HD 350 Exam 2

Five advanced techniques of MI:

"DEARS"

Precontemplation

"Denial" No intention of changing behavior Client is apathetic, therapist needs to ask questions about their life in general, the client may make connections on their own

Authority

"I was trained by expert"

Personal experience

"It has worked for me" "It has worked for another client"

Intuition

"This technique just feels right for the client"

Science

"When studied objectively, without bias, X worked much better than Y with clients, so I should use X." Not used as much as other methods to make decisions

Boundary violations:

*Role* E.g., romantic relationship, family members, child's teacher, and you can't be your client's maid of honor in their wedding

STEP 2: Tracking and Diagnostic Enactment

-Designed to systematically identify adaptive and maladaptive family patterns And to use these patterns to build a treatment plan -The therapist encourages family members to behave as they would if the counselor were not present and then diagnose interactional patterns Notice boundaries, roles, rules, etc.

STEP 1: Joining

-Joining techniques establish a therapeutic alliance with each family member and with the family as a whole -Joining requires that the therapist demonstrate acceptance of and respect towards each individual family member As well as acceptance of and respect toward the way in which the family as a whole is organized

STEP 3: Reframe

-Rephrase and relabel situations to reduce negative affect/emotions in family interactions While creating a motivational context for change Example: Daughter withdraws emotionally as her father vents his anger at her Therapist reframes the father's anger into caring by stating: "I can see how concerned you are for your daughter. You had so many dreams for her and you are worried that they will not be possible now. You must have a great deal of love for your daughter for her missteps to make you so angry." Father may respond sadly: "You are damned right. I am afraid that she has ruined her future, and she could have HIV- she won't tell me if she has been tested." The therapist would then turn to the daughter and say: "Did you know that your dad is worried about you?" STEP 4: Restructure Change the family dynamics from problematic to effective Example: Parental figures might be asked to engage in a conversation about managing the adolescent's behavior Therapist will block the adolescent from interfering with the conversation

Cognitive Behavioral Therapy (CBT); Based on several ideas:

1) The continued use of substances involves complex cognitive and behavioral processes 2) These processes are learned a. Associations develop (through conditioning) 3) These processes can be modified with the help of a warm, supportive, collaborating counseling relationship used to teach the client skills

During initial BCT sessions, therapists work to:

1) decrease the couple's negative feelings and interactions about past and possible future drinking/drug use 2) encourage positive behavioral exchanges between the partners "Catch Your Partner Doing Something Nice" exercise Each partner notices and acknowledges one pleasing behavior that the significant other performs each day "Caring Day" assignment Each partner plans ahead to surprise the other with a day when he/she does some special things to show caring Planning and engaging in mutually agreed-upon shared rewarding activities is important Many substance abusers' families have lost the custom of doing things together for pleasure Regaining it is associated with positive recovery outcomes

MI Principles:

1. Motivation is due to interpersonal interactions (collaboration; therapist and client are equals); it is not a character trait of the client a. Confrontation leads to resistance--"What is wrong with you?" b. Empathy and understanding lead to change 2. Ambivalence ("wavering") to change is normal and natural a. Competing positive and negative feelings b. Decision balance: pros and cons i. Anticipate that the client will go back and forth in decisions ii. E.g., a woman may be moved toward divorce one session, then the next she may be going on a honeymoon vacation with her husband

Rebirthing Therapy

10-year-old girl forced to do rebirthing therapy and couldn't breathe, ended up dying in therapy

Group Therapy

94% of U.S. treatment facilities use group counseling for treatment Low cost, popular

Roughly what percentage of rehabilitation facilities are abstinence-based?

99%

Evidence-based practice

A commitment to the use of therapy techniques that have been shown in the research to be helpful

Chance of a full "relapse" then depends on the following factors:

Abstinence violation effects If you think you have ruined your sobriety streak, can result in indulgence/relapse E.g., if you're on a diet and you have one potato chip, you may think: I've already ruined my diet, I might as well eat the whole bag." Outcome expectancies If you think the outcome of using/drinking will be positive, can contribute to relapse

SMART Recovery

Abstinence-based Suggests you should use techniques that are evidence-based As science changes, smart recovery takes on new techniques Focuses on changing thoughts/behaviors CBT through self-help Doesn't label those with substance use disorders as "addicts" Doesn't use disease model concept Doesn't force spirituality

"Apparently Irrelevant Decisions" (AIDS)

Addict will make unconscious decisions to get them closer to addiction Most often: re-connecting with old friends May miss hanging out with them, so they think it will be okay to be around them (don't consider the potential triggers) The lower brain is trying to get the person closer to the drug/object Because in an addicted brain, drugs are seen as survival Example: Dr. Witte and her husband talking about food while exercising May cut workout short ("we'll do our long workout tomorrow.") in order to go get food instead Counselors need to address AIDs mentioned by patients

New certification: peer support specialist

Addicts who are still in recovery but want to help others. In the future, we will likely see more peer support specialists than people with a bachelor's degree

DETOX medications for nicotine addiction

Agonist medications Nicotine Replacement Therapy Gum, nasal and oral inhalation, patch, etc. 90% of people who attempt to quit using nicotine relapse Nicotine replacement increases the rate of quitting by 50-70% Varenicline (Chantix) Partial agonist for nicotine receptors Has been found to double the chances of recovery

DETOX medications for opioid addiction

Agonists Work by activating receptors Any medication that activates or stimulates receptors Substitute the drug of addiction by acting like it E.g., nicotine patch stimulates nicotine receptors without having to smoke a cigarette E.g., methadone/suboxone: they are opioids, just a different form

Alabama certification:

Alabama Association of Addiction Counselors Alabama Alcohol and Drug Abuse Association [Preferred, international]

12-Step Programs

Alcoholics Anonymous (AA) is a 12-Step program Primary goal is to stay sober and help other alcoholics achieve sobriety (abstinence-based) Heavy focus on turning to one's higher power It takes the pressure and focus off of themselves; they don't believe in themselves, but believing in a higher power can improve their self-efficacy and combat self-blame/shame Meetings are frequent, available, and easy to find Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Crystal Meth Anonymous (CMA), Cocaine Anonymous (CA), etc.

