Fresh Start: A Brief Intervention for Co-Occurring Disorders

Fresh Start: A Brief Intervention for Co-Occurring Disorders Kim T. Mueser Center for Psychiatric Rehabilitation Boston University Mueser@bu.edu

Fresh Start:Living Beyond Alcohol and Drugs • Target population: clients with serious mental illness and active (post 3 months) substance abuse • Brief (6 – 8 sessions) intervention, but longer possible • Standardized in clinical guidelines and educational handout for client • Designed to be administered by case managers or any other clinician • Individual format assumed, but group format feasible • Home assignments for each session • Follow-up support and case management based on progress in Fresh Start Program • Incorporates motivational interviewing, education, and cognitive-behavioral teaching strategies

Program Philosophy • Motivation to overcome substance abuse instilled by helping clients articulate personal life goals and developing discrepancy between achieving goals and continual use (motivational interviewing) • Goal identification needs to be interpersonally engaging, explicit, and a focus of active work to be genuinely motivating for people with a serious mental illness • Discrepancy is most effectively created when clients are actively attempting to pursue personal goals • Clients benefit from information about the interactions between substance use and mental illness • When motivation for sobriety is harnessed, a concrete sobriety plan needs to be created, practiced, implemented, and modified as needed

Topic Session 1. Values Clarification and Goals Identification 1 - 2 2. Information About Drugs and Alcohol 1 - 2 3. Deciding Whether to Cut Down or Stop Using Substances 1 - 2 4. Making a Personal Sobriety Plan 2 - 4 Overview of Fresh Start Program

Topic 1. Values Clarification and Goals Identification: Goals • Explain purposes of Fresh Start program • Foster discussion of clients’ personal values, including areas of satisfaction and dissatisfaction with life domains • Help client identify one or two personal goals related to life changes and set some steps towards achieving those goals

Introduction to Program • Overcoming substance use problems requires changes in personal lifestyle (e.g., relationships, leisure activities) • In order to help people make these changes, it’s important to understand how they would like their lives to be different • Then, efforts can focus on helping people make desired changes and addressing the interference caused by substances • This program starts with exploration of what is important to each individual person

Establish Personal Goals • Goal: To establish personal, meaningful goals that the client is willing to work on • Talk with clients about their • Aspirations • Desires for how things could be different • Fantasies

Goals (cont.) • Get to know what the client was like in the past • Preferred activities • Admired people • Personal ambitions • Don’t discourage ambitious goals • Set small incremental goals and objectives • Accumulate a record of successes that you can review during setbacks

Examples of Goals • Finding a job • Completing high school • Finding a girlfriend/boyfriend • Getting a driver’s license • Getting one’s own apartment • Resuming parenting • Handling one’s own money • Buying a car

Reasons for Not Discouraging Ambitious Goals • Helps therapeutic alliance • Builds client self-efficacy • Inability to predict what changes people are capable of making • Good things happen on the way to pursuing ambitious goals • Ambitious goals sometimes change as people work towards them • Pursuit of goals lends meaning to life: it’s the journey, not the destination

Values Clarification • What type of friendships and relationships do you like to have? Which of your relationships would you like to improve? (e.g., with children, parents, boy/girlfriend, spouse, partner) • Money • Work • Education • Leisure time • Religion/spirituality • Creative expression, arts • Living situation • Health & fitness • Mental health (e.g., coping with depression, anxiety, voices)

Setting Goals • Break goal into smaller steps • Start with short-term goals • Get support for achieving goals • Don’t get discouraged if it takes longer to achieve goal than you thought • Try other strategies if first one doesn’t work • Make a plan to achieve goal: • Who will be involved? • What step will each person do? • What is the time frame? • What resources are needed? • What problems might come up and how could they be avoided?

Common Obstacles and Solutions to Establishing Goals Obstacles: • Hopelessness • Lack of self-efficacy • Potential goals seem too distant Solutions: • Empathic listening • Instilling hope • Identifying personal strengths • Believing each person is capable of change and recovery • Reframing past challenging experiences • Exploring first steps towards possible goals before setting specific goals

Develop Discrepancy • Explore client’s goals • Consider steps that need to be taken to achieve goals • Ask client to describe any possible consequences of not changing • Use reflective listening selectively to reinforce clients recognition that not changing interferes with goal attainment

Develop Discrepancy (cont.) • Actively work towards helping client achieve goals • Expect that discrepancy between problem area and goal attainment will develop through experience of trying to achieve goal, not anticipation and talk • Avoid directly confronting client with discrepancy; rather, use session to process interference and ask questions, using Socratic method

Develop Discrepancy (cont.) • Never lose site of the goal you’re helping the client work towards • Don’t worry if the client doesn’t perceive discrepancy at the first opportunity--there will be other opportunities! • When discrepancy develops, expect client to first try to modify problem behavior related to desired goal; don’t oppose this, but instead work out a plan and method for monitoring and evaluating its success

