, The University of Iowa(319) 335 [email protected]

Candace Peters, MA, CADCDirector of Training, Prairielands ATTC(319) 335 [email protected]

Shanita Eze, MA, ADNKirkwood Community College, Iowa City, IA [email protected] Eze is a registered nurse, who also holds a Bachelor of Arts Degree in Psychology and a

Masters of Arts in Education with specialization in Substance Abuse Counseling from the University of Iowa. Shanita has extensive experience working in a variety of settings as a nurse, including the specialties of virology, hematology, and oncology. Shanita has provided Counselor/Case Manager services in office and street environments. She provided service in multiple areas: homeless outreach and case management, women and children, intake/assessment, outpatient, adolescents, group and individual counseling, and residential. In 2004, Shanita was appointed adjunct professor at Kirkwood Community College where she provides instruction to nursing students.

Today’s Presenter Anne Helene Skinstad, PhD Project Director, Prairielands ATTC Faculty, The University of Iowa (319) 335 5368 [email protected] Candace Peters, MA, CADC Director of Training, Prairielands ATTC (319) 335 5368 [email protected] Shanita Eze, MA, ADN Kirkwood Community College, Iowa City, IA [email protected] Shanita Eze is a registered nurse, who also holds a Bachelor of Arts Degree in Psychology and a Masters of Arts in Education with specialization in Substance Abuse Counseling from the University of Iowa. Shanita has extensive experience working in a variety of settings as a nurse, including the specialties of virology, hematology, and oncology. Shanita has provided Counselor/Case Manager services in office and street environments. She provided service in multiple areas: homeless outreach and case management, women and children, intake/assessment, outpatient, adolescents, group and individual counseling, and residential. In 2004, Shanita was appointed adjunct professor at Kirkwood Community College where she provides instruction to nursing students.



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Module 7 – Treatment KnowledgeAgenda

14-Nov-078:30 AM registration9:00 AM Treatment Knowledge10:30 AM break10:45 AM Treatment KnowledgeNoon lunch (served)

1:00 AM Treatment Knowledge2:15 AM Referral, Service Coordination, and Documentation3:30 AM break3:45 AM Referral, Service Coordination, and Documentation4:30 AM close

15-Nov-078:30 AM registration9:00 AM Referral, Service Coordination, and Documentation11:00 AM break11:15 AM Professional Readiness: Attitudes and Valuesnoonlunch1:00 PM Professional Readiness: Attitudes and Values2:45 PM break3:00 PM Professional Readiness: Attitudes and Values4:30 PM close

Agenda See Agenda Handout for more information. 14-Nov-07 8:30 AM registration 9:00 AM Treatment Knowledge 10:30 AM break 10:45 AM Treatment Knowledge noon lunch 1:00 AM Treatment Knowledge


3:30 AM break


4:30 AM close 15-Nov-07 8:30 AM registration


11:00 AM break

11:15 AM Professional Readiness: Attitudes and Values

noon lunch


2:45 PM break


4:30 PM close

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Review Activity

Review Activity: Fill-in-the-blank Module 6: Clinical Evaluation: Treatment Planning Presenter will provide instructions. Refer to Handout A-C.



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Goals and ObjectivesModule 7: Treatment Knowledge

Goal: Introduce treatment and recovery models from a co-occurring specific perspective to include counseling theory, techniques, and relapse prevention perspectives.

Objectives:1. Define Evidence Based, Consensus Based, and Best

Practice; 2. Discuss the impact of the therapeutic relationship and

treatment alliance; 3. Develop co-occurring skills in best practices

implementation to include: Behavioral, Cognitive Behavioral, Cue Exposure, Contingency Management, Coping Skills, Cognitive Restructuring, Relapse Prevention, Motivational Interviewing, Stages of Change, and Pharmacological Therapy.

Module 7: Treatment Knowledge Goals and Objectives: Goal: Introduce treatment and recovery models from a co-occurring specific perspective to include counseling theory, techniques, and relapse prevention perspectives. Objectives: 1. Define Evidence Based, Consensus Based, and Best




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Evidence-Based -- Best Practices

Title Slide: Evidence-Based -- Best Practices



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s. Evidence-Based -- Best Practices

The use of current and best research evidence in making clinical and programmatic decisions about the care of the client.

