Substance Abuse & Counseling, Exam 2

Strategy Selection and Implementation Stage - (3)

(3) Strategy Selection and Implementation stage involves the counselor and client selecting and sequencing a plan of action or intervention strategies that are based on assessment data and are designed to help the client achieve the designated goals

Evaluation and Termination Stage (4)

(4) Evaluation and Termination stage involves assessing the effectiveness of the therapeutic interventions and the progress the client has made toward the desired goals and whether termination of treatment is appropriate (Cormier & Cormier, 1998, Interviewing strategies for helpers: Fundamental skills and cognitive-behavioral interventions. Pacific Grove, California: Brooks/Cole PublishingCompany)

CHAPTER 5: Assessment and Diagnosis Behavioral Characteristics ● Common presenting problems related to substance abuse:

Marital and family conflict Child abuse or neglect Unemployment Financial problems Multiple medical problems Anxiety Depression Suicide Problems with aggression and violence

Important Questions to ask the client and client's family/friends:

"Do you believe that your use of alcohol or other drugs has caused problems in your life?" "Do you believe that these problems (financial problems, etc) would have happened if alcohol or drugs were not a factor?" "Does the user's personality change while using?" "Has anyone been concerned or embarrassed about the use?" "Have you or others been uncomfortable about your safety in circumstances such as riding in a car when the user has been driving after having drink?"

Old proverb:

"the person takes a drink, the drink takes a drink, and the drink takes there person"

Loss of control:

can be thought of as a loss of predictability

Addiction is...

often classified as a "family illness"

CHAPTER 5: Assessment and Diagnosis Assessing the Behavioral Symptoms

Questionnaire (Figure 5.1, Pages 133-134) Social Characteristics As user becomes more involved in abuse or dependence, the primary relationship in life becomes the relationship with the substance Family Characteristics Family members, like the user, progress through different phases in their journey with the addict. Addiction is often classified as a "family illness" Four Stages in the Family System of the Addict 1. Denial 2. Home Treatment 3. Chaos 4. Control

Four stages involved in successful individual therapy: Relationship Stage (1)

(1) the Relationship stage which involves establishing an effective therapeutic relationship with the client; it is through the development of an effective therapeutic relationship that the therapist is able to influence the client and form a working alliance in which the client and therapist are working toward the same goals

Assessment and Goal Setting Stage - (2)

(2) Assessment and Goal Setting stage often begins concurrently or shortly after relationship building and its focus is to help both the counselor and the client obtain a better idea or grasp of what is happening with the client and what prompted the client to seek therapy at this time; all possible client issues or problems are assessed during this stage; a thorough assessment is important because the presenting problem is often not the real problem; example one: parents often bring a child to a therapist and claim that the kid is the problem when, in reality, the parents are not parenting the kid effectively or consistently; example two: an older adolescent or a young adult might be abusing drugs and alcohol to psychologically escape a dysfunctional, controlling family because his or her family is extremely enmeshed [too much emotional closeness] and cannot let him or her individuate and separate [physically, emotionally and psychologically] from his or her family of origin [family one grows up in] which is a major developmental task for young adults; as problems and issues are identified and defined in the assessment and goal setting stage, the counselor and client work together to develop outcome goals

Assessing Behavioral Symptoms, Suggested Question Categories:

- Preoccupation - Increased Tolerance - Rapid Intake - Using Alone - Use as a Panacea (cure-all) - Protecting the Supply - Nonpremeditated Use - Blackouts (for alcohol)

Several approaches to cognitive-behavioral therapy:

- Rational Emotive Behavior Therapy - Rational Behavior Therapy - Rational Living Therapy - Cognitive Therapy Dialectic Behavior Therapy

Characteristics of Cognitive-Behavioral Therapies:

- Thoughts cause Feelings and Behaviors. - Brief and Time-Limited. (Average # of sessions = 16 VS psychoanalysis = several years) 3. Emphasis placed on current behavior. 4. CBT is a collaborative effort between the therapist and the client. Client role - define goals, express concerns, learn & implement learning Therapist role - help client define goals, listen, teach, encourage. 5. Teaches the benefit of remaining calm or at least neutral when faced with difficult situations. (If you are upset by your problems, you now have 2 problems: 1) the problem, and 2) your upsetness. 6. Based on "rational thought." - Fact not assumptions. 7. CBT is structured and directive. Based on notion that maladaptive behaviors are the result of skill deficits. 8. Based on assumption that most emotional and behavioral reactions are learned. Therefore, the goal of therapy is to help clients unlearn their unwanted reactions and to learn a new way of reacting. 9. Homework is a central feature of CBT.