Topic 2. Providing Information About Drugs and Alcohol: Goals • Provide information about effects of alcohol and drugs • Explore reasons for using substances • Provide information about interactions between substance use and mental illness • Give opportunity for clients to talk about their experiences using drugs and alcohol in order to create awareness of both positive reasons for using substances and negative effects of use

Principles of Psychoeducation • “Chunk” material into small, manageable pieces • Elicit client’s experiences with substances & consequences • Adopt client’s language • Ask questions to elicit understanding and review previously covered material • Pause frequently to summarize information • Don’t be afraid to encourage client to talk about positive aspects of using

Alcohol Cannabis Stimulants Cocaine Amphetamines Hallucinogens LSD Ecstasy Peyote, mescaline Opiates Inhalants Glue Aerosols Caffeine Nicotine Benzodiazepines Commonly Used Substances and Their Effects

Why do People Use Substances? Discussion & Worksheet • Socialization • Celebration • Improve mood (e.g., depression, anxiety) • Cope with symptoms (e.g., voices, paranoia, unpleasant memories of traumatic events) • Avoidance of life problems • Chasing past fond memories of substance use • Routine • Something to look forward to • Nothing else to do • Part of one’s lifestyle

Stress-Vulnerability Model Biological vulnerability made worse by: • Alcohol and drugs • Stress Biological vulnerability made better by: • Medications • Effective coping • Social support • Involvement in meaningful activities

Problems Related to Substance Use: Discussion and Worksheet • Increased symptoms and relapses • Social/relationship problems • Interference with work, school, parenting • Daily living problems • Legal problems • Health problems • Safety problems • Psychological dependence • Physical dependence • Guilt, poor self-esteem, lack of self-efficacy, hopelessness

Topic 3. Deciding Whether to Cut Down or Stop Using Substances: Goals • Help clients weigh advantages and disadvantages of using alcohol and drugs • Help clients weigh advantages and disadvantages of sobriety • Foster a decision about whether or not to stop using substances • Use of “change talk”

Change Talk Strategy for resolving ambivalence • 4 categories of change talk • Recognizing disadvantages of status quo • Recognizing advantages to change • Expressing optimism about change • Expressing intention to change

Methods to Evoke Change Talk • Evocative questions- ask person for change statement • Change ruler- on a scale of 0 to 10 how important is it to make the change? On a scale of 0 to 10 how confident are you that you can make the change? Importance- ruler-why are you at _ and not at 0? What would it take for you to go from _ to a higher number?

Change Talk (cont.) • Exploring decisional balance • Elaborating-once a reason for change has been raised • Asking for clarification- in what ways, how much • Asking for a description of the last time it occurred • Asking what else within the change topic

Change Talk (cont.) • Querying extremes- describe extremes of concerns • Looking back- compare before the problem with the present • Looking forward- envision a changed future • Exploring goals and values- what things are most important, develop discrepancy

Change talk (cont.) • Paradox- the therapist takes the opposite side of changing • Follow through contact- one follow-up phone call after initial session increases likelihood of client returning

Pros and Cons of Using/Not Using Substances: Discussion & Worksheets • List advantages of using and disadvantages of using substances on worksheet • Specific reasons drawn from previous discussion • Preliminary decision: Do you want to stop using substances? (No, Maybe, Yes) • Separate worksheet completed for advantages and disadvantages of sobriety • Focus on how sobriety can help person achieve personal goal • Final decision: Do you want to stop using substances?

Dealing with Ambivalence • Denial and minimization are fundamental to addiction • Relying on commitment to change before undertaking efforts to change can play into the addiction, and fail to deal with the reality that change is often needed • Remember, ambivalence is normal, and is sometimes overcome by change itself • When client is ambivalent, reframe sobriety plan as a “behavioral experiment” designed to explore sobriety, and facilitate making a decision about staying sober

Topic 4. Making a Personal Sobriety Plan: Goals • Help people who want to stop using substances develop a personal sobriety plan • Identify ways for people to get support to continue their personal sobriety plan after the Fresh Start program has ended

Elements of a Personal Sobriety Plan • Remember reasons for not using substances • Get support for your decision to get sober • Develop a plan to prevent going back to using substances in high risk situations • Identify new ways of getting your needs met

Identifying Reasons for Not Using Substances • More able to manage mental illness • Improved social relationships • Improved ability to work, go to school, parent • Having your own apartment • Fewer legal problems • Better health • Feel better about self • More money to spend on other things

Getting Support for Your Decision to Get Sober • Family member • Friend • AA, NA, Dual Recovery group/sponsor • Spouse, partner, boy/girlfriend • Member of religious community • Teacher • Peer from peer support center