Cognitive Distortions

All-or-nothing thinking Sometimes called "black and white thinking" Example statements: "If I'm not perfect, I have failed." "Either I do it right or not at all." "I can't have a piece of birthday cake because I'll eat the entire cake." Mental filter Only paying attention to certain types of evidence Noticing our failures, but not seeing our successes Example statement: "Yes, I've made progress, but look at all the times I messed up!" Jumping to conclusions Two key types: Mind reading Imagining we know what others are thinking "Everyone at the meeting thought I was crazy. I'm not going back." Fortune telling Predicting the future "I am going to be morbidly obese one day." Emotional reasoning Assuming that because we feel a certain way, what we think must be true Example statements: "I feel embarrassed, so I must be an idiot." "When I think about giving up video games, it makes my stomach churn. I am so scared; it will be impossible." Labeling Assigning labels to ourselves or other people Example statements: "I'm a loser." "I'm completely useless." "They're such an idiot." "I am weak." Over-generalizing Seeing a pattern based upon a single event OR being overly broad in the conclusions we draw Example statement: "That 12-Step meeting was a disaster. AA sucks." Disqualifying the positive Discounting the good things that have happened or that you have done for some reason or another Example statements: "That doesn't count." "Yes, I was sober for 3 months, but I only stayed sober because there wasn't a lot of pressure to drink." Magnification (catastrophizing) and minimization Magnification (catastrophizing) Blowing things out of proportion Minimization Inappropriately shrinking something to make it seem less important Critical word use Using critical words like "should," "must," or "ought" can make us feel guilty, or like we have already failed If we apply "should" to other people, the result is often frustration Example statement: "This shouldn't be so hard!" "I should be very thin like the models in Vogue." Personalization Blaming yourself or taking responsibility for something that wasn't completely your fault Conversely, blaming other people for something that was your fault Example statement: "I totally screwed everything up. It's totally my fault."

Future of Relapse Prevention

Altering memories around use Learning the high reward [how the drug makes them feel] Knowing the high reward drives them to use Integrate research on PTSD and phobias Memory Reconsolidation Intervention Example: treatment for patient with a phobia of spiders 1st: ask questions about the phobia 2nd: take them into a room where a spider is in a glass case (exposure) 3rd: While in the room with the spider, ask them about their feelings of fear 4th: patient is given propranolol, then leaves treatment 5th: patient returns in a week or so, and find that they are no longer afraid to be in the room with the spider Disrupted fear memory

Amplify ambivalence

Ambivalence can become paralyzing and some people can get stuck in it Recognize and verbalize your client's ambivalence Have them explore the two different sides they are dealing with Pros and cons of changing Pros and cons of not changing ·Example questions: "What do you like about [drinking, using, gambling, etc.]? Have there been any problems for you or others caused by your [drinking, using, gambling, etc.]?" "Sounds like you really enjoy [drinking, using, gambling, etc.], but you also said that you've had some problems because of it. Can you tell me more about that?"

Contemplation

Ambivalence, wavering Aware a problem exists, no commitment to action

MAINTENANCE medications for opioid addiction

Antagonists Block receptors Typically not introduced until the patient has finished detox (agonists and antagonists don't mix well)

Classical and operant conditioning are used together:

Antecedents: classical conditioning aspect happen before, cause external and/or internal triggers/cues ----External triggers---- Who are you usually with when you binge? Where do you usually binge? When do you usually binge? ----Internal triggers---- What are you usually thinking about right before you binge? What are you usually feeling physically right before you binge? What are you usually feeling emotionally right before you binge?

MAINTENANCE medications for gambling addiction

Anti-craving treatment for maintenance Naltrexone (Vivitrol) Opioid antagonist "It's amazing, I can't explain it. It's not that I don't think about gambling, but I have no real desire to go anymore." Additional medications for maintenance Antidepressants (because of high/low moods) SSRIs (e.g., Prozac, Zoloft)

MAINTENANCE medications for alcohol addiction

Anti-craving treatment for maintenance Naltrexone (Vivitrol) Opioid antagonist Reduces some of the reinforcing properties of alcohol consumption Limits desire for alcohol because no reward Acamprostate (Campral) Glutamate antagonist Reduces some of the reinforcing properties of alcohol consumption Needs to be used when treating habitual drinkers Aversion treatment for maintenance Disulfiram (Antabuse) Creates an unpleasant state—kind of like a punishment—when drinking When person drinks, they may become sick

MAINTENANCE medications for nicotine addiction

Antidepressants Buproprion [e.g., Wellbutrin, Zyban] Norepinephrine-dopamine reuptake inhibitor that also works on nicotine receptors Effects: Reduces cravings Reduces mood-related internal triggers Nortriptyline [e.g., Aventyl, Pamelor] Not as effective as Wellbutrin Inhibits norepinephrine reuptake Effects: Reduces mood-related internal triggers

MAINTENANCE medications for food addiction [only for binge-related eating disorders]

Antidepressants SSRIs Stimulants (e.g., Vyvanse) Effective in decreasing the desire to binge Because they are appetite suppressants Anti-seizure medicine Topiramate (Topamax) Controls bingeing and purging Reduces food cravings Also causes weight loss Contrave (bupropion and naltrexone) Antidepressant that controls mood-based addictions Bupropion: typically used for depression and smoking cessation Naltrexone: alcohol/opioid/gambling dependence

DETOX medications for alcohol addiction

Anxiolytics E.g., Valium and other longer half-life benzodiazepines Long half-life: stays in your system longer Help alleviate alcohol withdrawal symptoms (they are addictive though) Carbamazepine (e.g., Tegretol) Anticonvulsant Helpful in suppressing alcohol withdrawal symptoms Not an addictive drug

Vivitrol works by:

Blocking opioid receptors--by sitting in the receptor Blocking the reward from opioid use Decreasing cravings Opioid antagonists can be used to treat behavioral addictions Because endorphins land on opiate receptors and use the opioid system Won't get excitement/pleasure from gambling, etc.

What treatment can you provide?

