Treatment of Substance Abuse and Co-occurring Disorders - CASAT by huangyuarong


									Treatment of Substance Abuse and
     Co-occurring Disorders
             in JRA’s
   Integrated Treatment Model
               Henry Schmidt III, Ph.D.
                   Cory Redman
                John Bolla, MA, CDP

  Washington State Juvenile Rehabilitation Administration

   CODIAC Co-occurring Disorders Conference
            Yakima, Washington
              October 1-2, 2007
Substance Abuse Treatment and JRA’s
 Integrated Treatment Model (ITM)
   All youth receive treatment throughout JRA
   Targets are identified based on treatment model
       DBT for residential
       FFPS for parole
   Substance abuse treatment fits within the broader ITM
       Skill-building across multiple domains
       Improve family functioning
         Treatment in a Nutshell
   Clear behavioral targeting
   Engage and motivate, elicit commitment
   Assess controlling variables for client’s use
     Reinforcers
     Cues/contexts of use
     Behavioral sequences (urges lead to plans…)
     Statistical risk factors (e.g., mental illness, family use)

   Modeling, Coaching and Reinforcing of skills
   Contingency Management
   Troubleshooting, Relapse Prevention
Treatment for Co-Occurring Disorders
   Mental health diagnosis less important than symptoms
   Psychiatric care as required
   Increase client understanding of MH issues and
    recognition as possible risk factors for target behaviors
   MH behavior may be a risk factor for a target behavior
   ‘Solutions’ for MH risk factors are selected, learned and
   Solutions are tailored to match client interests, current
    skills, broad ability
          Program Development
   Assessment of client needs
   EBPs for adolescents, juv justice population
   Reviewed treatment expert recommendations
   Fit with EBP treatment modalities currently in
    use (DBT; FFP; FIT)
   Identification of treatment assumptions, modes
   Adaptation and creation of treatment materials
 JRA Substance Abuse Treatment:
       Program Elements
 Screening and Assessment
 Prevention

 Pre-Treatment

 Treatment

 Aftercare
Substance Abuse Screen/Assessment
   Screens
       Global Appraisal of Individual Needs (GAIN – SS)
       Substance Abuse Screen (SAS)
       Client History Review (structured interview)
   Assessments
       Biopsychosocial Diagnostic ASAM Assessment
            Acute Intoxication and/or Withdrawal Potential
            Biomedical Conditions and Complications
            Emotional/Behavioral Conditions and Complications
            Treatment Acceptance/Resistance
            Relapse/Continued Use Potential
            Recovery Environment
       Behavior Analysis
    Intervention Decision Process
   Screen
   Assessment
   Assignment to Treatment Level
   Assignment to Aftercare
   Transition to Parole Services
             Goals of Prevention
   A comprehensive prevention curriculum for all youth
    not needing substance abuse treatment.
   Practice strategies for rejecting drugs and alcohol.
   To emphasize that use of tobacco, alcohol, and drugs
    are not the norm among teenagers.
   Help youth to develop greater self-worth, self-efficacy,
    and self-confidence.
   Enable youth to effectively cope with anxiety,
    depression, anger, shame, guilt, fear, etc.
   Link prevention activities within the home, schools, and
          Elements of Prevention
   Pschoeducation re:
     Harmful effects of drugs and alcohol (including
     Peer norms for use

     Risk factors for use

   Skill Building
     Refusal skills
     ‘Reasons to not use’ – strengthen commitment and
      abstinence/moderation beliefs and expectancies
         Goals of Pre-Treatment
   Prepare youth for substance abuse treatment.
   Introduce preliminary education and
    information about substance abuse.
   Identify individual’s risk and protective factors,
    triggers and cues, patterns of use, and functions
    and drivers.
   Increase desire to engage in treatment.
      Elements of Pre-Treatment
   Orientation to treatment
   Assess stage of change
   Increase motivation and engagement toward
    participation in pre-treatment and treatment
   Obtain commitment to explore and understand
    personal substance abuse
             Goals of Treatment
   Decrease:
     substance abuse.
     physical discomfort from abstaining.

     urges and cravings to use drugs.

     apparently irrelevant behaviors.

     keeping options to use drugs open.

     capitulating to use drugs.

