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Summary of Clinical Methods used in two of the most common evidenced based practices

Summary of Clinical Methods used in two of the most common evidenced based practices. Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL

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Summary of Clinical Methods used in two of the most common evidenced based practices

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  1. Summary of Clinical Methods used in two of the most common evidenced based practices Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL Presentation at “Juvenile Justice Conference on Alcohol & Other (AOD) Treatment for Adolescents”, Thursday, April , , Marlborough Massachusetts. The content of this presentations are adapted from materials provided by Drs Mark Godley, Susan Godley & Susan Sampl. The opinions are those of the author and do not reflect official positions of the consortium or government. Available on line at www.chestnut.org/LI/Posters or by contacting Joan Unsicker at West Chestnut, Bloomington, IL , phone () -, fax () -, e-Mail junsicker@Chestnut.Org

  2. Biological changes in the body, brain, and hormonal systems that continue into mid-to-late s Shift from concrete to abstract thinking Improvements in the ability to link causes and consequences (particularly strings of events over time) Separation from a family-based identity and the development of peer- and individual-based identities Increased focus on how one is perceived by peers Increasing rates of sensation seeking/experimenting Development of impulse control and coping skills Concerns about avoiding interpersonal emotional or physical violence Realizing that they are not invincible to environmental risks (which are often less proximate or likely) Normal Adolescent (-) and Young Adult (-) Development

  3. Most adolescents do not recognize their substance use as a problem and are being mandated to treatment (and are angry about it) Co-occurring problems (mental, trauma, legal) are the norm and often predate substance use Treatment has to take into account the multiple systems (peers, family, school, welfare, criminal justice) involved in their lives Adolescents have less control of their lives and recovery environment than adults Need to be creative in dealing with family and peer relationships because they are still central to the adolescent’s self-identity and are not easily changed Conceptual Challenges to Address

  4. Families often play a pivotal role, but vary in their ability and willingness to help Peer groups are very powerful – but can have both negative and positive effects One or two very disruptive people can destroy a group and actually lead to worse outcomes Need to minimize confrontational approaches unless you have the time and control necessary to do them well and safely Less availability of aftercare, -step groups and peer based recovery support Family, Peer Groups, and Community

  5. Examples need to be reflect the substances, situations, and triggers relevant to adolescents Motivational strategies and consequences have to be reflect things of concern to adolescents Concepts need to be expressed in “concrete” (vs. abstract) terms to match developmental stage Curricula need to take into account individual differences in severity, co-occurring problems, and development – which often change during the course of treatment Need for treatment facilities that are physically durable and to have access to recreational facilities Adapting Treatment Manuals/Materials

  6. CYT Motivational Enhanced Treatment/Cognitive Behavior Therapy (MET/CBT) • Sampl, S., & Kadden, R. () • University of Connecticut Health Center • Farmington, CT USA Cannabis Youth Treatment Trials Treatment Series Volume

  7. Feedback, Rapport-Building, Orientation to Treatment and Review of the Personalized Feedback Report Peer reference norming Tell me about…(endorsed symptoms of abuse and dependence) Review reasons for quitting…ask which they think is most important Review of Progress, Functional Analysis, Personalized Goal Setting, and Orientation to the Group Sessions Individual MET Sessions & (- min)

  8. Group CBT Sessions - (- Min) • Marijuana Refusal Skills • Increasing Social Support and Pleasant Activities • Coping with Emergencies and Relapse Plus Random Urines over six weeks

  9. Theoretical Basis of MET/CBT • Roger’s empathic listening and reflection therapy • Prochaska & DiClemente’s The Stages of Change Model • Miller’s Motivational Interviewing • Miller & Rollnick’s Motivational Enhanced Treatment (MET) approach from Project Match • Monti’s Cognitive Behavioral Therapy (CBT) from Project Match • Stephens, R. S., Babor, T. F., Kadden, R., & Miller, M., MET/CBT Approach from the (adult) Marijuana Treatment Project

  10. The Stages of Change Model Permanent Exit? Relapse? Pre-contemplation Maintenance MET Action Contemplation Determination CBT