Evidence-Based -- Best Practices Evidence-Based:

- The use of current and best research evidence in making clinical and programmatic decisions about the care of the client

- Interventions that show consistent scientific evidence being related to preferred client outcomes.

- The use of current and best research evidence In making clinical and programmatic decisions about

the care of the client.

Consensus-based: - Agreement regarding treatment practice

achieved through the general concurrence of treatment practitioners, researchers, clients, and other experts.

- Example— Practice Guidelines in Treating Clients with Co-Occurring Disorders; TIP Manuals

- Determine the strength of available research evidence

- Integrate clinician expertise and client values in development of recommendations

Often times the term “evidence-based” and/or “consensus-based” are utilized when speaking about “best practices” and vice-a-versa.

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What Is Our Goal for Substance Abuse Treatment?

To provide an optimum opportunity for change.

To provide persistent, incremental improvements in the quality and effectiveness of substance abuse treatment which results in better quality recovery for more people.

What Is Our Goal for Substance Abuse Treatment? – Not unlike our goal for Mental Health Treatment!

To provide an optimum opportunity for change.

To provide persistent, incremental improvements

in the quality and effectiveness of substance abuse treatment which results in better quality recovery for more people.



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What Does All This Mean?

We have an opportunity to improve treatment services.There are effective and cost-efficient treatments available for alcohol and drug dependence.

(Institute of Medicine, 1998. Bridging the Gap Between Practice and Research. Washington, DC: National Academy Press)

What Does All This Mean? We have an opportunity to improve treatment

services. There are effective and cost-efficient treatments

available for alcohol and drug dependence. Our challenge is to integrate substance abuse

and mental health services to enhance the opportunity for change in those we serve.

(Institute of Medicine, 1998. Bridging the Gap Between Practice and Research. Washington, DC: National Academy Press)

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Evidence-Based Practice for Addiction Treatment

Cognitive–behavioral interventionsCommunity reinforcementMotivational enhancement therapy12-step facilitationContingency management Pharmacological therapies

1. L. Onken (2002). Personal Communication. National Institute on Drug Abuse.2. Principles of Drug Addiction Treatment: A research-based guide (1999). National Institute on Drug

Abuse

Evidence-Based Practice for Addiction Treatment

Cognitive–behavioral interventions Community reinforcement Motivational Enhancement Therapy 12-step facilitation Contingency Management Pharmacological therapies

1. L. Onken (2002). Personal Communication.

National Institute on Drug Abuse. 2. Principles of Drug Addiction Treatment: A

research-based guide (1999). National Institute on Drug Abuse

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Evidence-Based Practices for Alcohol Treatment

Brief InterventionSocial Skills TrainingMotivational Enhancement and Motivational InterviewingCommunity ReinforcementBehavioral ContractingPharmacological

Miller et al., (1995) What works: A methodological analysis of the alcohol treatment outcome literature. In R. K. Hester & W. R. Miller (eds.) Handbook of Alcoholism Treatment Approaches: Effective Alternatives. (2nd

ed., pp 12 – 44). Boston: Allyn & Bacon.

Evidence-Based Practices for Alcohol Treatment

Brief Intervention Social Skills Training Motivational Enhancement and Motivational

Interviewing Community Reinforcement Behavioral Contracting Pharmacological

Miller, W.R, Brown, J. M., Hester, R.K., Wilbourne, M.S. (1995). What

works: A methodological analysis of the alcohol treatment outcome literature. In Hester, R.K., & Miller, W.R. (Eds.). (2000). Handbook of Alcoholism Treatment Approaches: Effective Alternatives. (2nd ed., pp. 12 – 44). Boston: Allyn & Bacon.