Behavioral Characteristics

- almost always occurs within the context of other problems, such as marital and family conflict, child abuse or neglect, unemployment, financial problems, multiple medical problems, anxiety, depression, suicide, and problems with aggression and violence.

CHAPTER 5: Assessment and Diagnosis Behavioral Characteristics ● A drug or alcohol problem exists and requires treatment if:

...the use of substance continues despite interference in any on of the six major areas of a person's life: Job or school Relationships with family Social relationships Legal problems Financial problems Medical problems

Four Stages in the Family System of the Addict Stages or Phases

1. Denial - they deny there is a problem and try to hide the substance abuse both from each other and from those outside the family. 2. Home Treatment - family trying to get the addict to stop using, hiding drugs or bottles, nagging, threatening, persuasion, and sympathy are attempted 3. Chaos - problem becomes so critical it can no longer be denied or kept secret from those outside the family 4. Control - a spouse or family member attempts to take complete control of and responsibility for the user

"Big" Names associated with Cognitive Behavioral Therapy

1. Epictetus, Greek philosopher. Observed that people are not disturbed by things that happen but by the view they take of things that happen. 2. Albert Ellis, Ph.D. "grandfather of cognitive behavioral therapy." 3. Aaron Beck, MD, a psychiatrist (University of Pennsylvania

Transtheoretical Model: Six Stages People Experience in Making Changes

1. Precontemplation 2. Contemplation 3. Determination 4. Action 5. Maintenance 6. Relapse

Course Objectives

1. Review basic concepts of Cognitive Therapy. 2. Discuss clinical application of Cognitive Therapy as it relates to patient populations seen in Behavioral Health. A. Populations B. Basic Tools of CBT C. Treatment Plan

Substance-related disorders have been traditionally divided into two basic groups:

1. Substance Use Disorders (Substance Dependence and Substance Abuse) 2. Substance-Induced Disorders (including Substance Intoxication and Substance Withdrawal)

Substances are grouped into 11 classes

1. alcohol 2. amphetamines 3. caffeine 4. cannabis 5. cocaine 6. hallucinogens 7. inhalants 8. nicotine 9. opiods 10. phencyclidine (PCP) 11. sedatives, hypnotics, or anxiolytics (anti-anxiety drugs)

As a general rule, a drug or alcohol problem exists and requires treatment if the use of the substance continues despite significant interference in any one of the six major areas of a person's life:

1. job or school 2. relationships with family 3. social relationships 4. legal problems 5. financial problems 6. medical problems

Families of abusers have patterns of behavior as well

Families of abusers have patterns of behavior as well

COGNITIVE BEHAVIORAL THERAPY

Helen Tafoya-Barraza, MA. LPCC University of New Mexico Hospitals - Behavioral Health

Rational Emotive Therapy aka Rational Emotive Behavioral Therapy

A form of cognitive-behavioral therapy in which somebody is encouraged to examine and change irrational thought patterns (irrational thinking) and beliefs in order to reduce dysfunctional behavior. What is irrational thinking? What types of thinking are problematical for human beings

Criteria for Substance Abuse

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: 1. Recurrent 2. Recurrent 3. Recurrent 4. Continued

Criteria for Substance Dependence:

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: 1. Tolerance 2. Withdrawal 3. The substance is often taken in larger amounts over a longer period than was intended 4. There is a persistent desire or unsuccessful effort to cut down or control substance use 5. A great deal of time is spent in activities necessary to obtain the substance (e.g.: visiting multiple doctors or driving long distances), use of the substance (e.g.: chain smoking), or recovery from its effects 6. Important social, occupational, or recreational activities are given up or reduced because of substance use 7. the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (eg. current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

9. Labeling and Mislabeling -

An extreme form of overgeneralization. Instead of describing your error, you attach a negative label to yourself. When someone else's behavior rubs you the wrong way, you attach a negative label to that person. Mislabeling involves describing an event with language that is highly colored and emotionally loaded. Example: You miss a basketball shot and say, "I'm a born loser" instead of saying, "I messed up on that one shot."

