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Training Requirements for Mental Health Practitioners (http://health.state.tn.us/Boards/index.htm)

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Title: Training Requirements for Mental Health Practitioners (http://health.state.tn.us/Boards/index.htm)


1
Training Requirements for Mental Health
Practitioners (http//health.state.tn.us/Boards/in
dex.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

2
  • 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 its an apprenticeship program
  • 6000 supervised hours (by a licensed counselor)
  • 270 hours classroom training (e.g., community
    college courses, workshops)

3
  • Written exam
  • Case presentation
  • Philosophy of treatment paper
  • Sowhat are the pros and cons of each type of
    professional in working with substance abuse
    disorders?

4
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

5
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

6
  • 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

7
  • 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

8
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)

9
  • 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

10
  • 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

11
  • 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

12
  • 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

13
  • 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

14
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

15
  • 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)

16
  • 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

17
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

18
  • 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

19
  • 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 (Ill quit
    later This one time is okay)
  • Leads to instrumental actions (calling dealer,
    looking for liquor)

20
  • Interventions often occur at the belief stage
  • People have core beliefs
  • Im a failure
  • Im unlovable
  • Im 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, Im only setting myself up
    at failure
  • Lead to automatic thoughts which lead to
    unhealthy behaviors

21
  • 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 cant do that or I wont fit
    in or The others will not like me. He
    therefore stays home, feels sad, and uses to cope
    with his negative affect

22
  • 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)

23
  • 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
    Im drinking, BUT I have more problems the next
    day and I dont really know how much fun I would
    have sober because Im 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

24
  • 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.

25
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

26
  • 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)
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