Can provide consultation and possibly a referral

*Physical contact*

Cannot touch client in any way, unless they initiate it and even then you should not be too friendly physically

Do not disclose specific information unless police have a warrant to search

Case law: if an outside party knows therapist's knowledge of client, they could blame the therapist and cause a new/modified law

Support self-efficacy

Client's need to believe they can do it Help them see that they have experience, strength, and courage to do so Highlight success in their past If a plan for change doesn't work, make another plan to help them see that it is possible ·Example statements/questions: "You have a good plan of action!" "It sounds like you are struggling with making these changes, but you have had some success at making some changes already." "It sounds like you have made real progress. How does that make you feel?"

Grief counseling

Clients want to know therapists understand what it is like to lose someone

2012 study conducted by National Center on Addiction and Substance Abuse at Columbia University

Concluded that the U.S. is in need of a "significant overhaul" Questioned whether the country's "low levels of care that addiction patients usually do receive constitutes a form of medical malpractice"

What if client tells you they are engaged in illegal behavior to obtain drug money?

Confidential, you cannot tell police

Chance of a "lapse" depends on the following factors:

Coping skills, self-efficacy, and outcome expectancies When presented with a high-risk situation, it will result in a lapse if you: Don't know how to cope (coping skills) Don't think you have the strength to walk away or get through it (self-efficacy) Think the outcome of using/drinking will be positive (outcome expectancies)

Behavioral Couples Therapy; BCT

Couples in which one partner abuses drugs or alcohol usually also have extensive relationship problems Often high levels of: Relationship dissatisfaction Instability Verbal and physical aggression

Non-12-Step Programs

Created in opposition to 12-step model 12-step uses higher power Non-12-step is based on rational thinking and decision-making

Aspects of CBT

Daily-self monitoring ·Used to identify situations that put one at risk for use ---Self-report: 1st thing you do as a counselor E.g., what are they thinking about while bingeing? -Time of day, patterns, places, what they're eating, location, context, comments (generality of what's going on/feelings while eating)

Sex Addiction

Discussing normal/abnormal and goals for sexual behaviors and sexual relationships Addressing "grey" behaviors i.e., is it okay to talk in a chat room? Would that lead to a chat room affair? Cognitive techniques Definition of intimacy Thoughts about self-worth, etc. Medications to reduce libido Naltrexone (Vivitrol) Mood stabilizers Learning nonsexual friendship and intimacy Relationship/marital counseling Relapse prevention and lifestyle changes Peer support Sex Addicts Anonymous (SAA) Sex and Love Addicts Anonymous Program for anyone who suffers from an addictive compulsion to engage in or avoid sex, love, or emotional attachment

Stages of Change Example:

Dr. Witte's husband and his untucked shirt ·Pre-contemplation ·Denial: "Everybody else does it!" ·Had a meeting with the dean, but wore his usual outfit He felt like he wasn't dressed appropriately, sparked contemplation ·Contemplation Put belt on (contemplation) then take it off ·Preparation Ordered belt and khakis online ·Action Tucked his shirt in some days and not others ·Maintenance Changed entire closet, like many addicts change their life out ·Relapse When friends come into town, wears a hat and shirt untucked

Some forms of evidence-based therapy appear radically different than "typical" methods that counselors use

E.g., confrontation versus motivational interviewing

Patterns of functioning are reciprocal [X causes Y, and Y causes X]

E.g., criticizing partner leads to the partner drinking, which leads to more criticism, etc. Known as a "destructive cycle"

Some forms of evidence-based therapy are impractical in terms of cost, duration, etc.

E.g., restricted number of sessions by managed care Due to lack of funds, training, resources, etc.

Consensus

Everyone is using X with their clients, so I should try it"

How can you manage this stress?

Exercise, hang out with friends, force a dichotomy [work vs. home]

Relapse

Fall back into old patterns of behavior Upward spiral: learning from each relapse

Psychoeducational Groups

Focus of treatment is on educating members and fostering self-understanding Structured, agenda Usually there is a lecture, then facilitated discussion E.g., lecture on family history of people with addiction problems, then ask for personal stories Counselor-dictated; however, these can be run by those without a bachelor's degree Usually for mild substance use disorders or one minor charge on criminal record Planned lessons Time-limited Transfer of information Educational material E.g., assertiveness training, stress management Group exercises Role-play Discussions

Gay conversion therapy

Forced into hetero preference, typically ends in suicide

Case Series, Case Reports

Good for unique cases, but cannot be generalized to populations

Psychotherapeutic Groups

Have to be a licensed therapist to oversee group

Examples of "crossing a boundary":

Having a romantic relationship with client Treating a family member or close friend Texting/calling client outside of office setting

Goal of psychotherapeutic groups:

Help clients gain insight into deeper issues E.g., foundation of addiction, interpersonal problems, trauma history, etc.) Group dynamic is used for growth Group members may share common experiences Therapist can mediate discussion/sharing by asking questions such as: "Who else has father issues?" Solve any arising conflicts No agenda; however, topic may be established E.g., family-of-origin issues, shame-based issues, grief issues Counselor should be well-educated about mental illness (co-occurring disorders) and the group therapy process Confidentiality works both ways "If you share my stuff, I'll share yours" Therapist can't bring things from an individual's sessions into the group

Systematic Reviews

Highest level of confidence, can back up findings with more evidence than other studies i.e., meta-analysis [overall average effect size of several randomized controlled experiment results]

Tenacity

I have always believed that clients need X to change"

These are driven by client demand and focus on making a profit off of clients

If clients want yoga (or another service), facilities will offer them even if they aren't proven to be helpful, because it is what attracts clients to their program

Lapse and Relapse

If high-risk situations cannot be avoided, there is a chance for a lapse or relapse Lapses, if not handled correctly, lead to full-on relapses

Relapse Rehearsal

Imagine or role play a relapse situation and what to do in the situation Example: Imagine you come home one evening and your drug friend is outside your apartment with a bag full of X, which he tells you is free. Your family isn't home, and he asks to come into your apartment. What do you do?