4. Disqualifying the positive -

An individual transforms neutral or even positive experiences into negative ones. You reject positive experiences by insisting they "don't count" for some reason or the other. In this way you can maintain a negative belief that is contradicted by your everyday experiences. Example: When someone praises your appearance or your work, you tell yourself, "They're just being nice" or you say to them, "It was nothing really."

Behaviorally...

Behaviorally, substance abuse can be considered any use of a psychoactive substance that causes damage to the individual, family, and/or society

Phase One: The Prodromal Phase

Casual or social use begins to change the first signs of dependency can be charted: - increase of tolerance - first blackout or loss of significant time to drug use - sneaking drinks or drugs - preoccupation with drinking or drug use - gulping drinks or hurried ingestion of chemicals - avoiding reference to drinking or drug use

Two Types of Disturbance 1/2: Discomfort Disturbance

Discomfort disturbance: - results from demands about others (e.g. 'People must treat me right') and about the world (e.g. "The circumstances under which I live must be the way I want"). Discomfort disturbance - two types: Low frustration-tolerance (LFT) results from demands that frustration not happen, followed by catastrophizing when it does. It is based on beliefs like: "The world owes me contentment and happiness." Low discomfort-tolerance (LDT) arises from demands that one not experience emotional or physical discomfort, with catastrophizing when discomfort does occur. It is based on beliefs like: "I must be able to feel comfortable all of the time."

Two Types of Disturbance 1/2: Ego Disturbance

Ego disturbance: - emotional tension resulting from the perception that one's 'self' or personal worth is threatened - and lead to other problems such as avoidance of situations where failure, disapproval, etc. might occur. - looking to other people for acceptance; and unassertive behaviour through fear of what others may think.

The Self-Defeating Rules (Irrational Beliefs)

Ellis suggested that a small number of core beliefs underlie most unhelpful emotions and behaviours. Core beliefs are underlying rules that guide how people react to the events and circumstances in their lives. Here is a sample list of such of these: 1. I need love and approval from those around to me. 2. I must avoid disapproval from any source. 3. To be worthwhile as a person I must achieve success at whatever I do. 4. I can not allow myself to make mistakes. 5. People should always do the right thing. When they behave obnoxiously, unfairly or selfishly, they must be blamed and punished. 6. Things must be the way I want them to be. 7. My unhappiness is caused by things that are outside my control - so there is nothing I can do to feel any better. 8. I must worry about things that could be dangerous, unpleasant or frightening - otherwise they might happen. 9. I must avoid life's difficulties, unpleasantness, and responsibilities. 10. Everyone needs to depend on someone stronger than themselves. 11. Events in my past are the cause of my problems - and they continue to influence my feelings and behaviours now. 12. I should become upset when other people have problems, and feel unhappy when they're sad

CHAPTER 5: Assessment and Diagnosis Assessing the Social and Family-Related Symptoms

Important to have family members, friends and/or important others in the addict's life Family Questionnaire (Figure 5.2, Page 136) Information gathered from others can be compared with the responses given by the client in order to assess the degree of minimization or denial Common Social Consequences: Frequent job loss A driving under the influence (DUI) arrest or other legal problems Break-up of important relationships A series of moves ("The geographic cure") History of psychological or medical problems Lack of interest in activities that were once important

LEFT OFF HERE AT 743PM 4/3/17

LEFT OFF HERE AT 743PM 4/3/17

Lecture Notes Week 8

Lecture Notes Week 8

Lecture Notes, Week 6

Lecture Notes, Week 6

CHAPTER 5: Assessment and Diagnosis Dual Diagnosis

Many individuals with substance abuse problems also meet the criteria for other psychological disorders. Other social and familial factors appear more frequently in substance-abusing groups. Genetic factors Lack of Family Cohesiveness (Early death or divorce or separation of parents) Adolescent behaviors - Adolescents who later became substance abusers are more likely to: o Identify with groups who shared alcohol and drugs during adolescence o Be more impulsive o Display greater evidence of rebelliousness and/or nonconformity - Relationship between suicide and substance abuse Approximately 25% of substance abusers entering treatment have made a suicide attempt at some point in the past

CHAPTER 7: Individual Treatment Substance Abuse Counseling: Theory and Practice / Fifth Edition