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Evidence Based Practices for Adolescents

Parent Training: Family Check-up Model (Kavanaugh, K., and Dishion, T.J., 2002)

Family TherapyCognitive Behavioral TherapyOut-of-Home CareWhat Doesn’t Work

Evidence Based Practices for Adolescents

Parent Training: Family Check-up Model (Kavanaugh, K., and Dishion, T.J., 2002)

Family Therapy Cognitive Behavioral Therapy Out-of-Home Care

What Doesn’t Work

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Bio-Psycho-Social Model

Assessment– Biological: illness, head injury, allergy,

medications, chronic pain, dental, optical, lice, skin irritations, hearing, physical abuse, liver disease

– Psychological: DSM-IV, domestic abuse

– Social: housing, child care, transportation, legal, family, culture

Bio-Psycho-Social Model Assessment

– Biological: illness, head injury, allergy, medications, chronic pain, dental, optical, lice, skin irritations, hearing, physical abuse, liver disease

– Psychological: DSM-IV, domestic abuse

– Social: housing, child care, transportation,

legal, family, culture

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Therapeutic Relationship

Title Slide – Therapeutic Relationship



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Therapeutic Relationship

Therapeutic Alliance– Definition– Ethical Responsibilities– Power distribution

Therapeutic Relationship Therapeutic Alliance

– Definition – Ethical Responsibilities – Power distribution

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Nature of the Therapeutic Relationship

Experience of working in a team effort: collaboration between client and therapistExperience of Therapist as an opportunity for changeExperience of having an advocate

Nature of the Therapeutic Relationship

Experience of working in a team effort: collaboration between client and therapist

Experience of Therapist as an opportunity for change

Experience of having an advocate

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s. Therapeutic Relationship: Function

Allows the patient to express previously undisclosed emotions and thoughtsInfluences the patient through reinforcement, suggestions, etcProvides the patient with supportModels adaptive interpersonal functioning

Therapeutic Relationship: Function Allows the patient to express previously

undisclosed emotions and thoughts Influences the patient through reinforcement,

suggestions, etc Provides the patient with support Models adaptive interpersonal functioning



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Therapeutic Relationship: Client’s Development

Feeling heard, understood, accepted, respected, and empoweredFeeling the therapist is concernedFeeling the therapist is working with him or her

Therapist realistically optimisticFeeling that positive change is occurringGender and Cultural Effects: Stigma, Primary Parental Role, Domestic Abuse Cycle

Therapeutic Relationship: Client’s Development

Feeling heard, understood, accepted, respected, and empowered

Feeling the therapist is concerned Feeling the therapist is working with him or her

Therapist realistically optimistic Feeling that positive change is occurring Gender and Cultural Effects: Stigma, Primary

Parental Role, Domestic Abuse Cycle

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Therapeutic Relationship: Therapist’s Contributions

EmpathyPositive view of the patient’s motivationMaintaining trust and confidentiality

Therapeutic Relationship: Therapist’s Contributions

Empathy Positive view of the patient’s motivation Maintaining trust and confidentiality

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Group Exercise: Journal Article Review

Group Exercise: Journal Article



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Journal Article Review

Required Reading:Bednar, S.G. (2003). Substance Abuse and Woman Abuse—A Proposal for Integrated Treatment. Federal Probation, 67, 52-58.

Optional Reading:Walton-Moss, B., McCaul, M.E. (2006). Factors Associated with Lifetime History of Drug Treatment Among Substance Dependent Women. Addictive Behaviors, 31, 243-253.

Journal Article Review Required Reading:

Bednar, S.G. (2003). Substance Abuse and Woman Abuse—A Proposal for Integrated Treatment. Federal Probation, 67, 52-58.

Optional Reading:

Walton-Moss, B., McCaul, M.E. (2006). Addictive Behaviors, 31, 243-253.

