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

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_at_Chestnut.Org

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Normal Adolescent (-) and Young Adult (-)
Development

• 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/experimentin
  g
• 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)

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Conceptual Challenges to Address

• 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 adolescents self-identity and are not
  easily changed

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Family, Peer Groups, and Community

• 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

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Adapting Treatment Manuals/Materials

• 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

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Motivational Enhanced Treatment/Cognitive
Behavior Therapy (MET/CBT)
CYT

• Sampl, S., Kadden, R. ()
• University of Connecticut Health Center
• Farmington, CT USA

Cannabis Youth Treatment Trials
Treatment Series Volume
7
Individual MET Sessions (- min)

• 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 quittingask which they think
  is most important
• Review of Progress, Functional Analysis,
  Personalized Goal Setting, and Orientation to the
  Group Sessions

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Group CBT Sessions - (- Min)

• Marijuana Refusal Skills
• Increasing Social Support and Pleasant Activities
• Coping with Emergencies and Relapse
• Plus Random Urines over
• six weeks

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Theoretical Basis of MET/CBT

• Rogers empathic listening and reflection therapy
• Prochaska DiClementes The Stages of Change
  Model
• Millers Motivational Interviewing
• Miller Rollnicks Motivational Enhanced
  Treatment (MET) approach from Project Match
• Montis 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

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The Stages of Change Model
Permanent Exit?
Relapse?
              
Pre-contemplation
Maintenance

MET
Contemplation
Action
Determination
CBT
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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

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Five Strategies of MET

• . Express Empathy
• . Develop Discrepancy
• . Avoid Argumentation
• . Roll with Resistance
• . Support Self-Efficacy

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. Express Empathy

• Conveyed Non-verbally
• eye contact
• body position
• facial expression
• Conveyed Verbally
• through reflections

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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 youre feeling
• Avoid labeling, lecturing, preaching, shaming,
  ridiculing, warning, arguing, or threatening

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. 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

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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

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. Avoid Argumentation

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

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Strategies for Gentle Encouragement

• Establish rapport and build trust
• Raise doubts by
• Eliciting the clients 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

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.
ROLLING WITH RESISTANCE

• Dont 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)

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. 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

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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.

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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

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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

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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

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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

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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

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Tips for Using CBT in your Clinical Work with
Adolescents

• Individualize with adolescents concerns and
  avoid a cookbook feeling
• Monitor for boasting about antisocial behaviors,
  or excluding some participants
• Try to make it lively and interesting

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Supplemental CBT Sessions (Webb et al )

1. 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.
2. Anger awareness skills, highlighting both
   internal and external cues and triggers.
3. Anger management skills, including the use of
   calm-down phrases and anger reducing thoughts.

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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.

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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

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The Assertive Continuing Care (ACC) ProtocolA
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
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Continuing CareDefined

• 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., )

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General Models of Continuing Care

• Step up or lateral transfer, e.g., OP -gt Res
• Relapse/poor response to treatment
• Step down transfer, e.g., Res -gtOP
• 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

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

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Time to Enter Continuing Care and First Use after
Residential Treatment





Percent of Adolescents






Days after Residential (capped at )
Source DARTS and Godley et al
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Who Links to Continuing Care?





Percent of Clients Linked






Days from Residential Discharge
Source CSAT ART Grantees Wilcoxon (Gehen)
statistic (df)., p lt.
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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, plt..
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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
Expected UCC
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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

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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

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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., )

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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

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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

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Case Manager Dos

• 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 sessionsbe in
  the neighborhood and drop by
• Talk to supervisor about difficulties with any
  procedures as well as client-specific issues.

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Case Manager Donts

• Cant 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

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Safety Issues

• Is this home safe? Read the Clients 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 Phonecall office at home
• Situations we have encountered

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Adolescent Community Reinforcement Approach (ACRA)
CYT
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
49
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

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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, Brys work on parenting
  practices

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Assumptions for ACRA

• 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.

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Key Concepts

• Positive and enthusiastic approach
• Uses lay language
• Keeps it simple
• Flexible
• Uses role-playing
• Uses homework

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Key Procedures
Goals of Counseling
ACRA Triangle
Functional Analysis
Happiness Scale
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Treatment Mechanisms

• Functional Analysis of Substance Use to identify
  the internal and external triggers that lead to
  substance use, document these behaviors and
  identify consequences of these behaviors.
• Functional analysis of pro-social behaviors that
  compete with substance use
• Skills training in relapse prevention,
  communication, problem solving, etc.
• Incorporation of above into a treatment plan
• Monitoring progress with the Happiness scale

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Primary Goals

• Goals for Adolescents
• Promote abstinence
• Participation in pro-social activities
• Positive relationships with family
• Positive relationships with peers
• Goals for Caregivers
• Motivate participation in ACRA
• Promote adolescents abstinence
• Positive communication and problem-solving skills
• Promote critical parenting practices

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Goals of Counseling (Simplified Treatment Plan)
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Critical Parenting Practices

• Good modeling
• Increase positive communication
• Monitor the adolescents whereabouts
• Involvement in adolescent's life outside the home

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(No Transcript)
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ACRA Happiness scale
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Detailed List of Procedures from Manual

1. Functional Analysis of Substance Use Behavior
2. Functional Analysis of Prosocial Behaviors
3. The Happiness Scale and the Goals of Counseling
4. Increasing Prosocial Recreation
5. Relapse Prevention Skills
6. Communication Skills
7. Problem-Solving Skills Training
8. Urine Testing
9. Caregiver Overview, Rapport Building,
10. and Motivation
11. Caregiver Communication Skills Training
12. CaregiverAdolescent Relationship Skills
13. Treatment Closure

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Optional Procedures from Manual

1. Dealing With Failure To Attend
2. Job-Seeking Skills
3. Anger Management

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Other Recommendations for Post-residential
Continuing Care

• Consent to participate in CC should be obtained
  within the first week of residential treatment
• Linkage after residential discharge should be
  accomplished in the first week following
  discharge
• Using an assertive approach, nearly all clients
  can be linked to CCregardless of discharge type.
• Maybe half of the As Planned discharges do not
  need the extra effort required of assertive
  approaches.but which half?

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Other Recommendations (Continued)

• Strive for high adherence to CC criteria
  (criteria) with every client
• For the most resistant clients consider
  motivational approaches such as contingency
  management to increase attendance, prosocial
  activities, and abstinence
• Facilitate linkage to needed services (medical,
  psychiatric, school, legal/probation, -step, etc)
• Develop local and community-wide recovery support
  activities to improve clients recovery
  environment

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Contact and Additional Information

• Michael L. Dennis, Ph.D., CYT Coordinating Center
  PI
• Lighthouse Institute, Chestnut Health Systems
• West Chestnut, Bloomington, IL
• Phone () -, Fax () -
• E-Mail Mdennis_at_Chestnut.Org
• Manuals and Additional Information are Available
  at
• http//www.chestnut.org/li/apss/CSAT/protocols/ind
  ex.html