CBT format

Initial stage of therapy Behavioral Focus on specific behaviors and situations in which internet addiction causes the most difficulty in the client's life Later stages of therapy Focus on cognitive assumptions and distortions And their effect on behavior Psychoeducation Teachers in schools Self-monitoring Thoughts and emotional states before, during, and after online activities Also, cognitions, emotions, and behavioral activity that occurs in tandem or in response to online behavior i.e., keeping a log of conflict with parents over internet use or peeing into a bottle Personal inventory of activities no longer engaged in since using the Internet Challenge cognitive distortions "just a few more minutes won't hurt" "worthless in real life" Motivational Interviewing Used to help patients gain insights into the costs and benefits of internet use Develop problem-solving strategies to reach a goal of controlled internet use Online treatment Modelled on 12-step treatment philosophies Offer books and resources for parents and teachers dealing with internet-addicted adolescent

Preparation

Intent upon taking action Decision is made, plan to act within near future E.g., decide to stop drinking

(2 *Boundaries*) What are the boundaries of the professional relationship with your clients?

It should not be a 2-way relationship that functions as a friendship You cannot disclose your personal issues with your patient, unless it is helpful in the treatment process Should not be Facebook/Snapchat friends Should only focus on the client's issues Client has disclosed private, intimate information that they haven't shared with others

One problem is that individuals in recovery believe they can be great counselors solely because they are in recovery

Lack counseling skills, experience, and other qualifications

Cohort Studies

Larger groups of people [cohorts, so can be based on age, geographic location, etc.] are studied and can be compared to general population or control groups Better for generalizations than lower tiers (case reports, case-control studies, editorials)

Strategies to address each step of RP model:

Lifestyle Imbalance Increasing lifestyle balance E.g., developing positive addictions Jogging Meditation Desire for Indulgence Substitute indulgences E.g., recreational activities, massage Urges and Craving Stimulus control techniques E.g., Removing all items associated with alcohol use Avoiding environments where previous use occurred Urge Management E.g., coping imagery Cravings/urges are only temporary, so find something to help you get through temporary period "crave surfing" or "urge surfing" Rationalization, Denial, and AIDs Revised decision matrix, which outlines: Positive and negative immediate consequences of: Decision to remain abstinent Decision to resume alcohol/drug use Positive and negative delayed consequences of: Decision to remain abstinent Decision to resume alcohol/drug use Education about warning signs of relapse (e.g., AIDs, positive expectancies, lifestyle imbalances) If a patient can identify these warning signs, they can expect them and have a better chance to avoid/handle them Relapse road maps i.e., analysis of potential high-risk situations and the available choices Used in conjunction as a high-risk situation strategy High-Risk Situation Avoidance strategies Self-monitoring and behavior assessment E.g., situational competency test Evaluate whether or not they know how to make positive decisions Analysis of relapse fantasies and descriptions of past relapses

Marlatt's Model [First Half]

Lifestyle imbalances lead to desire for indulgence Desire leads to urges and cravings Person utilizes rationalization, denial, and AIDs Leads to them being put in a high-risk situation, potentially resulting in relapse

Therapists can prevent relapse by catching on to lapses in clients

Listen for if they went off the deep-end or if they just had a small slip-up Especially relevant in binge-eaters, since food is often present May binge on one occasion, or have one of their "forbidden foods" Therapist should communicate to them that these small lapses do not mean they've fallen off the wagon

Develop discrepancy

Listen to their goals and try to create a gap between where the person has been/currently is and where they want to be Create discrepancies between their current position and their future goals in life Let them realize their current behavior is not leading them toward their goals ·Example questions to ask: "Where do you want to be in 5 years?" "On one hand, you say that your [future career/ your family/etc.] is important to you, yet you continue to [drink, use, gamble, etc.], help me understand..." "How do you think your life would be different if you were not [drinking, using, gambling, etc.]?" "How will things be in a year from now if you continue to [drink, use, gamble, etc.]?"

Express empathy

Listen to your client and get an idea of their concerns and reasons for behaving as they do View the world through their eyes, not your own When your client feels understood, they are more likely to open and share their experiences Do not be judgmental ·Example statements/questions: "Yes, making changes is hard work... it is VERY hard work!" "This must be difficult for you."

Maintenance

Long-term change in place Sustained change: new behavior replaces old

Editorials, expert opinions

Lowest level of confidence Opinions are subjective and may be inaccurate Also, may be based on a certain theoretical perspective not used by therapists universally

If you think a technique will work, what is the danger in using it?

Mark Schwartz, Castlewood Treatment Center Brainwashed patients into thinking they committed heinous acts upon others (e.g., sacrificing rituals, etc.)

Marlatt's Relapse Prevention Model: RP

Marlatt's model is one of the most well-known models used to prevent or manage relapse Marlatt proposed a cognitive-behavioral explanation for WHY people relapse Relapse doesn't happen overnight, there is a build-up to it Can notice build-up [relapse predictors] Lapses [minor slip-ups] can lead to full-blown relapses if not acknowledged effectively Relapses can be brief or major Patient can either get back on track, or fall into a downward spiral A treatment program was developed based on his explanation

Agonists used in opioid detox:

Methadone Opioid agonist Get injection each morning, and dose is slowly released throughout the day Typically get injection at a clinic, since methadone can be sold on the street Suboxone Partial opioid agonist Built in safety net if they relapse (tolerance) Active ingredients: Buprenorphine + Naloxone Buprenorphine [Subutex]: opioid agonist Naloxone controls the medication by blocking opiate effects Activated when heated up; has to be taken orally Keeps people from misusing the drug because they don't feel the pleasurable sensation Doesn't stimulate receptors as much as methadone/pain pills/ heroin

You have a duty to protect your client, even if the court gets involved

Minimize damage by staying involved, not just handing their case file off Privately discuss their case in an ethical manner How you wrote their case notes affects their case *E.g., "they robbed a bank" vs. "they engaged in risky behavior"* Legal/ethic: "I cannot confirm/deny" or "Yes, this patient is a client at my facility"

Eating Disorders

Multidisciplinary teams Self-monitoring and eating/weight regulation Collaborative weekly weighing Food journal and structured diet 3 planned meals each day, plus 2 or 3 planned snacks so there is not a 4-hour interval between meals/snacks Cognitive Techniques Addressing dietary rules: Dieting Food avoidance [forbidden foods] Addressing mood or event triggers Addressing black-and-white thinking, self-worth issues, etc. Family therapy Especially for anorexia nervosa Peer Support Overeaters Anonymous Eating Disorders Anonymous (EDA) Relapse prevention Lapse vs. relapse Addressing lapses is important in eating disorders because it is easier for them to lapse since food is always around In-patient treatment

Multisystemic Therapy:

Multisystemic family therapy For families with adolescents involved with substance abuse and/or other delinquent behaviors Treatment is based on an ecological perspective Format includes individual and family sessions And sessions with outside "systems"

What if a client tells you he/she plans to use drugs to purposefully overdose to commit suicide?

