Training Requirements for Mental Health Practitioners

(http://health.state.tn.us/Boards/index.htm)

• Licensed Professional Counselor– Core graduate coursework (e.g., abnormal

psychology, counseling theories, group dynamics)

• 60 hours total needed

– 500 hours prac/internship– Post-graduate hours

• Licensed Psychologist

– Pass national licensing examination– Graduate from doctoral granting training

program– Complete full-time one year pre-doctoral

internship– Complete 1900 hours post-doctoral

experience

• Licensed Alcohol and Drug Abuse Counselor– In many ways it’s an apprenticeship program

• 6000 supervised hours (by a licensed counselor)• 270 hours classroom training (e.g., community

college courses, workshops)

– Written exam– Case presentation– Philosophy of treatment paper

• So…what are the pros and cons of each type of professional in working with substance abuse disorders?

Overview of Substance Abuse Treatment

• “Traditional” settings are generally inpatient, day treatment, or intensive outpatient– Patient participants for certain number of days

• Sometimes mandated– Group and/or individual sessions every day– Sometimes occupational therapy, vocational therapy,

and other services included– May include drug testing (for outpatient programs)– Often include detox services– 12-step is a dominant model

• This setting is fairly unique for mental health services

Overview of “Behavioral” Therapies for Addiction

• Treatment has existed for quite some time, but until fairly recently (last 20 years) not well-evaluated

• Broad program evaluation studies of traditional inpatient programs showed that:– Many individuals with SUD did not seek or access

treatment– Drop out of treatment was high– Those who went into treatment had reasonably good

outcomes (although relapse was high)• Much more these days is done via day treatment

or outpatient programs

• Disconnect between clinical practice and scientific evidence of different treatments– Responsibility lies with both parties, I believe

• Clinicians may be unwilling to consider alternative treatment strategies

• Researchers may test treatments that are either tough to implement or too specific to be useful in the “real world”

– Challenging nature of randomized controlled trials (e.g., rule outs, need to identify active components, etc.)

• One strategy could be to identify underlying principles common to most substance abuse disorders, which could guide broad classes of treatments

– One possibility includes substance abuse disorders as consisting of:

• (a) impulse control problems• (b) excessive desire to use or craving• (c) insufficient ability to inhibit desire to use

– “gas” versus “brake” analogy

– Fundamental process of addiction, then, includes excessive drive due to learning and conditioning and “bad brakes” because of poor coping skills, emotional regulation, lack of alternatives, etc.

• Keep in mind underlying biological factors as well

Models of SUD Treatment

• Brief Motivational Models– Brief (as little as one session) interventions have been

shown to be effective at treating SUD• Sometimes as effective as longer treatments

– These treatments include:• Assessment and feedback on substance use• Nonjudgmental stance/empathy from clinician• Emphasis on individual choice (e.g., decisional balance

exercises)• Acceptance of ambivalence (direct contrast to traditional

models)• Emphasis on a range of client goals (e.g., reduction vs.

abstinence)

– These treatments do not include• Intense confrontation• Abstinence as the only goal (but not discouraged)• Requirement of self-help meetings

– Another advantage of brief treatments is their flexibility

• Studies have shown success in emergency rooms, primary care settings, criminal justice settings, etc.

– These studies have been effective with those at earlier stages of substance use-disproves the “rock bottom” idea

• Contingency Management– Provide tangible rewards for not engaging in

undesirable behavior (substance use in this case)

• Methadone maintenance is an example• Rewards often include vouchers for cash, food,

employment, etc.

– Research clearly indicates that this approach can be effective at increasing abstinence

• Basic behavioral principle: reward the desired behavior (not using)

– Most important weakness is that tangible contingencies cannot last forever

• Substance use may rebound

– Treatment settings may not have resources for contingencies

– May be especially appropriate for severe users unresponsive to other treatments or for those with poor compliance

• Theoretically, other changes may occur (via other treatments) when the person is not using as a result of the contingencies

– For example???

• Cognitive-Behavioral Models– Underlying principle involves identifying

patterns of thoughts and behaviors that sustain substance abuse

– Strategies therefore involve modifying thoughts and behaviors to reduce drives and improve ability to stop behaviors

– Practicing alternative behaviors is a major component

• The importance of practicing in CBT is often overlooked

– Important CBT skills include:• Avoiding high-risk situations• Delaying or moderating impulsive behavior (e.g.,

distraction)• Coping with uncomfortable internal states• Reducing stress• Improving social support

• Family/social models– Support exists for interventions that include

significant others in treatment, reinforce family bonds, improve family functioning, etc…

– Including parents in adolescent treatment may be critical

Basic Processes Necessary (Maybe!) for Effective Treatment

• APA task force identified over 140 “effective” therapies– Too overwhelming for most clinicians

• “Shore up Brakes”– Treatments need to:

• improve behavioral control • changing learned pathways • alter reinforcement of abused substances• strengthen alternative reinforcers

– Think about how specific models do this

• Motivational and cognitive-behavioral treatments enlist executive functioning, which can impact many of these areas

• Contingency management and family therapies provides rewards for alternative behaviors

– Cognitive remediation may be effective (i.e., the mind as a muscle)

• Reduce drives (foot off the gas)– Behavioral treatments are less direct– Initiation of abstinence allows brain to adapt– Work in conjunction with drug treatments that

reduce drives (e.g., medication compliance)

• How does all of this information make its way into the practice realm?– Perhaps a focus on a small set of overlearned

principles as a core• MI techniques• Contingency management• Basic CBT skills

– More specialized work progresses from that

Cognitive Therapy

• Example of a more specific treatment for SUD– Think about how it applies to the principles we

discussed earlier

• CT, developed by Aaron Beck, is one of the dominant cognitive-behavioral models– Although “B” not explicit in the theory,

behaviors are often addressed in therapy

• Precursor of effective treatment is developing a solid working relationship with the client– Necessary, but not sufficient (unlike Rogers and Ellis,

but for different reasons)

• Treatment usually revolves around identifying the cognitive and behavioral sequences that lead to the problematic behavior (substance use in this case)– Thoughts are given a more primary role than in other

models (e.g., strict behavioral treatments)– Assumption is that substance use is learned, and can

therefore be modified

• Sequence of a disorder:– Activating stimuli (either internal or external:

e.g., anxiety, interpersonal difficulties)– Beliefs are activated (e.g., drinking makes me

feel better)– Results in automatic thought (“I need a drink;”

“I want to get high”)– Leads to urges/cravings– Results in facilitative thoughts (“I’ll quit later;”

“This one time is okay”)– Leads to instrumental actions (calling dealer,

looking for liquor)

• Interventions often occur at the belief stage– People have “core beliefs”

• I’m a failure• I’m unlovable• I’m a good person

– These beliefs lead to conditional assumptions or rules

• If I open myself up to people, I will only get hurt• If I try hard at work, I’m only setting myself up at

failure

– Lead to automatic thoughts which lead to unhealthy behaviors

• For example:– Mike had a very poor childhood, and

perceives himself as unlovable. He believes that if he tries to make friends he will not be successful, so when confronted with social opportunities he says to himself “I can’t do that” or “I won’t fit in” or “The others will not like me.” He therefore stays home, feels sad, and uses to cope with his negative affect

• So, what does cognitive therapy look like?– Strong alliance is key– Oftentimes first steps involve examining automatic

thoughts• Ask questions to address the “reality” of these thoughts;

search for alternative examples• In many cases, situation is not as bad as it is perceived by

the client

– Later in the process core beliefs are analyzed in the same way

– Behaviors in response to these thoughts are analyzed (substance use in our case)

• Important that client sees the link between the thoughts and the behaviors

• Sometimes the developmental history is examined (contrary to certain stereotypes)

– Specific treatment goals are set collaboratively• Monitored on a weekly basis• If not met, one analyzes thoughts and behaviors related to it• Advantage-disadvantage analysis can be used in setting

goals– Have client list advantages and disadvantages of using/quitting,

but include reframe for advantages of using and disadvantages of quitting

» For example, “I seem to enjoy a party more when I’m drinking, BUT I have more problems the next day and I don’t really know how much fun I would have sober because I’m usually intoxicated…”

– At the beginning, and in general, one stays in the present

• The past may be analyzed, but linked to the present– For example, patient may benefit from understanding

sequences that led up to the belief that she is incompetent, but therapist must link that to present beahvior

– Sessions are usually structured• Set an agenda, periodically check in, review

previous session, assign homework

– Perhaps the key factor in treatment is learning how to respond to dysfunctional thoughts

• Collaboratively identify thoughts that are dysfunctional

• Learn coping statements (e.g., “coping cards”)

– Include other factors as part of treatment as well

• For example, 12 step participation, engaging in healthier behaviors, etc.

Burke et al., 2003

• Good example of how “effective” treatments are identified

• Involved a “meta analysis,” which is a quantitative summary of studies– Studies that involved (a) a motivational

interviewing interventions, (b) a comparisons, and (c) random assignment to conditions were included in the analyses

– A meta analysis summarizes the effects across the entire body of studies

• Compared to control groups, MI interventions were effective at:– Reducing drug use (d = .56)– Reducing alcohol use (d = .25-.53)– 51% of those receiving MI “improved” substantially,

compared to 38% after no treatment

• There were no differences between MI and other “bona fide” interventions, but MI treatments were, on average, 180 minutes shorter than the other treatments (e.g., cognitive-behavioral relapse prevention)

• MI effects were consistent over time (e.g., no differences at 20 vs. 67 weeks follow-up)