   Increase community reinforcement of “clear
    mind” behaviors.
        Dialectical Behavior Therapy
   Developed by Marsha Linehan and colleagues, for
   Chronically suicidal women meeting criteria for
    Borderline Personality Disorder
   Manualized, one-year outpatient treatment model
   Successful in working with difficult-to-engage,
    difficult-to-treat populations
              DBT Adaptations
   Substance Abuse
       Linehan et al. (1999)
   Adolescents
     Outpatient, Rathus & Miller (2002)
     Inpatient, Katz et al. (2004)

   Residential settings
     Inpatient psychiatric, Swenson et al. (2001)
     Forensic inpatient - McAnn, Ball, Ivanoff (2000)

     Washington State JRA – Trupin et al. (2002)

   Other Disorders: Batterers, couples
                Why DBT and
          Adolescent Substance Use?
   Behavioral Dyscontrol
       Truancy, criminality, substance use, self-injury
   Emotional Dyscontrol
    Low-skilled in identifying and regulating emotions

 Cognitive Rigidity (developmental)
   b/w thinking, oppositional, rule-governed morals

   Interpersonal Issues
    Socially isolated or shifting groups, deviant peers, etc.
 Issues of Self (developmental)
    Unstable sense of self, low self-esteem
 Basics of DBT

JRA’s Residential Treatment
       DBT Modes of Treatment
   Individual Therapy
   Group Skills Training
   Telephone Contact
   Therapist Consultation Group
   Pharmacotherapy (as needed)
     Functions of Comprehensive

   Enhance Client Motivation
   Acquire Skills
   Generalize Skills
   Structure Environment for Treatment
   Enhance Therapist Motivation and Skills
            Important Elements
DIALECTICS - Balance of Acceptance v. Change

 Clients are doing the best that they can

 Maladaptive behavior occurs because
   Lack of skills to do otherwise
   History of it being reinforced

   Strong contextual risk factors

  Thus, the behavior makes sense in context
     DBT Treatment Hierarchy
 Suicidal, Self-Injurious Behavior
 Treatment-Interfering Behavior
 Quality-of-Life Interfering Behavior

            Behaviors are targeted sequentially
            Only one or two targets at a time
 Substance use is top quality-of-life interfering
New Concepts for DBT-SUD
‘Dialectical Abstinence’
DBT-SUD Path to Clear Mind
         Decrease Substance Abuse
  Decrease Urges and Cravings to use Drugs

 Decrease Apparently Unimportant Behaviors

Decrease ‘Keeping Options to Use Drugs Open’

     Decrease Capitulating to Use Drugs

    Increase Community Reinforcement &
            ‘Clear Mind’ Behaviors

              CLEAR MIND
          Strong Emphasis on
    Attachment Strategies for Clients
       DBT already successful at retaining difficult-to-treat
        clients (BPD)
   Increased emphasis on engaging clients
       Increase positive contact outside of session
          Post cards, birthday and special occasion cards
          Increasing non-demanding contact during first 3 months
                Daily telephone check-in, exchange of messages
          Conducting therapy ‘in vivo’
          Altering session length (non mood-dependent)

          Supportive friends and family network meetings
    Attachment strategies for patients
   Finding ‘lost’ clients
     Clients are ‘dropping off’ until formally out of
     Often drop off when lapsing, relapsing
            Therapist task is to ‘find’ client who is not responding to
             phone calls
       Social network mapping – all relevant networks
            Where gone in the past? What places does s/he frequent?
       Orient clients to ‘getting found’ ahead of time
    Working with Mandated Clients
Also requires a large emphasis on Engaging and

   Cannot expect client to show up wanting to
   Many clients ignore negative impact of lifestyle
   Confrontation not effective
   Caution against settling for compliance over
JRA’s Residential DBT-SUD Model
   Individual sessions with case manager
   Skill acquisition groups
   Skill generalization groups
   Milieu intervention
   Family skills groups
   Staff meetings
   Psychopharmacology (for MH, not SUD)
    JRA Residential Tx. Hierarchy
   Engage and Motivate – ALWAYS!
   Suicidal/Self-injurious Behavior
   Aggressive Behavior
   Escape Behavior
   Treatment-interfering Behavior
   Quality-of-life-interfering Behavior
     Substance Abuse, Dependence
     Criminal Behavior, Gang Involvement, Truancy, etc.
     Engage and Motivate Clients
   Know your client’s goals, strengths
   Explore pro-social, community- or family-
    oriented values
   Nonjudgmental exploration of issues around
    substance use
   Orient to program – this is what we have to
   Commit to work full-time to help client reach
    own goals (partnership, coach)
    Engage and Motivate Clients
   Distinguish between education and treatment
   Elicit a commitment to treatment before
    beginning change strategies (Linehan; Miller &
   Soft commitment is acceptable; ‘foot in the door’
   Problem-solve client wanting to quit
     What would s/he find helpful?
     What has worked in the past?