Need to break confidentiality, call hospital and put them in in-patient

*Time, place, space*

Need to have set times [time] for appointments in the office [place/space] Some therapy settings are in different settings; i.e., outreach But still have structured boundaries

Can you treat any substance use disorder?

No, because patients may have comorbid disorders [e.g., bipolar + eating disorder, etc.]

Abstinence-Based Treatment

Only works in under 10% of opiate addicts 90% of opiate addicts in abstinence-based treatment return to opiate abuse within one year Problematic because this abstinence lowers their tolerance and when they return to use, they use the same amount they did before and OD

Cognitive Behavioral Therapy

Outperforms other forms of therapy consistently

Examples of theoretical orientations:

PSYCHODYNAMIC: Not evidence-based Spend a lot of time talking about childhood in therapy Focus: how did this pattern develop as a child and over time? SOLUTION-FOCUSED: Not evidence-based No concern for what has happened in the past Focus is placed on the future ("What do you want your life to be?") HUMANISTIC: Not evidence-based Theme: every human being is trying to reach their full potential, but something (often external) is holding them back Oftentimes, parents hold people back ("I love you when...") Child learns how to get acceptance; feel judged externally Carl Rogers' theory: Give patients unconditional support and make them feel they are valued. They will naturally find full potential COGNITIVE-BEHAVIORAL: Evidence-based treatment for addiction, etc. Underlined by psychology (conditioning, etc.) Based on the National Registry of Evidence-Based Programs and Practices (NREPP), many of the therapy techniques that have "proven successful" use a cognitive-behavioral orientation

There are 3 types of groups in group therapy:

PSYCHOEDUCATIONAL GROUPS PSYCHOTHERAPEUTIC GROUPS Psychoeducational and psychotherapeutic groups are run by licensed therapists, or something similar SELF-HELP GROUPS

Coping Skills

Practice deep breathing Progressive muscle relaxation Meditation

Cognitive Restructuring

Practice thinking lapse is a mistake, not a result of personal failure

*Self-Help Groups*

Ran by a client People who want support and open doors to others who also want support Mutual support without a licensed leader Purpose is to exchange social support Emphasize treating all members fairly and giving everyone opportunity to express their viewpoints Commonly seen in substance abuse and grief domains Reciprocal helping--Give help and receive help AA is the most popular model And other anonymous groups (i.e., Gambler's Anonymous, Narcotics Anonymous, etc.) Uses the 12-step model

There are several ways to measure the effectiveness of a particular therapy technique

Randomized Controlled Trials---AKA randomized experiments Use a unique research design that helps truly determine whether a therapy technique is effective FDA: uses randomized controlled trials Usually standard in therapy techniques Structure of randomized controlled trial:

In-Class video:

Recovering addict goes into relapse: The relapsing addict talks about: How he is dealing with problems from childhood The patience it takes to abstain from the drug long-term and how impatient he is Disliking group therapy and being around others Also, he is using in a place where he used before treatment--environmental association ***How would we help him? Go through psychodynamic evaluation/treatment To handle his childhood issues Behavioral Activation Therapy/Behavioral Contract Give him small goals each week that he can complete to increase his self-efficacy and patience Remind him that recovery is a long process with many milestones and lapses, but that doesn't mean you have to fall off the wagon and give up Individual therapy Due to his discomfort around others Help him gain appropriate coping skills to manage his issues Get him out of his comfort zone, because drug use is his form of comfort

Similar treatment settings can be used:

Residential treatment Hospital/inpatient setting Intensive outpatient settings

Roll with resistance

Resistance to change is normal and should be expected Arguing with a person or creating a power struggle will make things worse Back off immediately if they resist When you tell someone what to do, they will be less likely to do it Instead: Seek to clarify and understand their situation Invite them to give you their perspective Help them come up with their own solutions ·Example statements/questions: "What do you want to do? How do you want to proceed?" "It's okay if you don't want to quit; it's your choice." "Maybe you aren't ready to quit; it sounds like it is a big part of your life right now."

Non-12-Step Groups:

Secular Organizations of Sobriety; SOS Formed in opposition to the spiritual emphasis Against acknowledging higher power Focuses on personal responsibility and the role of rational thinking in recovery with no emphasis on spirituality Rational Recovery; RR Views alcoholism as reflecting negative, self-defeating thought patterns Also view alcoholism as a voluntary behavior Goal is abstinence Focus is on self-efficacy No consideration of religious matters Moderation Management; MM Welcomes anyone concerned about their drinking (regardless of the level of consumption) Not about abstinence, focus is on cutting back (moderation) Goal is to reduce drinking Specific guidelines for cutting back are made E.g., "I can't have more than 2 beers a night and I can't drink more than 7 beers in a week."

SSRIs and MAOIs

Selective Serotonin Reuptake Inhibitors (SSRIs) [e.g., Prozac, Zoloft] work by: Increasing the amount of serotonin in the synapse by blocking reuptake pumps Therefore, serotonin remains in the synapse longer because it is not transported back into the neuron Result: more serotonin in the synapse, can re-connect to serotonin receptors Monoamine Oxidase Inhibitors (MAOIs) work by: Inhibiting enzymes that clear the synapse of neurotransmitters (prevents enzymes from degrading them, so they remain in the synapse) Specifically, monoamines (e.g., dopamine, serotonin, etc.)

Benefits of group therapy [beyond individual therapy]:

Sense of community Extra support system Learn from other people -What works or doesn't work for some vs. what counselor suggests -Offers other perspectives and other ways of learning new information -Should be facilitated by therapist (mediate disagreements, arguments, etc.)

Case-Control Studies

Several case reports on same topic or use controlled-groups for case studies Typically compare experimental group (e.g., group who gets treatment) to control group (e.g., group who doesn't receive treatment)

What form of therapy should you use with your clients?