Dealing with “High Risk” Situations • Being offered to use substances • Being pressured to use substances • Running into a former drug connection • Holidays • Going to a party • Having money in your pocket • Encountering other cues for using substances • Feeling bad or stressed out • Having nothing to do • Spending too much time alone • Remembering good times using substances

Social Skills Training • Can be used for basic social skills (e.g., conversation skills, friendship) or to deal with substance use situations • Training sequence: rationale, break down skill into steps, model skill, engage client in role play, positive feedback, corrective feedback, more role playing, homework • Complex skills acquired through shaping • Strong research support for social skills training for severe mental illness & addiction

Social Situations • Decline in a firm voice tone • Don’t make excuses for saying “no” • Repeat refusal if needed • Offer alternative activity if it’s a friend • “level” with friends about importance of sobriety • Leave situation if needed

Stimulus Control • Minimizing exposure to stimuli that trigger undesirable behavior (e.g., substance abuse) • Not having alcohol/drug paraphernalia around • Avoiding situations where substances likely to be used • Avoiding cues likely to trigger urges to use (e.g., money in pocket) • Increasing difficulty of accessing substances once exposed to triggers • Not having much money around • Direct deposit to bank account • Having representative payee or someone else joint owner of bank account

Coping Skills Enhancement • Can be applied to symptoms (depression, hallucinations, anxiety, etc.) or cravings • Behavioral analysis of current coping skills • Increasing use of effective but under-utilized strategies • Introducing new coping strategies • In-session modeling & practice • Out-of-session homework

Cravings • Distract yourself by doing something that focuses your attention elsewhere • Cheerlead with self-talk (e.g., “I can cope…”) • Use relaxation techniques until cravings pass • Use prayer • Contact a friend

Coping with Symptoms • Depression • Schedule pleasant activities • Challenge negative thinking • Exercise • Use positive self-statements • Anxiety • Use relaxation techniques • Challenge thoughts that cause you to worry • Gradually expose yourself to feared but safe situations

Coping with Symptoms • Hallucinations • Distract yourself with other activities • Accept the voices or other hallucinations without giving them undue attention or control over your life • Use relaxation to tolerate the distress • Sleep Problems • Avoid caffeine use in the afternoon • Avoid naps • Go to bed at the same time each night • Develop a pleasant nighttime routine (e.g., reading watching TV) • Exercise

Relaxation Training • Stress common contributor to substance abuse & psychiatric relapses • Identify stressful situations • Identify personal signs of stress • Teach relaxation skills • Relaxed breathing • Pleasant imagery • Muscular tension/relaxation • Practice skills in non-stressful situations to develop competence

Leisure & Recreational Skills • Common problem in schizophrenia & depression • Substance use often substitute for other leisure activities • Steps for developing new activities • Experience of pleasure grows with familiarity with activity • Specific focus on developing over time ability to enjoy leisure activities, based on 3-stage model of savoring: • Anticipation • Savoring the moment • Reminiscing

Finding New Ways of Getting Your Needs Met • Socializing with others • Feeling accepted by other people • Feeling good • Escaping boredom • Dealing with bad feelings • Help with sleeping • Having something to do and look forward to

Providing Continued Support and Case Management • Client has achieved sobriety • Continue working on goals • Ensure Personal Sobriety Plan is in place • Client has reduced substance use, but continues to have problems related to using substances • Continue working on goals • Develop discrepancy between goals and substance abuse • Modify Personal Sobriety Plan, with particular emphasis on supports for sobriety and dealing with high risk situations

Providing Continued Support and Case Management (Cont.) • Client continues to use substances, DESPITE expressing a desire to cut down or quit • Continue working on goals • Develop discrepancy between goals and substance abuse • Revisit and modify Advantages/Disadvantages of Using/Sobriety Worksheets • Modify Personal Recovery Plan

Providing Continued Support and Case Management (Cont.) • Client continues to use substances, but is ambivalent about cutting down or quitting • Continue working on goals • Assume that deep down inside the client really wants to quit • Approach developing a sobriety plan as a series of behavioral experiments designed to explore what it’s like not using substances • De-emphasize the need to commit to sobriety, and increase focus on behavioral change related to cutting down or not using

Summary • Fresh Start provides education and language for discussion co-occurring substance use problems in persons with serious mental illness • The core of the program is setting and following through on personal goals • While motivational enhancement is built into the program, a plan for cutting down or stopping substance use is created regardless of client’s commitment to sobriety • The primary driving forces supporting sobriety are: • Discrepancy between substance use and personal values and goals • Provision of direct information regarding effects of substance use • Development of alternative strategies for getting needs met

Fresh Start: A Brief Intervention for Co-Occurring Disorders