  11. Assumptions of MET • Therapist style is a powerful determinant of client motivation and change • Change is more likely when the motivation comes from adolescent, rather than being imposed by the therapist, family, school, or court • Need to show respect for the client and demonstrate understanding (vs. confrontation) • Ambivalence about change is normal • Change involves a process

  12. Five Strategies of MET . Express Empathy . Develop Discrepancy . Avoid Argumentation . Roll with Resistance . Support Self-Efficacy

  13. . Express Empathy Conveyed Non-verbally: • eye contact • body position • facial expression Conveyed Verbally through reflections

  14. Reflective Listening • Open vs. Closed Ended questions… • “How often did you xxx…” vs. “Tell me about when you xxx...” • “How many of your friends use drugs?” vs. “How have your friends reacted to your going into treatment?” • “Have you had problems with xxx..?” vs. “Tell me about the problem you mentioned with xxx…?” • Demonstrating understanding of what the client is communicating • “It sounds like you” • “So you” • “It seems to you that” • “It sounds like you’re feeling” • Avoid labeling, lecturing, preaching, shaming, ridiculing, warning, arguing, or threatening

  15. . Develop Discrepancy • Discrepancy is thought to be the engine that drives change • Help the client describe the discrepancy between how their life is when abusing substances and how it was/could be without • Often need help seeing the pattern of similar situations and drawing the link to consequences

  16. Facilitating the Risk/Reward Analysis • Normalize ambivalence to encourage contemplation • Help “tip the decisional balance scales” by: • Eliciting pros and cons of use and change • Emphasizing client choice and responsibility • Elicit self-motivational statements, and summarize them

  17. . Avoid Argumentation • Resistance is a cue to modify your approach • Treat ambivalence (mixed feelings) as normal • Use double-sided reflections

  18. Strategies for Gentle Encouragement • Establish rapport and build trust • Raise doubts by: • Eliciting the client’s perceptions of the problem • Providing feedback • Facilitating feedback of a significant other • Avoid premature prescriptive advice • Express concern, back off if necessary and keep the door open

  19. . ROLLING WITH RESISTANCE • Don’t get rattled when the client says something against change • Best response is empathy, plus slightly hopeful comment • May need to use small steps (such as relapse sampling instead of lifetime commitment)

  20. . Support Self-Efficacy • Reinforce any willingness: • to hear information • to acknowledge the problem • to take steps toward change • Make the connection between previous successful change and potential to change the current problem

  21. Assumptions of CBT • Substance use is a learned behavior in which use becomes triggered by environmental stimuli, thoughts and feelings and is maintained by reinforcing effects. • Individuals who wish to stop or reduce substance use need skills to cope with these triggers, as an alternative to drug and alcohol use. • Effective learning of these new coping skills requires repetition and practice with feedback.

  22. Structure of CBT Group Sessions • Introduction and Rapport Building • Review of Progress • Introduction and Teaching Coping Skills • In-Session Practice Exercise • Assign Real-Life Practice Exercise • Closing

  23. CBT Session Drug/Alcohol Refusal Skills • Review Rationale: • Narrowing of Social Circle • Best to avoid high risk people • Need for refusal skills • Teach Styles of Refusal • Provide Rehearsal through Role-Play • Describe Real-Life Practice exercise

  24. CBT Session Increasing Pleasant Activities • Review Rationalea positive alternative to smoking marijuana • DiscussFun if not high? • Brainstorm activities • Ask them to commit to do one before the next session

  25. CBT Session Planning for Emergencies and Coping with Relapse • RationalePreparation for high-risk situations increases likelihood of effective coping • Brainstorm potential high-risk/emergency situations • Give introduction to problem-solving skills • Review that relapse is not uncommon and provides an important opportunity for learning • Develop Emergency Plan for coping with lapse or full relapse