Several decision-making methods:

*Self-disclosure*

Sharing too much of your personal information with the client 9 times out of 10, this will not help the client Your situation may be worse than the client's, causing them to withdraw and feel their issues aren't significant

Action

Short-term change is in place Active modification of behavior

Tissue box conundrum

Should you hand it to them or let them get it themselves? Handing: makes you responsible for reacting to their emotions Getting it themselves: they control emotions and handle them

Skills to cope with triggers/antecedents

Social interventions Enhancing social support Learning refusal skills E.g., having a mentor, calling someone Environmental interventions --Avoidance of cues E.g., problem gambler taking a different route home, so they don't see the billboard about the casino --Cue exposure aka "exposure therapy" Expose them to triggers/fears, so they don't elicit a response Break the association Encounter trigger without doing anything actively Just gauging how it makes them feel Better than avoidance But more dangerous Emotional interventions Enhancing coping skills to regulate emotions Emotions can be triggers; e.g., loneliness, anxiety, etc. Physical interventions Only short-term Distraction techniques E.g., snapping self with a rubber band when tempted, leaving the house, etc. Cognitive interventions Modify cognitive distortions [the way you are thinking]

High risk situations occur in a number of ways:

Sometimes high risk situations occur because of lifestyle imbalances which leads to desires for indulgences For example, during finals week (lifestyle imbalance) you may: Grab junk food because it is easier/more convenient Drink afterwards because you've worked so hard studying "I worked so hard studying for that test and now that it's over, I can go get drunk!" Getting the feeling that you deserve to indulge However, the RP model suggests maintaining balance [e.g., avoiding certain situations, not indulging]

Most treatment programs are in the southeastern Asian countries:

South Korea South Korean government has established a network of over 150 counseling centers for treatment of internet addiction And have introduced treatment programs at almost 100 hospitals China South Korea and China Boot camp style programs for internet-addicted adolescents

MI acknowledges that clients go through a process of change (different stages)

Stages of Change

Steps of BSFT:

Step 1: Joining Step 2: Tracking and Diagnostic Enactment Step 3: Reframe Step 4: Restructure

Marlatt's RP Model [Second Half]

Strategies to address these steps of the model: Lack of Coping Response Coping skills training E.g., relaxation training, stress management, and assertiveness training Relapse rehearsal So, they know what to expect and how to handle it appropriately Lack of Coping Response/Decreased Self-Efficacy, Positive Outcome Expectancies Efficacy-enhancing strategies E.g., viewing change process as skills acquisition, breaking down overall tasks into subtasks Decreased Self-Efficacy, Positive Outcome Expectancies Eliminating myths and placebo effects E.g., education about immediate vs. delayed of alcohol effects, using the decision matrix Initial Substance Use Lapse management E.g., contract to limit alcohol use, reminder cards with instructions on how to cope with a lapse Abstinence Violation Effect Cognitive restructuring E.g., considering lapse a mistake instead of a personal failure

Important Aspects of Neural Communication with Regard to Pharmacotherapy:

Synapse Space between 2 neurons Pre-synaptic neuron activated by drug, sensation, etc. Needs to get message to next neuron Pre-synaptic neuron releases vesicles containing neurotransmitters (e.g., dopamine, serotonin, etc.) Neurotransmitters travel across synapse to next neuron Land on specific receptors (e.g., dopamine lands on dopamine receptors, etc.) on the post-synaptic neuron [which activates as a result] Once the second neuron is activated, there are still neurotransmitters in the synapse These free-floating neurotransmitters either: Reuptake back into the first neuron Transporter proteins transport the neurotransmitters back into the first neuron Degraded by enzymes Enzymes typically end in "-ase"

·Through CLASSICAL CONDITIONING:

The client has made associations between drug use and cues in the environment These cues [e.g., popping open of a can, smell of marijuana, anxiety etc.] cause cravings Think about Pavlov's dog/food/bell experiment

Through OPERANT CONDITIONING:

The client's behavior has been shaped by rewards/reinforcement for drug use Pleasure and/or escape reinforces behavior Think about B.F. Skinner's experiments with mice and food levers

Through SOCIAL COGNITIVE THEORY:

The client's thoughts and behaviors have been shaped by the environment Behaviors, attitudes, and beliefs/expectations about drugs/alcohol learned through peer and/or family interactions

Theoretical perspective

There are many different theoretical perspectives E.g., behaviorism, psychodynamic, humanistic, cognitive, biological, public health, social work, family development, etc. What is the foundation underlying the issues? i.e., "The mother/child relationship sets the stage for all other relationships so let's talk about your relationship with your mother"

What about counselors that have never had alcohol/drug problems? Do they have a capacity for empathy?

These counselors may see clients as challenging and frustrating, they may subconsciously stigmatize or make assumptions ·However, those who can relate may be impeded empathetically ·Blinded by own personal experiences, question client

Sometimes high risk situations are not imposed by other people or the environment--i.e., random daily decisions [e.g., taking a different driving route]

They may result from: Making rationalizations Denying reality Making "apparently irrelevant decisions" [AIDs] All of these can place the person in a vulnerable situation Example: Dr. Witte and her husband are eating lunch and he tells her that he will pick up the kids from school So, on the way home, she stops in a store and shops; whereas if she had picked up the kids, she wouldn't have gone shopping

Study of addiction counselors showed that:

Those who held a 12-step treatment philosophy were significantly less likely to support a pharmacotherapy intervention even when they had been provided evidence as to pharmacotherapy's effectiveness ~90% of government funding towards substance abuse is for medicated treatment

Internet Gaming Addiction

Treatment Determine if the individual is addicted to the internet, or if their addiction stems from using the internet E.g., a gambler who uses the internet to gamble has a gambling addiction, not an internet addiction Treatment goals should be realistic given the pervasiveness of the Internet in school and home life Abstinence from the internet may not be possible Role in homework, assignments, social life, etc. Controlled or regulated Internet use is often the target goal CBT strategies For internet addicted adolescents Monitoring their thoughts and identifying those that trigger addictive feelings and actions Learning new coping skills and relapse prevention strategies For internet addicted adolescent and their parents: Learning how to manage online relationships Techniques for controlling impulses Techniques for recognizing and stopping problematic behavior Parent training Teaching parents to recognize their child's emotions Increase problem solving and communication between family members Develop techniques for managing adolescents with problem technology use