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Evidence Based – Best Practices (cont)

BehavioralCognitive BehavioralCue ExposureContingency ManagementCoping SkillsCognitive RestructuringRelapse PreventionMotivational InterviewingStages of ChangePharmacological

Evidence Based – Best Practices Behavioral Cognitive Behavioral Cue Exposure Contingency Management Coping Skills Cognitive Restructuring Relapse Prevention Motivational Interviewing Stages of Change Pharmacological

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Behavioral and

Cognitive Behavioral

Title Slide - Behavioral and Cognitive Behavioral



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Behavioral

Substance abuse is an interplay of internal states, behaviors, and environment

Nothing is entirely “biological”

Looking at behavior and environment leads to optimism about treatment

Behavioral Substance abuse is an interplay of internal states,

behaviors, and environment

Nothing is entirely “biological”

Looking at behavior and environment leads to optimism about treatment

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1 Ounce of Behavior Change

is worth

10,000 Pounds of Insight

1 Ounce of Behavior Change

is worth

10,000 Pounds of Insight

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Behavioral Conditioning

Classical Conditioning– Particular stimuli related to the addictive

behavior

Operant Conditioning– Past addictive behavior produced positive

consequences

Behavioral Conditioning Classical Conditioning

– Particular stimuli related to the addictive behavior become paired with the behavior

– Further contact with such stimuli produce conditioned response

Operant Conditioning – Past addictive behavior produced positive

consequences – Future use in presence of discriminative

stimuli – Addictive behavior is more rewarding than

alternatives



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Self-Control

• Self-Monitoring provides a functional analysis of addictive behavior.

• Assesses self-defeating thinking, high risk situations, skill deficits, consumption patterns, emotional states, cues and risks for relapse.

• Helps clients develop alternative coping skills

Self-Control • Self-Monitoring provides a functional analysis of

addictive behavior.

• Assesses self-defeating thinking, high risk situations, skill deficits, consumption patterns, emotional states, cues and risks for relapse.

• Helps clients develop alternative coping skills

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Behavioral: Self-Monitoring

• As little as 2 weeks of self-monitoring before treatment can often highlight the situational antecedents and skills deficits that underlie an addictive behavior pattern.

Roger H. Peters PhD, Richard K. Sherman, MS, Richard Sandberg, and Alan Marlatt

Behavioral: Self-Monitoring • As little as 2 weeks of self-monitoring before

treatment can often highlight the situational antecedents and skills deficits that underlie an addictive behavior pattern.

Roger H. Peters PhD, Richard K. Sherman, MS, Richard Sandberg, and Alan Marlatt

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My family went to the park without me.

SadI hate people telling me what to do.

KitchenAloneWine9:30 amSun

JailSadI’m worthless

BarAloneBeer10:00 amSat

ConsequencesFeelingsThoughtsWhereWhoWhatTimeDay

Self-Monitoring Feedback Form See Module 7 – Handout 1 for details.



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Group Exercise: Self-Monitoring Feedback Form

Title Slide - Group Exercise: Self-Monitoring Feedback Form

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Group ExerciseDivide into pairs.Choose one person to role play a client in recovery. Consider modeling a client you have worked with ensuring confidentiality.The alternate person will role play the clinician.Client: take a few minutes to complete the Self-Monitoring Feedback Form. This form would have been discussed with the client in the previous session and completed as homework.Initiate a face-to-face session reviewing the Self-Monitoring Feedback Form as a guide for discussion.

9:45 am

Group Exercise See Module 7 – Handout 1 for details.

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Cue Exposure

• Urges and cravings are often triggered by emotional states and external events

• Reduce and eliminate exposure to cues or high risk situations.

• Teach clients that cues are early warning signals to develop immediate alternative activities.

10:30 am

Cue Exposure • Urges and cravings are often triggered by

emotional states and external events that have been paired with addictive behavior.

• Reduce and eliminate exposure to cues or high

risk situations. (Covert Sensitization Strategies)

• Teach clients that cues are early warning signals to develop immediate alternative activities that reduce and eliminate exposure to the cue.