  26. Assumptions Behind CBT Group Therapy • Breaks through isolation • Skill deficits are inter-personal in nature and need to be practiced to work • Group is realistic yet “safe” setting in which to practice • Provides additional opportunity to recognize problem and its link to consequences • Provides therapists the opportunity to observe and provide feedback on inter-personal behavior • More time in treatment is better

  27. Tips for Using CBT in your Clinical Work with Adolescents • Individualize with adolescent’s concerns and avoid a cookbook feeling • Monitor for boasting about antisocial behaviors, or excluding some participants • Try to make it lively and interesting

  28. Supplemental CBT Sessions (Webb et al ) • A five stage problem-solving model is presented consisting of (a) general orientation, (b) problem identification, (c) generating alternatives, (d) decision-making, and (e) verification. • Anger awareness skills, highlighting both internal and external cues and triggers. • Anger management skills, including the use of calm-down phrases and anger reducing thoughts.

  29. Supplemental CBT Sessions (cont.) • Communication skills, including active listening, assertiveness and positive ways of responding to criticism • Menu of coping options for cravings and urges for marijuana combined with a log exercise • Awareness of depressed feeling and their management through techniques like substituting positive for negative thoughts • Managing thoughts about marijuana, the most common excuses for relapse and discussing termination.

  30. Most Common Modification • Currently being replicated in over dozen agencies around the country with consistent outcomes • Most Common Modifications: • Addition of family session at beginning and end • Addition of mental health component • Better linkage to continuing care • Modification to meet cultural, racial or other special population needs

  31. The Assertive Continuing Care (ACC) Protocol:A Case Manager's Manual for Working with Adolescents AfterResidential Treatment of Alcohol and Other Substance Use Disorders Assertive Continuing Care (ACC) Experiment Godley, S. H., Godley, M. D., Karvinen, T., & Slown, L.L (2001). Chestnut Health Systems Bloomington, IL USA

  32. Continuing Care—Defined • The provision of a treatment plan and organizational structure that will ensure that a patient receives whatever kind of care he or she needs at the time. The treatment program thus is flexible and tailored to the shifting needs of the patient and his or her level of readiness to change. (p. , ASAM Placement Criteria-nd edition; Mee-Lee et al., )

  33. General Models of Continuing Care • Step up or lateral transfer, e.g., OP -> Res • Relapse/poor response to treatment • Step down transfer, e.g., Res ->OP • Successfully completed index treatment • Decrease frequency/intensity • Tx progress results in decreased OP freq and/or intensity • Attend step meetings • Advice frequently given upon tx discharge • Non AOD Tx referrals • E.g., family counseling; psych medication monitoring

  34. Linkage to Continuing Care within days Following Residential Treatment for Adolescents Source Illinois Statewide DARTs

  35. Why do so many clients fail to link to continuing care? • May never get a referral – why? • Referral advice to see another provider (medical model) is “hit or miss” at best • Even transferring to another counselor within agency can be a problem. • Low Motivation/Treatment Fatigue- clients ready to be finished • Financial disincentives

  36. Dischargedtransfer within agency DischargedReferred to other agency Unplanned Discharge Who Links to Continuing Care? % % % % % Percent of Clients Linked % % % % % % Days from Residential Discharge Source CSAT ART Grantees Wilcoxon (Gehen) statistic (df=)=., p <.

  37. Do adolescents attend step meetings after residential discharge? % * % % % % % * . % % % % % % . % Attended One or More Meetings Median No. Meetings Attended Adults Adolescents Significant chi-square for enrollment and Mann-Whitney U for meeting attendance, p<..

  38. Actual UCC Outpatient Continuing Care Criteria % % % % % % % % % % % % % % % % % % % % % % Weekly Tx Weekly step meetings Relapse prevention Communication skills training Problem solving training Regular urine tests Meet with parents -x month Weekly telephone contact Contact w/ probation/school Referrals to other services Follow up on referrals Discuss probation/school compliance AdherenceMeets + Criteria Expected UCC Expected

  39. What Makes Assertive Approaches … Assertive? • Shifts linkage/retention responsibility from the adolescent/parent to the clinician • All admitted adolescents are eligible - not just graduates or “as planned” discharges • Understands the “clock is ticking” from the date of discharge and initiates continuing care within first-second week out of treatment • No confrontation, sessions are positive and reinforce progress toward goals