Gambling Addiction

Treatment Self-monitoring Wins/losses E.g., how much money they've lost and how much money they could lose if they continue to gamble Moods, Thoughts, etc. Challenge cognitive distortions Gamblers fallacy Illusion of control Imagery to enhance self-efficacy Visualizing going to a club/casino and pulling back Puts gambler more in seat of control over their problem External controls Ban self from casino Lock internet Keeping money out of pockets Lifestyle changes Alternatives to gambling Coping techniques Exercise Deep breathing Guided meditation Visualize going to club or casino and pulling back Peer support Gamblers Anonymous Maintenance medication Naltrexone (Vivitrol) Relapse prevention Lapse vs. relapse

Evidence-Based Practice

Treatment you are providing has evidence to support its effectiveness

·Licensed Psychologist

Treats patients based on pathology (e.g., bipolar, drug abuse, etc.)

·Licensed Clinical Social Worker (LCSW)

Treats patients in different contexts [E.g., using food to cope with depression]

*Most SERIOUS boundary violation is that of a sexual nature*

Unethical for both current and former patients They are attracted to you because of your position in their life

Contingency Management and Behavioral Contracting

Used in CBT Agree to make changes and alter the reward schedule so rewards come when new behaviors are implemented [e.g., behavior contract] Make it formal, patient needs to sign

Functional Analysis

Used to determine antecedents and consequences

Behavior:

What and how much do you usually eat? Over how long a period do you usually binge?

Long-Term Negative Consequences

What are the negative results of your binge eating in these areas? Interpersonal Physical Emotional Financial Other

(Short-term and long-term consequences) Short-term Positive Consequences

What do you like about binge eating with [nobody, person/people you binge with]? What do you like about binge eating in [the kitchen, the bathroom, etc.]? What are some of the pleasant thoughts you have while you are binge eating? What are some of the physical feelings you have while you are binge eating? What are some of the pleasant emotional feelings you have while you are binge eating?

(3) Confidentiality

What if a client tells you he/she is using or selling illegal drugs? Do you have to tell the police? Only report if signals imminent danger for themselves or others E.g., your client is a drug dealer and at their last deal, someone got shot and killed; you can't/don't have to call the police

The 5 W's (triggers)

When The time periods when the client uses drugs Where The places where the client uses and buys drugs Why The external cues and internal emotional states that can trigger drug craving Whom The people the client uses drugs with Or the people from whom he/she buys drugs What happened The effects the client receives from the drugs --The psychological and physical benefits

Lapse Management

Write down instructions on how to cope with a lapse Prepare a contract to limit use during the rest of the lapse

(1) Competency requires:

education, training, and experience

MI is an

empathetic, patient-focused counseling style that increases motivation to change Curiosity, not judgment It's about what the patient brings to you, not your opinion on what they do It is grounded in theory and evidence-based >200 clinical trials, both adults and adolescents

Brief Strategic Family therapy; BSFT

family-treatment model developed for delinquent youth Believes families are the strongest and most enduring force in the development of children and adolescents

Marlatt's RP model focuses on:

high risk situations

Relationship dysfunction in turn is associated with

increased problematic substance use and relapse

What is the reward that keeps you doing the behavior?

operant conditioning

Consequences:

operant conditioning aspect The function of a behavior is determined by the consequences that follow the behavior

Vivitrol:

opioid antagonist Main ingredient: naltrexone May be an implant, injection, or pills

Also, at the beginning of BCT, the therapist and the couple together develop a:

recovery contract As part of the contract, the partners agree to engage in a daily abstinence trust discussion The substance using partner typically says something like, "I have not used drugs in the last 24 hours and I intend to remain abstinent for the next 24 hours." In turn, the non-substance-abusing partner expresses support by responding, "Thank you for not drinking or using drugs during the last day. I want to provide you the support you need to meet your goal of remaining abstinent today." The non-substance-abusing partner records the performance of the abstinence trust discussion and other activities in the recovery contract (attending self-help support groups, taking medication, etc.) on a calendar provided by the therapist In a way, this partner helps hold the substance-abusing partner accountable for keeping up their side of the contract Later sessions focus on communication skills training, problem solving strategies, etc. For example: Communication skills (i.e., paraphrasing, empathizing, and validating) can help the substance-abusing patient and his/her partner better address stressors, which will reduce the risk of relapse "Let me see if I heard you correctly, what you are saying is XXXXX" "I can understand how frustrated you must be right now..."

One concern is that drug/alcohol counselors typically

require less general education [e.g., no college degree] and less education in counseling than other professions in the counseling profession Traditionally, addicts help other addicts

Counselors without research training do not place a strong emphasis on

scientific support for a technique They are swayed more by marketing techniques than scientific evidence

High risk situations:

situations in which relapse is more likely to occur E.g., emotional distress, hanging out with your drug dealer, putting yourself in the same environment you used in before

Abstinence-based treatment is based on

tenacity "Treatment is just supposed to be abstinent"

Brief Strategic Family Therapy is based on:

the Family Systems Model --Families are interdependent systems Hierarchy Each family system has a structural hierarchy One parent (or both parents) may run the house (top of the hierarchy) Child may run the household Out-of-control child may be the focus of attention in the house, putting them in control at the top of the hierarchy Alliances Sometimes certain family members will join together to form an alliance They may share secrets with each other, but not the rest of the family They may "team up" against other people in the family or attend events together, etc. Triangles Sometimes 2 people don't feel comfortable expressing conflict or negative emotions toward each other So, they bring in a 3rd party to help reduce the conflict/emotions Example: Parents are dissatisfied in their marriage May start focusing on teenager's misbehavior so they don't have to talk about their own problems OR one parent may talk to the daughter/son about the other parent so they don't have to talk to each other directly --The family's habitual or repetitive patterns of interaction influence the behavior of each family member --Families have a state of homeostasis Family seeks a constant state of stability or balance When one member of the family changes, it will impact the other members of the family AND the overall balance/stability of the family system Example: Father lost his job, stress level in house increased which caused you to feel depressed Mother had to find second job to cover the bills and you had to help your father with meals because your mother works all the time --Families have rules Rules are established to help maintain homeostasis Typically unspoken but everybody in the family knows them Examples: Nobody takes the remote control from dad Nobody talks about mom's alcoholism We say "I love you" when we get off the phone with each other --Family members have roles Roles are established to maintain homeostasis Each member in the family has a role (or multiple roles) Roles include: Peacekeeper Troublemaker Mediator Responsible one, etc. --Family members have boundaries between each other The connection/bond between 2 family members can vary dramatically 2 people might exchange information, express emotions, and share secrets with each other Other family members may know nothing about each other, rarely talk to each other, and rarely impact each other Boundaries can range from enmeshed (no boundary between 2 people) to rigid (closed boundary between 2 people)