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Contingency Management

• Providing reinforcement for abstinent behavior

• Clean urines are given vouchers worth money

• Clean urines guaranteed homeless a work program and therapeutic housing

• Rewarding the target desired behavior

Contingency Management • Providing reinforcement for abstinent behavior • Clean urines are given vouchers worth money • Clean urines guaranteed homeless a work

program and therapeutic housing • Rewarding the target desired behavior

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Coping Skills

• Teach clients skills to successfully cope with interpersonal, social, emotional and personal problems (Monti, et. al, 2001)

• While some clients are skill deficient,others can’t execute skills because of anxiety, maladaptive beliefs and/or depression

Coping Skills • Teach clients skills to successfully cope with

interpersonal, social, emotional and personal problems (Monti, et. al, 2001)

• While some clients are skill deficient, others can’t

execute skills because of anxiety, maladaptive beliefs and/or depression



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Cognitive Behavioral

Cognitive behavior therapy (CBT) combines

Behavior therapy helps you weaken the connections between troublesome situations and your reactions to them.

Cognitive therapy teaches you how certain thinking patterns are causing your symptoms.

Very simply put, CBT attempts to help patients recognize, avoid, and cope.

Cognitive Behavioral Cognitive behavior therapy (CBT) combines two very effective kinds of psychotherapy — cognitive therapy and behavior therapy.

Behavior therapy helps you weaken the connections between troublesome situations and your reactions to them. Reactions such as fear, depression or rage, and self-defeating or self-damaging behavior. It also teaches you how to calm your mind and body, so you can feel better, think more clearly, and make better decisions.

Cognitive therapy teaches you how certain

thinking patterns are causing your symptoms — by giving you a distorted picture of what's going on in your life, and making you feel anxious, depressed or angry for no good reason, or provoking you into ill-chosen actions.

Very simply put, CBT attempts to help patients recognize, avoid, and cope. That is, RECOGNIZE the situations in which they are most likely to use cocaine, AVOID these situations when appropriate, and COPE more effectively with a range of problems and problematic behaviors associated with substance abuse.

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Relapse Prevention

Functional AnalysisIdentify High Risk SituationsCoping Skills TrainingEnhance Self-EfficacyRelapse Reframed as teachable momentChallenge Positive Alcohol ExpectanciesLifestyle Balance

Relapse Prevention Functional Analysis Identify High Risk Situations Coping Skills Training Enhance Self-Efficacy Relapse Reframed as teachable moment Challenge Positive Alcohol Expectancies Lifestyle Balance



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Stages of Change Model

Pre-ContemplationContemplationPreparationActionMaintenance

Stages of Change Model Pre-Contemplation Contemplation Preparation Action Maintenance

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Cognitive Restructuring

• “It would be too hard to stop drinking. I’d lose all my friends, be bored, and never be comfortable”

• Cognitive restructuring requires assessment of client’s maladaptive alcohol and other drug beliefs

• Use socratic questioning to help clients test the accuracy of their beliefs

Cognitive Restructuring • “It would be too hard to stop drinking. I’d lose all

my friends, be bored, and never be comfortable”

• Cognitive restructuring requires assessment of client’s maladaptive alcohol and other drug beliefs

• Use socratic questioning to help clients test the

accuracy of their beliefs

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s. Motivational Enhancement Therapy

“This approach provokes less resistance and encourages clients to progress at their on pace toward deciding about, planning, making, and sustaining positive behavioral change”

Enhancing Motivation for Change in Substance Abuse Treatment, 1999, p. 21

Motivational Enhancement Therapy “This approach provokes less resistance and encourages clients to progress at their on pace toward deciding about, planning, making, and sustaining positive behavioral change”



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Motivational Enhancement Therapy:Assessment and Feedback

• Substance use patterns• DSM-IV substance

dependence/abuse diagnosis

• Life functioning problems• Functional Analysis

• Biomedical Effects• Neuropsychological

Effects• Family History• Psychological Problems• Personalize/Interpret

Results

Motivational Enhancement Therapy: Assessment and Feedback

• Substance use patterns • DSM-IV substance dependence/abuse diagnosis • Life functioning problems • Functional Analysis • Biomedical Effects • Neuropsychological Effects • Family History • Psychological Problems • Personalize/Interpret Results

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Motivational Enhancement Therapy Strategies

• Reflective Listening• Double Sided Reflection • Rolling with Resistance• Reframing • Empathy• Reduce Resistance by