  40. What Makes Assertive Approaches …Assertive? (Continued) • Sessions are usually held in the community (home, school, after work, restaurant, park) or by phone • Clinician may drop by unannounced if missed sessions • Case Mgmt and transportation assistance to access needed services • Telephone calls between sessions to check “homework” progress and provide support

  41. Assertive Continuing Care (ACC) Enhancements • Case Management based on ACC manual (Godley et al, ) to assist with other issues (e.g., accessing needed services, job finding, monitoring, support) • Individual sessions for adolescent, parents, and together based on ACRA manual (Godley, Meyers et al., )

  42. ACC Case Management Services • Goal Provide assistance linking to needed services & regularly accessing prosocial & recreational activities • Critical Procedures: • Home based • Linkage • Monitoring lapse cues & attendance at services including step and other mutual support meetings • Advocacy to receive services • Social support

  43. Main Case Management Activities • Meet with client in home and other community settings • Do some activities with client that are fun • Assess needs and help client link to other needed services • Serve as an advocate for the client to get needed services • Discuss/coordinate services with other providers, schools, etc • Job finding assistance • Limited transportation assistance

  44. Case Manager Do’s • At intake explain office and home or other community visits • Stress need to meet at least weekly • Keep sessions positive, search for the positive to build upon • If they have a telephone, call in between sessions (support, reminders, etc) • Spend time with youth doing some fun activities that they want to do either to build rapport or to celebrate accomplishments • If two or more consecutive missed sessions—be in the neighborhood and drop by • Talk to supervisor about difficulties with any procedures as well as client-specific issues.

  45. Case Manager Don’t’s • Can’t take parental responsibility • Know the code of professional practice for your agency and respect those boundaries • Avoid giving, loaning, or accepting money or gifts • Maintain friendly, but professional relationship

  46. Safety Issues • Is this home safe? Read the Client’s case record from residential tx to help determine safety. • Pay attention to your instincts when you visit • Preferable if adolescent is not home alone • Know where exits are; keep a clear pathway to exit • Stay in living areas of the home. • If concerned you may suggest a coworker accompany you • May go with adolescent to other community location for session • Always carry a Cell Phone—call office at home • Situations we have encountered

  47. CYT Adolescent Community Reinforcement Approach (ACRA) Godley, S. H., Meyers*, R. J., Smith*, J. E., Godley, M. D., Titus, J. M., Karvinen, T., Dent, G., Passetti, L., & Kelberg, P. (). Chestnut Health Systems Bloomington, IL USA, and *University of New Mexico Albuquerque, NM USA Cannabis Youth Treatment Trials Treatment Series Volume

  48. ACRA Treatment Structure • Individual sessions with the adolescent • sessions with the caregiver • individual sessions with the caregiver • sessions with the caregiver and the adolescent • ACRA is based, not session based

  49. Theoretical Basis for ACRA • Operant Conditioning Model • Skills Training • Social Systems Approach • Azrin, Sisson, Meyer & Godley Community Reinforcement Approach with alcoholics • Meyers & Smith CRA adaptation for individuals concerned about the drinking of significant others • Smith, Meyers, & Delaney adaptation of CRA for homeless people dependent on alcohol • Higgins et al. combination of CRA with contingency management for treatment of cocaine addiction • Azrin et al. adaptation of CRA to adolescents • Catalano, Hops, & Bry’s work on parenting practices

  50. For many adolescent marijuana users, their social environment encourages marijuana use The therapist needs to help the adolescent recognize that their drug use is incompatible with other short- or long-term reinforcers (e.g., parental approval, staying out of criminal justice system, having a girl/boy friend) maximize family/peer/community resources and activities to reward non-drug using behavior increase alternative positive, non-drug related social/recreational activities developing social skills (e.g., problem solving, drug refusal, etc.) will increase the likelihood of success in these endeavors. Assumptions for ACRA

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