Sometimes cues/triggers are present which cause

urges/cravings Cues/triggers can be: People, places Emotional states [e.g., depression, anxiety] Interpersonal interactions [e.g., rejection, conflict, etc.] Arguments in romantic relationships, familial relationships, peer relationships, etc. Social pressures "Come on, just have one beer with me!"

Meta-analysis

used to prove technique's effectiveness

Research suggests that counseling style differs

·Counselors without a history of substance problems use different treatment methods, have different belief systems, and adhere to ethical standards differently than counselors in recovery ·Counselors in recovery may be more likely to help client in the middle of the night, visit them at home or vice versa, etc.

Examples of Therapy Techniques that are Discredited (And Some Even Harmful)

·Critical Incident Stress Debriefing--Used for PTSD ·Scared Straight Interventions ·Facilitated Communication ·Attachment Therapy--E.g., rebirthing therapy ·Recovered memory techniques--E.g., hypnosis, guided imagery ·Therapy for dissociative identity disorder (DID, multiple personality disorder) ·Grief counseling for individuals with normal bereavement reactions--May be grieving normally and do not need counseling, but are forced into it ·Expressive-experiential therapies--E.g., focused expressive psychotherapy, gestalt therapy, encounter groups) ·Boot camp interventions for conduct disorder ·Drug Abuse and Resistance Education (DARE) programs ·Thought-field therapy--I.e., finger tapping

States have different requirements for counselor/therapist credentials

·Licensed Clinical Mental Health Counselor (LPC) ·Licensed Clinical Social Worker (LCSW) ·Licensed Marriage and Family Therapist (LMFT) Those with LPC, LCSW, or LMFT credentials can have their own practice without a supervisor ·Licensed Psychologist

States have different requirements for drug and alcohol counselors; Certification

·Lower than a license ·Only shows competency

(4) Counselors in Recovery

·One-third of all addiction counselors are addicts in recovery ·AA guidelines suggest at least 3-5 years of sustained recovery before becoming a counselor Informal standard You may have an opinion on a recovery method that worked for you that the client may not like (e.g., 12-Step Program, going cold turkey, etc.) If a client is using your drug of choice, it can cause triggers (e.g., odors, actions)

MI Techniques; Five basic techniques to use early and often in MI:

·Open-ended questions: "Tell me about it" ·Reflective listening "It sounds like..." (makes them talk more) Most powerful and cheesy technique ·Affirmation/validation: "Good idea" "How did you think of that?" "How did you do that?" ·Summarization: "So, let me see if I have this right, you said XXX" (good and bad) ·Eliciting change talk: "What are the costs/benefits of changing and of not changing?"

Stages of Change: Vignettes

·Pre-contemplation Toby has been drinking a considerable (4-5 times per week) amount of alcohol during the last 6 months and his friends have noticed that he is having personality and mood changes. They have tried to talk to him about their concerns, but he continues to defend his behavior and assures them he doesn't have a problem. ·Contemplation Margaret is considering cutting back on her pot smoking. She doesn't feel like it is a problem, but believes she needs to cut back because she has recently taken a job that requires her to do a considerable amount of public speaking. She perceives that her public speaking is a lot better when she hasn't been smoking a lot of pot. On the other hand, she wonders if it might be the late nights out with friends, not the pot smoking, that causes her to feel she is not as good a speaker as she could be. ·Preparation Steve has gained a lot of weight in the last year. He often feels out of control when he eats and has cravings for certain high fat, high carb foods. He is starting to get concerned so he made an appointment with a nutritionist. Sharon has been concerned about her gambling for the past 8 months. She called a counseling center in her community and made an appointment to talk to a counselor about her options. She also contacted the local Gamblers Anonymous and requested information about self-help meetings. ·Action Daniel has been abstinent for the past 10 days. He has mostly stayed home and slept, but he went to A.A. a few times. He is proud of himself for stopping but feels like he has to find more options. John has been in treatment before and was able to stay sober for about 6 months; he recently relapsed for about 5 days. He called his sponsor and immediately attended a 12-step meeting. He also called his old counselor for an appointment so he can get back in the substance abuse program that he attended in the past. ·Maintenance Cheryl successfully completed a substance abuse treatment program about 9 months ago. She is attending self-help meetings and has a sponsor. She wants to make sure that she does not relapse and is exploring ways to maintain long-term sobriety.

(5) Self-Care

·Prevent burnout, compassion fatigue, etc. ·Cannot do job as well if you aren't interested in it anymore ·Poor working conditions due to lack of resources, lack of support, high treatment demands from managed care and the criminal justice system ·High turnover rates for counselors

Limits to confidentiality will be explained *BEFORE* therapy begins: Confidentiality can be broken if:

·The client plans to harm him/herself or others ·The client is court-referred (have to share information with court) ·There is good evidence of abuse against children or dependents (e.g., elderly dependents) ·Other health care professionals may be given access to this data so they can provide suitable care ·Insurance companies will often have access to some of this information ·If the client has a signed consent form to allow the information to be shared with a third party

If you are licensed, can you treat ANY client that walks in your door?

·You may be competent in treating people with depression/anxiety, but not a client who has schizophrenia or addiction ·You would need to refer them to someone else who specializes in their issue, or call in a supervisor to help you effectively learn how to treat them ·Licensed does not equal competency