Patricia Stevens, Robert L. Smith Prepared by: Dr. Susan Rose, University of the Cumberlands

HOMEWORK Course Content: Week 8

Probably the most important REBT strategy is homework. This can include such activities as: Reading Self-help exercises Experiential activities Journaling Thought Stopping Intentional Reframing Therapy sessions are really 'training sessions', between which the client tries out and uses what they have learned. ABC's of REBT A →B →C A = Activating Event B = Beliefs, Thoughts, Attitudes, Assumptions C = Consequences, Feelings, Emotions, Behaviors, Actions Nouveau ABC's

Definitons of Terms

Psychotherapy - set of clinical techniques use to improve mental health. Counseling = psychotherapy. Behavior Therapy (Behavior Modification Therapy) - changing somebody's behavior Classical Conditioning - creation of response to stimulus (Pavlov's dogs) Operant Conditoning - learning through positive and negative reinforcement Cognitive Therapy - psychotherapy aimed at changing way of thinking.

TEXTBOOK - Chapter 5

TEXTBOOK - Chapter 5

Principles of REBT

The basic aim of REBT is to leave clients at the completion of therapy with ● The freedom to choose their emotions, behaviours and lifestyle (within physical, social and economic restraints) A method of self-observation and personal change that will help them maintain their gains. ●Realisticthoughts,emotions,andbehavioursthatarein proportion to the events and circumstances an individual experiences. ● AHereandNoworientation. ● Finally, the emphasis is on profound and lasting change in the underlying belief system of the client, rather than simply eliminating the presenting symptoms. The client is left with self-help techniques that enable coping in the long-term future.

7. Emotional Reasoning -

You assume that your negative emotions necessarily reflect the way things really are. "I feel it, therefore it must be true." Example: "I feel stupid, therefore I am stupid." "I feel overwhelmed and hopeless, therefore my problems must be impossible to solve."

6. Magnification (Catastrophizing) or Minimization -

You exaggerate the importance of things (such as your mistakes or someone else's achievement), or you inappropriately

5. Jumping to Conclusion -

You make a negative interpretation even though there are no definite facts that convincingly support your conclusion. a. Mind reading - You arbitrarily conclude that someone is reacting negatively to you and you don't bother to check it out. Example: Your spouse is upset about work and is quiet at home. You think, "She's mad at me. What did I do wrong?" b. Fortune Teller Error - You anticipate things will turn out badly and you feel convinced that your prediction is an already established fact. Example: You call your friend who doesn't get back to you. You don't call back and check out why because you say to yourself "He'll think I'm being obnoxious if I call again. I'll make a fool of myself." You avoid your friend, feel put down and find out he never got your message.

3. Mental filter -

You pick out a single negative detail and dwell on it exclusively, thus perceiving that the whole situation is negative and filtering out the positive. Example: in a 20 minute oral presentation, for 2 minutes you lose your concentration and feel you are rambling. Because of this you think, "I gave a horrible presentation," discounting that for 18 of the 20 minutes you performed well.

2. Overgeneralization -

You see a single negative event as a never ending pattern of defeat. Example: When one woman declined a date, the man concluded, "I'm never going to get a date. No one will ever want me."

Cognitive Distortions - Course Content Week 8 1. All‐or‐nothing thinking -

You see things in black or white categories. If your performance falls short of perfect you see yourself as a total failure. Example: A straight A student who receives a B on an exam concludes, "Now I'm a total failure."

10. Personalization -

You see yourself as the cause of some negative external event which in fact you were not primarily responsible for. It causes you to feel extreme guilty. Example: A father sees his child's report card with a note from the teacher indicating the child isn't working well. He immediately replies, "I must be a bad father. This shows how I've failed."

8. Should Statements -

You try to motivate yourself with should and shouldn'ts as if you have to be whipped and punished before you could be expected to do anything. Musts and oughts are also offenders. The emotional consequence is guilt. When you direct should statements at others you feel anger, frustration and resentment. Example: "I should have gotten all the questions right," causes feelings of guilt. "He should have been on time," causes feelings of resentment, anger and frustration.