Shifting Focus

• Circular Questioning• Co-creating success• Measuring motivation or

scaling• Note taking• Open ended questions• Empathy• Encourage client choice• Summarizing

Motivational Enhancement Therapy Strategies

• Reflective Listening • Double Sided Reflection • Rolling with Resistance • Reframing • Empathy • Reduce Resistance by Shifting Focus • Circular Questioning • Co-creating success • Measuring motivation or scaling • Note taking • Open ended questions • Empathy • Encourage client choice • Summarizing



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Motivational Interviewing Principles

William R. Miller, PhD and Stephen Rollnick, PhDRationale & Basic Principles: Implementation of Skills

Express Empathy!Develop Discrepancy Roll with Resistance -- Avoid Argumentation!Elicit-Efficacy!

Motivational Interviewing Principles William R. Miller, PhD and Stephen Rollnick, PhD Rationale & Basic Principles: Implementation of Skills

Express Empathy!

Develop Discrepancy

Roll with Resistance -- Avoid Argumentation!

Elicit-Efficacy!

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Motivational Interviewing: Rationale

What makes Motivational Interviewing a unique counseling approach is how its skills are employed by clinicians.

Motivational Interviewing requires attention to timing issues, specific strategize and application methods, and maximizing the effectiveness of these skills.

Motivational Interviewing: Rationale

Clinicians commonly think that they are already practicing Motivational Interviewing since most clinical training encompasses basic counseling skills such as active listening, use of open-ended questions, use of affirmation, and summarizing.

What makes Motivational Interviewing a unique

counseling approach is how its skills are employed by clinicians.

Motivational Interviewing requires attention to

timing issues, specific strategize and application methods, and maximizing the effectiveness of these skills.



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Co-Occurring Substance Use and Mental Health

Title Slide – Co-Occurring Substance Use and Mental Health

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Co-Occurring Substance Use and Mental Health Disorders

Mental Health Disorders

Substance Use Disorders

Co-Occurring Substance Use and Mental Health Disorders

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What are “Co-occurring Disorders”?

The presence of at least two disorders:

One being substance abuse or dependence

The other being a DSM-IV major mental disorder, usually:– Major Depression – Bipolar Disorder– Schizophrenia

What are “Co-occurring Disorders”? The presence of at least two disorders:

One being substance abuse or dependence

The other being a DSM-IV major mental disorder, usually:

– Major Depression – Bipolar Disorder – Schizophrenia

Mental Health Disorders

Substance Use Disorders



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Characteristics of Co-occurring Disorders (General)

Repeatedly cycle through treatment, probation, jail, and prison • More likely to re-offend or to receive

sanctions when: Not taking medication, not in treatment, experiencing mental health symptoms, using alcohol or drugs

• Use of even small amounts of alcohol or drugs may trigger recurrence of mental health symptoms

Characteristics of Co-occurring Disorders (General) Repeatedly cycle through treatment, probation, jail, and prison

• More likely to re-offend or to receive sanctions when: Not taking medication, not in treatment, experiencing mental health symptoms, using alcohol or drugs

• Use of even small amounts of alcohol or drugs may trigger recurrence of mental health symptoms

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Differentiation Between Axis I and Axis II Disorders

Axis I: for reporting all the various disorders or conditions in the Classification except for the Personality Disorders and Mental Retardation.

Axis II: Personality Disorders; Mental Retardation: for reporting Personality Disorders and Mental Retardation. – It may also be used for noting prominent maladaptive

personality features and defense mechanisms.

Differentiation Between Axis I and Axis II Disorders

Axis I: for reporting all the various disorders or conditions in the Classification except for the Personality Disorders and Mental Retardation. Also reported on Axis I are Other Conditions That May be a Focus of Clinical Attention. If more than one Axis I disorder is present, the principal diagnosis or the reason for visit should be indicated by listing it first.