   Label ‘not being motivated’ as normative,
    cyclical, problem to be solved – not moral failing
    Structure Supports Engagement
   Token economy
   Level system tied to commitment, treatment
    participation and progress
   Compelling reinforcers for clients to earn
   Non-contingent staff warmth and
   Peers are bought into the program
       Low support for drug using, war stories (seen as
        unskillful, not goal-oriented)
   Public recognition for accomplishing treatment
            Relevant Assessment of
           Drug and Alcohol History

   Statistical v. Idiographic Risk Factors
       ASAM Biopsychosocial Assessment, Researched risk
        factors, Chain Analysis

   Psychological Constructs v. Behavioral

   Understand in which situations the client used
    (topography – complete picture)
             The Chain Analysis
   Pick specific instances of different situations
   Moment-by-moment narrative of events
   Identify the controlling variables for use –
     What problems did using solve?
     What were prompts for using? What got the ball
     What were vulnerabilities for using – made it more
      likely the youth would use? (External or internal
   Client and therapist both understand what drove
    substance use
Assess for Relapse – Plan for Success

   Problem-solve future use – what is present in
    community environment that could lead to
       What skills will be needed to address this?

   What changes in environmental structure could
    be made to support treatment and long-term
    goal attainment? (‘Burning bridges’)
                           Skill Acquisition
   Broad palette of skills
   Skills are behaviorally specific.
   Particular skills are focus for individualized treatment,
    needed to address specific elements of client’s risk for use.
   Groups and individual work incorporate principles of
       Modeling
       Shaping
       Reinforcement
            Arbitrary vs. Natural
   Staff speak the same language throughout program
                Skill Generalization
   Milieu program – all interactions are opportunities to
    drag out and strengthen skillful behavior, diminish
    unskillful behavior
   Remind clients to take skills into all contexts
       School
       Family meeting
       Interactions with peers
       Recreation and work activities
       Interactions with staff, etc.
   Highlight positive outcomes of skill use (staff help
    youth to notice)
   Encourage client self-reinforcement
      Structuring the Environment
   Visual cues to remind youth and staff of the treatment
   Invite youth’s parents/significant others to participate
   Youth report on progress in program (new skills, chains
    for use, relapse prevention plan)
   Family meetings focus on what has been effective in
    eliciting commitment, maintaining motivation; what has
    ‘tripped up’ youth
   Youth are taught to begin to structure their own
    environment, begin to display those skills
   Community resources are identified, contacted and
    agree to participate with youth (mentors, programs,
                 Motivating Staff
   Knowledge that leaders are developing/have vision for
    complete program
   Confidence in skill level and knowledge of treatment
    director (or identified program specialist)
   High-quality training, when needed (paced, relevant to
    expanding demands of job, etc.)
   Examples of high-quality work (paperwork, video or
    live demonstration of clinical tasks)
   Weekly staff consultation meeting focused on
    describing treatment, de-polarizing staff (and increasing
                  Motivating Staff (2)
   Advancement based on demonstration of skills
   Managers are provided training to manage well
       Focus on systematic skill development
            Link learning skills to individual staff goals
   Staff see results of their own treatment efforts
       More skillful youth
          Committed to long-term goals
          Accomplishing important tasks

          Understanding what drives own behavior

          Building a support network

          Preparing for success (relapse prevention plans)
        JRA Community Aftercare
   Functional Family Parole
   Families’ needs are identified and discussed prior to the
    youth being released to the community on parole.
   Youth and family with special needs (mental health,
    substance abuse, etc.) are assisted by the Parole
    Counselor in being linked to community based
   Families are contacted regularly and youth with
    substance abuse issues are monitored by random
Family Integrated Transitions (FIT)
   EBP to transition juvenile offenders with the co-
    occurring disorders back into their community
   Designed and implemented by Eric Trupin, Ph.D. and
    David Stewart, Ph.D., from the University of
   To meet the needs of these high risk youth, several
    evidence-based programs were combined. Those are:
        o Multi-Systemic Therapy (MST) as the core
          treatment model, plus:
        o Dialectical Behavior Therapy (DBT)
        o Motivational Enhancement Therapy (MET)
        o Relapse Prevention/Community Reinforcement
          FIT Target Population
   Ages 11 to 17.5, with a substance
    abuse/dependency and mental health need
   At least 2 months left on sentence
   Residing in Snohomish, King, Thurston or Mason
    counties (JRA Regions 3, 4, and 6) with a family
    or stable placement
   Sex offenders are NOT excluded from the target
FIT Demonstrated Outcomes
   33% reduction in felony recidivism
        FIT reduces recidivism from 40.6% to 27.0%.
 Cost of Program: $8, 968 spent per youth
 Benefit-cost ratio related to the reduction in crime is
  a savings of $3.15 for every dollar spent – or total of
  $19, 247 per youth in the FIT program

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