Most important aspect of any assessment, the cornerstone of the diagnostic process

a carefully planned and conducted diagnostic interview - questions about client's habits of using both prescription and/or illicit drugs, alcohol, tobacco and caffeine - include family, friends, coworkers, etc. (collateral interviews) - assessment of a clients readiness for change

Mental health problems -

can have both psychological, social and somatic dimensions. These issues often make it hard for people to manage their lives and achieve their goals. Therapists/mental health professionals are expected and legally bound to respect client privacy and client confidentiality.

Tolerance:

decreasing effects of a drug on the body, due to repeated ingestion and habituation, resulting in the need to greatly increase the amounts of the drug to achieve intoxication

Diagnosis is perhaps most relentlessly complicated by:

denial and minimization of the severity of a drug abuse problem (denial is cognitive dissonance, it solves their internal dichotomy, the imbalance between I like doing this, but I know its bad for me)

"Substance":

drug of abuse, a medication, or a toxin that is used in a manner incongruent with medical treatment - it is NOT the substance itself, but the manner in which it is employed that provides the critical information for a diagnosis of substance abuse or dependence

Skunk identification

if it looks, smells, and walks like a skunk, it's probably a skunk

Phase Two: The Crucial Phase

labeled "crucial" because it offers the most hope for an intervention in the growing physical and psychological dependence before some of the more severe medical and social consequences enter the picture. Behavioral symptoms include: - loss of control of substance use - denial and minimization of use - confrontation by others - behavioral loss of control - guilt and remorse - periodic abstinence or change in patters of use - losses (friends, divorce, job or financial setbacks, hobbies, or a normal daily routine that does not revolve around substance use, less obvious include loss of willpower, self-respect, abandonment of moral or spiritual values) - medical and psychological interventions - growing alienation and resentment - more frequent substance use

Cognitive Distortions

shrink things until they appear tiny (your own desirable qualities or the other person's imperfections). Example of Magnification: A student answers a professor's question incorrectly and thinks, "How awful. Now he thinks I', stupid and I'll fail this class, never graduate and never get a good job."

Assessment:

the "act of determining the nature and causes of a client's problem"

Social Characteristics

the primary relationship eventually becomes the relationship with the substance, and social relationships suffer

Phase Three: The Chronic Phase

typified by a more profound loss of behavioral control and by the physical manifestations that accompany chronic drug or alcohol abuse. General symptoms: 1. continuous use of the substance for longer periods 2. indefinable fears and vague spiritual desires 3. impaired judgment and irrational thinking 4. tremors, malnutrition, overdoses, decreased tolerance, and/or other physiological problems associated with the drug 5. obsessive use of the substance until recovery or death

Barriers to treatment: the incorrect concept by the counselor that substance abusers are all:

uncaring, irresponsible, untrustworthy, dangerous, or untreatable

Treatment Plan Course Content: Week 8

• Who is involved? Mental Health Techs, Nurses, Clinicians, Case Managers • Reinforce/implement cognitive interventions included in the tx plan. • Read the tx plan & reinforce items with in your scope of practice • Chart to the treatment plan. • If the Treatment Plan indicates "client will be redirected from discussing substance use" you may chart something like, "client was redirected from discussing substance use four times this evening." • Separate course on charting to the Treatment Plan.

CHAPTER 5: Assessment and Diagnosis DSM-IV Diagnosis: Criteria for Substance Dependence

● A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 3 (or more) of the following, occurring at any time in the same 12-month period: 1. Tolerance 2. Withdrawal 3. Substance is taken in larger amounts or over a longer period than was intended 4. A persistent desire or unsuccessful effort to cut down or control substance use 5. A great deal of time is spent in activities to obtain the substance, use the substance or recover from its effects 6. Important social, occupational, or recreational activities are given up or reduced because of substance use 7. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by a substance

CHAPTER 5: Assessment and Diagnosis DSM-IV Diagnosis: Criteria for Substance Abuse

● A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring at any time in the same 12-month period: 1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home 2. Recurrent substance use in situations in which it is physically hazardous 3. Recurrentsubstance-relatedlegalproblems 4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused by exacerbated by the effects of the substance

Direct Effect Strategies: Mindfulness Technique

● An avenue to effectively control stress and undesirable feelings ● "Live in the moment" ● "Sitting" with one's emotions

Individual Therapy

● Assortment of approaches: Cognitive-behavioral therapy Social skills training Behavior therapy ● Therapeutic Alliance (Counselor Relationship): Concept central to all therapeutic relations Fundamental principle: listening to the ATOD individual without passing judgment Important part of Therapeutic Alliance Validation Nonverbal communication Positive regard Language used by the counselor to create motivation toward behavioral change