Axis II: Personality Disorders; Mental Retardation:

for reporting Personality Disorders and Mental Retardation. It may also be used for noting prominent maldaptive personality features and defense mechanisms. The listing of personality Disorders and Mental Retardation on a separate axis ensures that consideration will be given to the possible presence of Personality Disorders and Mental Retardation that might otherwise be overlooked when attention is directed to the usually more florid Axis I disorders.



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General Assessment Approach for Co-occurring Disorders

1. Assess the significance of the substance use disorder *Obtain longitudinal history of Mental Health

and Substance Abuse symptom onset: Primary and Secondary occurrence

*Analyze whether Mental Health symptoms occur only in the context of Substance Abuse

*Determine whether sustained abstinence leads to rapid and full remission of Mental Health symptoms

General Assessment Approach for Co-occurring Disorders 1. Assess the significance of the substance use disorder

Obtain longitudinal history of Mental Health and Substance Abuse symptom onset: Primary and Secondary occurrence

Analyze whether Mental Health symptoms occur only in the context of Substance Abuse

Determine whether sustained abstinence leads to rapid and full remission of Mental Health symptoms

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General Assessment Approach for Co-occurring Disorders

2. Determine the length of current abstinence

3. Reassess Mental Health symptoms at end of 4-6 weeks of abstinence

4. If Mental Health symptoms resolve, potential referral for Substance Abuse services

5. Assess Social Needs: family issues, work related issues, housing status

General Assessment Approach for Co-occurring Disorders 2. Determine the length of current abstinence

If not 4-6 weeks in duration, delay diagnosis until abstinence has been achieved

3. Reassess Mental Health symptoms at end of 4-6 weeks of abstinence 4. If Mental Health symptoms resolve, potential referral for Substance Abuse services; if not, potential referral for Mental Health or specialized Developmental Disability services 5. Assess Social Needs: family issues, work related issues, housing status (homelessness)

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Characteristics of Co-occurring Disorders (Treatment-related)

• More rapid progression from initial use to substance dependence

• Poor adherence to medication• Decreased likelihood of treatment

completion• Greater rates of hospitalization• More frequent suicidal behavior• Difficulties in social functioning• Shorter time in remission of symptoms

Characteristics of Co-occurring Disorders (Treatment-related)

More rapid progression from initial use to substance dependence

Poor adherence to medication Decreased likelihood of treatment completion Greater rates of hospitalization More frequent suicidal behavior Difficulties in social functioning Shorter time in remission of symptoms



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Characteristics of Co-occurring Disorders (Behavioral)

• Difficulty comprehending or remembering important information (e.g., verbal memory)

• Not recognize consequences of behavior (e.g., planning abilities)

• Poor judgment • Disorganization • Limited attention span • Not respond well to confrontation

Characteristics of Co-occurring Disorders (Behavioral)

Difficulty comprehending or remembering important information (e.g., verbal memory)

Not recognize consequences of behavior (e.g., planning abilities)

Poor judgment Disorganization Limited attention span Not respond well to confrontation

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Co-Occurring Conditions in Adolescence

Ninety Percent w/Lifetime Co-Occurring Disorder had one MH Disorder prior to Onset of Substance Abuse. Median onset MH Disorder at Age 11 years.Onset Substance Abuse between 16 and 21 years.

Co-Occurring Conditions in Adolescence

Ninety Percent w/Lifetime Co-Occurring Disorder had one MH Disorder prior to Onset of Substance Abuse.

Median onset MH Disorder at Age 11 years. Onset Substance Abuse between 16 and 21

years.

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High

Sev

erity


Alco

hol a

nd o t

her d

rug a

buse

Mental Illness

IIISubstance abuse

system

IPrimary healthcare settings

IIMental health

system

IVState hospitals,

jails/prisons,emergency rooms, etc.

Primary Locus of Care by Severity See Module 7 – Handout 2 for details.



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Group Exercise:Primary Locus of Care by Severity

Title Slide – Group Exercise

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Group Exercise

Individually, write a short example from your therapeutic experiences of “one” of the four quadrants from the “Primary Locus of Care by Severity”You will have ten minutes to complete this portion of the exercise.In small groups of three share your example and discuss whether you believe your client was appropriate placed defending your assessment.

12:00-12:15 pm

Group Exercise Individually, write a short example from your Co-

occurring therapeutic experiences of “one” of the four quadrants from the “Primary Locus of Care by Severity”

You will have ten minutes to complete this portion of the exercise.

In small groups of three share your example and discuss whether you believe your client was appropriate placed defending your assessment.

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Evidence-Based Best Practices(continued)

Pharmacotherapy

12:15pm

Title Slide - Pharmacotherapy



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Pharmacotherapy

DetoxificationCravings for AlcoholReplacement AversiveAntagonistMixed (Agonist-antagonist)

Pharmacotherapy

Detoxification Cravings for Alcohol Replacement Aversive Antagonist Mixed (Agonist-antagonist)

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Medications for Relapse Prevention: Alcohol

Naltrexone (1994)

Disulfiram (1950)

AcamprosateNalmefeneSerotonin re-uptake inhibitors

Medications for Relapse Prevention: Alcohol

Naltrexone (1994) Disulfiram (1950) Acamprosate Nalmefene Serotonin re-uptake inhibitors

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Neurotransmitters and Alcohol Dependence

DopamineOpioidsGlutamate GABASerotonin

Neurotransmitters and Alcohol Dependence

Dopamine Opioids Glutamate GABA Serotonin



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Pharmacological Treatment for Opiate Addiction

Methadone Replacement

Levo-alpha-acetyl-methadol(LAAM)

Buprenorphine

Pharmacological Treatment for Opiate Addiction

Methadone Replacement: a narcotic agonist, which means that it is a drug that stimulates an opioid receptor, producing morphine-like actions.

Levo-alpha-acetyl-methadol (LAAM): an oral

narcotic analgesic used to treat opiate dependencies. Has been removed from the market by the FDA

Buprenorphine: a mixed agonist-antagonist.

Antagonists block the effects of opiates by binding to receptors without stimulating them. Buprenorphine produces a long-lasting effect, and can be prescribed by qualified physicians in a doctors office. For more information: http://www.nida.nih.gov/NIDA_Notes/NNVol16N2/Buprenorphine.html

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Treatment for Nicotine Dependence

Nicotine Replacements are available as gum and patches over-the-counter.They can be used by people outside formal stop-smoking programs, but they're less effective when used that way. Also available by prescription as a nasal spray and as a puffer ("inhaler").

American Heart Association, July 12, 2004, Nicotine Substitutes/Nicotine Replacements

Treatment for Nicotine Dependence

Nicotine Replacements are available as gum and patches over-the-counter.

Nicotine replacement therapy has been shown to be safe and effective in helping people stop using cigarettes when used as part of a comprehensive smoking cessation program.

They can be used by people outside formal stop-smoking programs, but they're less effective when used that way.

Nicotine Replacement Therapy is also available by prescription as a nasal spray and as a inhaler.

American Heart Association, July 12, 2004, Nicotine Substitutes/Nicotine Replacements



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Summary

Title Slide – Summary

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Summary and Questions

Goal: Introduce treatment and recovery models from a co-occurring specific perspective to include counseling theory, techniques, and relapse prevention perspectives.

Objectives:1. Define Evidence Based, Consensus Based, and Best Practice; 2. Discuss the impact of the therapeutic relationship and treatment

alliance; 3. Develop co-occurring skills in best practices implementation to

include: Behavioral, Cognitive Behavioral, Cue Exposure, Contingency Management, Coping Skills, Cognitive Restructuring, Relapse Prevention, Motivational Interviewing, Stages of Change, and Pharmacological Therapy.

12:45

Summary and Questions Goal: Introduce treatment and recovery models from a co-occurring specific perspective to include counseling theory, techniques, and relapse prevention perspectives. Objectives: 1. Define Evidence Based, Consensus Based, and Best






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Module 7 Treatment Knowledge - UI Health Care science, education and ... Self-Monitoring Feedback Form ... Module 7 Module 7 –– Treatment Knowledge Module 8 – Referral,