Direct Effect Strategies: Cognitive- Behavioral Therapy

● Based on a theory of personality which maintains that people respond to life events through a combination of cognitive, affective, motivational, and behavioral responses ● Goals of Cognitive Therapy To correct faulty information processing To help patients to modify assumptions that maintain maladaptive behaviors and emotions ● Primary Technique: Self-control training

CHAPTER 5: Assessment and Diagnosis The Diagnostic Interview

● Collateral interviews often help to give a more complete picture of both the user and the impact they are having on others in their environment. ● Readiness for Change Transtheoretical model ● Structured Interview format Substance Use History Questionnaire

Broad Spectrum Strategies

● Coping Skills Training/Life Skills Training ● Vocational Readiness The success of maintaining recovery relies heavily on the substance abuser's ability to work and to fill the day with positive activities ● Support Groups Twelve Step Groups

Clinical Applications of REBT Course Content: Week 8

● Depression ● Anxiety disorders, including obsessive-compulsive disorder, agoraphobia, specific phobias, generalised anxiety, posttraumatic stress disorder, etc. ● Eating disorders, addictions, impulse control disorders ● Anger management, antisocial behaviour, personality disorders ● Sexual abuse recovery ● Adjustment to chronic health problem, physical disability, or mental disorder ● Pain management ● General stress management ● Child or adolescent behaviour disorders ● Relationship and family problems ● Personal growth ● Workplace effectiveness CBT effective for use with ● Self / Personal Growth ● Individual Clients ● Groups ● Marriage / relationships ● Family ● Workplace ● Varying Intellectual ability/learning impairments CAUTION: Cognitive therapies do not appear to work as well with those who are cognitively impaired.

Direct Effect Strategies

● Effective Strategies in the past: Aversion therapy Solution focus therapy Reality therapy (later replaced by Choice theory) ● Current Strategies: Motivational interviewing Cognitive-behavioral therapy Mindfulness training

Beginning Individual Treatment

● First step for treatment: Individual's mental and emotional readiness for treatment ● DiClemente's 5 Stages of Change: 1. Precontemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance ● Type of treatment depends on: Type of treatment available in the community The level of treatment that might be paid for by insurance ● Amerian Society of Addiction Medicine's 4 Levels of Treatment 1. Outpatient 2. Intensive Outpatient and Partial Hospitalization 3. Medically Monitored Inpatient 4. Medically Managed Inpatient ● Intervention: an action or occurrence that causes an individual to try quitting the use of substances Process of intervention can involve all significant people in the individual's life Individuals involved in the intervention decide to "break the silence" ● EthicalandLegalConcerns State all rules and actions at the outset All participants should be fully aware of their rights and responsibilities After the intervention and into effective treatment

Broad Spectrum Strategies: Harm Reduction

● Harm reduction includes education about the drug of choice along with therapy to encourage a decision in favor of abstaining or reducing harm. ● Harm reduction includes activities other than substance abuse, ie: Safe sexual contact, HIV, Gambling ● Harm reduction offers an alternative for individual to reduce risky behaviors in the event that s/he is not ready to separate from the drug of choice or other harmful behaviors. ● Overall goal is to assist the individual to identify copying strategies when faced with harmful events and reduce risky behaviors. ● Harm Reduction from the Therapist's Perspective Therapeutic relationship is vital Goal setting is part of the relationship One of the principles of harm reduction: "Meet the client where s/he is at" o Set proximal (short-term) goals

CHAPTER 5: Assessment and Diagnosis Diagnosis

● Inconsistent attitudes and precise standards for what constitutes an "addiction" have always complicated the diagnosis of substance abuse. ● Differential Diagnosis - It is frequently the case that one of the most challenging aspects of diagnosing substance abuse is the interplay of addiction and other mental disorders - Longitudinal approach is useful in differentiating between psychiatric and substance-abuse symptoms - Many symptoms of substance intoxication and withdrawal improve or are alleviated within days or weeks.

Introduction

● Insurance Providers have changed amount of time allowed for treatment Requires counselors to provide swift, yet efficient techniques

CHAPTER 5: Assessment and Diagnosis Issues in Assessment

● No single medical or psychological test can determine with absolute certainty that a person is drug or alcohol dependent - Inconsistencies in social attitudes complicate what actually defines substance abuse - Stigma associated with addiction leads to denial ● Several problems interfere with diagnostic process: - Therapist biases about substance abuse clients - - Client's attitude about alcohol or drugs and sense of shame in seeking help may create a barrier to accurate assessment

CHAPTER 5: Assessment and Diagnosis Behavioral Characteristics - Phase 1

● Phase 1: The Prodomal Phase In this early phase, the following behavioral changes generally occur: Increase of tolerance First blackout or loss of significant time to drug use Sneaking drinks or drugs Preoccupation with drinking or drug use Gulping drinks or hurried ingestion of chemicals Avoiding reference to drinking or drug use

CHAPTER 5: Assessment and Diagnosis Behavioral Characteristics - Phase 2

● Phase 2: The Crucial Phase In this second phase, the following behavioral symptoms generally occur: Loss of control of substance use Denial and minimization of use Confrontation by others Behavioral loss of control Guilt and remorse Periodic abstinence or change in patterns of use Losses Medical and psychological interventions Growing alienation and resentment More frequent substance use

CHAPTER 5: Assessment and Diagnosis Behavioral Characteristics - Phase 3

● Phase 3: The Chronic Phase In this last phase, the following symptoms appear and often continue in a vicious cycle until the user either dies or finds help: Continuous use of the substance for longer periods Indefinable fears and vague spiritual desires Impaired judgment and irrational thinking Tremors, malnutrition, overdoses, decreased tolerance, and/other psychological problems with the drug Obsessive use of the substance until recovery or death

CHAPTER 5: Assessment and Diagnosis DSM-IV Diagnosis

● Substance: a drug of abuse, a medication, or a toxin that is used in a manner incongruent with medical treatment. ● Substances are grouped in 11 classes: 1. Alcohol 2. Amphetamines 3. Caffeine 4. Cannabis 5. Cocaine 6. Hallucinogens 7. Inhalants 8. Nicotine 9. Opioids 10. Phencyclidine (PCP 11. Sedatives/Hypnotics/Anxiolytics (Anti-anxiety drugs)

Direct Effect Strategies: Motivational Interviewing Success

● Success of MI relies heavily on the language of the therapist Change talk: a technique in which the individual expresses the benefit for change and the hope that change will come in the future Techniques of "Change talk": Exploring the addiction Examining past experiences Looking forward to recovery and setting positive treatment goals Examining values along with behavior Identifying the positive and negatives of the current decision to change Planning and committing to change

LEARNING TO USE CBT/REBT Course Content: Week 8

● Techniques of CBT/REBT are best learned by attending an appropriate training course. ● To practice it is important to have a good understanding of irrational thinking. ● The most effective way to learn how to help clients uncover and dispute irrational beliefs is to practice on oneself.

CHAPTER 5: Assessment and Diagnosis Screening and Assessment Instruments

● The Michigan Alchoholism Screening Test (MAST) ● The Short Michigan Alcoholism Screening Test (SMAST) ● The Drug Abuse Screening Test (DAST-20) ● The Cage Questionnaire ● The Substance Abuse Subtle Screening Inventory (SASSI-3 & SASSI-A2) ● The Alcohol Use Inventory (AUI) ● The Addiction Severity Index (ASI) ● Adolescent Diagnostic Interview (ADI) ● The Millon Clinical Multiaxial Inventory (MCMI-II) ● Minnesota Multiphasic Personality Inventory (MMPI-2) ● ASAM Criteria for Patient Placement

Direct Effect Strategies: Motivational Interviewing Goals & Principles

● Two main goals: 1. To move the ATOD individual in the direction of making a positive change toward recovery 2. To resolve ambivalence by increasing internal motivation and increasing self-efficacy ● Five principles of MI: 1. Express empathy 2. Roll with resistance 3. Develop discrepancy 4. Support self-efficacy 5. Avoid argumentation

Direct Effect Strategies: Pharmacotherapy

● Way to use medications in conjunction with therapy: 1. Detoxification: To safely withdraw from a substance 2. Relapse prevention Alcohol: Disulfiram (trade name Antabuse) or Acamprosate calcium (trade name Campral) Opiate: Suboxone, buprenorphine, or methodone