Psychotherapy For Clients With Addictive Disorders.

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The 187 Models of Treatment for Addiction video Transcript and the Video Link.

TRANSCRIPT

This episode was pre-recorded as part of a live continuing education webinar.

I’d like to welcome to everybody to today’s presentation on the models of

treatment. So, what we’re really going to talk about is some different theoretical

approaches because not all of us necessarily ascribe to the same

theoretical approach and when we’re working in multidisciplinary teams

sometimes we have to think about the different influences from each person in

that team in order to make a compelling argument for what we want to have happen

in order to create that win-win situation so that’s kind of what we’re

going to look at today we’re going to define the principles of effective

treatment which hey you know good to know Psychotherapy For Clients With Addictive Disorders.

explore current trends and practices in treatment programs and those are rapidly

changing some of the things that we used to do we don’t do anymore and some of

the things that we haven’t been doing we may start doing in the not so distant

future so I’m going to interject a little bit of new stuff as it relates to

the President’s Commission on opioid use or whatever it was called that report

that just came out will identify some common approaches to treatment the main

components of each approach we’re not gonna go in depth we’re just gonna kind

of hit the highlights like I said so you can figure out if you’re working with

somebody who uses that theoretical framework how to create a win-win and

how to work together harmoniously and we’re going to compare and contrast each

approach a little bit in terms of which clients you might use it with and how it

might work in different settings such as mental health sandal own private

practice versus community behavioral health etc and maybe different ways that

you might be able to implement it so principles of effective treatment

addiction and mental health issues are complex but treatable conditions that

affect the brain the body and behavior so this is one of the new changes and

we’ll talk about that later but we’re really focusing on the whole person

now we recognize that it’s not just the way somebody thinks it’s not just their

neurotransmitters it is a whole brain body behavior thing and any change in

any one of these areas can affect the other area so if you start making better

behavioral choices then potentially like we talked about yesterday with people

with alcohol-related brain damage if they make better behavioral choices

chances are their brain health is going to improve and their body health will

improve and their mood theoretically will improve – no single treatment is

going to be appropriate for everyone so when people come into our clinic or

facility or whatever you call the place that you work we can’t necessarily

assume that group 12-step treatment or individual humanistic counseling is

going to work for them we need to look and say what does this person need now

individual humanistic may work in terms of addressing the cognitions and the

mental health stuff but they also may need some brain body stuff with either a

psychiatrist or a physician and maybe some social skills or something else so

we need to look at the comprehensive picture treatment needs to be available

to be effective and you’re thinking well duh but in the big scheme of things when

we look at how many people actually are able to access treatment only about 10%

of people with addictions are able to access specialized treatment each year

and the numbers a little bit higher for mental health but it’s not you know

wonderful you know less than 50% of people who have treatable mental health

conditions receive treatment so we want to look at why is that and one of the

reasons soapbox warning is because treatment is too expensive for a lot of

people they have deductibles that are $1,300 and up I look the average

deductible for a person a single person is $1300

which means insurance doesn’t cover anything Psychotherapy For Clients With Addictive Disorders.

until they pay the first thirteen hundred dollars out of pocket now if a

clinician charges a hundred dollars a session that’s thirteen sessions which

could be virtually the entire course of treatment before insurance even kicks in

and a lot of people don’t have that kind of money just kind of laying around so

we want to look at the affordability and availability of treatment which is one

of the reasons I push groups a lot because groups are a way that we can

provide a lot of services for affordable amounts for the clients and still you

know put food on our own tables so looking at how can we as clinicians make

treatment more available to those in our community virtual services that’s

something that we can look at telemental health so people don’t have to get

babysitters don’t have to travel group therapy having services on the weekends

or or during the evenings those are always great now you’re thinking well

that’s what I want to be with my family true so it’s always a trade-off you got

to figure out you know could you do evenings two days a week or something in

order to be available and that’s something that you know is a choice that

you’ve got to make on your own I know when we were setting up new programs, we

would always look at where the demand was where did we have the waiting list

was it the morning programs or was it the evening programs and you know what

kinds of services were in highest demand so effective treatment attends to the

multiple needs of the individual so we’re not just doing that mental health

assessment and going okay you’ve got you need the criteria for major depressive

disorder so we’re gonna treat that and we’re going to talk about all the

reasons that you’re depressed well effective treatment is also going Psychotherapy For Clients With Addictive Disorders.

to look at their nutrition their social their living environment is their stress

their their work environment and you know attending to any medical needs that

may need to be addressed to also deal with the depression current trends and

practices focus on the client competencies and strengths instead of

saying we’re going to get rid of your depression we’re going to say we’re

going to help you feel better yeah it’s the same thing but instead of

getting rid of something we’re adding something we’re putting something

awesome in its place and one of the principles of behavior modification is

that you don’t want to just punish a behavior you don’t want to just get rid

of things because if you get rid of it you have to have something to put in its

place so too often parents and caregivers and clinicians even sometimes

will get in the habit of taking away things you know or let’s take people

they make new year’s resolutions I’m gonna stop smoking I am going to stop

eating sugar, I am going to stop doing this and stop doing that well that’s

just grand but all those things serve a purpose so what are you going to do

instead, and that’s one thing that we want to ask what are we working towards

what’s our goal and what strengths does the person have maybe their social

skills are weak okay you know maybe they’ve got a lot of social anxiety that

contributes to their other mood issues okay Psychotherapy For Clients With Addictive Disorders.

well, we’ll deal with that but let’s look at what strengths they have maybe

they’re really articulate maybe they’re really smart maybe they are introverts

and they just don’t really realize that people who are introverted tend to get

more stressed out in large groups so we can help educate them about their

strengths as an individual so we want to focus on strengths and build clients up

we want to focus on what’s worked in the past instead of saying okay you’re in my

treatment program let’s start at square one we’re saying okay you’re in my

treatment program what’s worked for you before so let’s build this foundation

and figure out what kinds of tools you already have in your toolbox before we

start trying to put more stuff in there and that will also help us figure out

like I said what’s worked before if see cognitive behavioral hasn’t worked for

them before then we don’t want to throw a bunch of cognitive behavioral tools in

their direction we might ask what about it didn’t work for them so we can you

know make sure that we’re going down the right path but we’re going to figure out

for that person what helps the most and the CBT works well for people who have

um unhelpful thoughts and cognitions sometimes but sometimes if they’ve got

emotional dysregulation they may feel like the clinician just doesn’t get how

intense this is when the clinician says well you just need to change the way

you’re thinking about things they’re like it ain’t that easy doc so we want

to make sure that we provide individualized client centered treatment

and shift away from labeling you notice I try really hard not to say addicts

alcoholics I say people with addictions or addictive issues I try not to say a

person with depression I try to say a person who has depressive symptoms

because I want to look at the person I want to emphasize that the person is in

there and for me when I say a person with depressive symptoms that reminds me

that depression doesn’t look the same for most people you know there there’s a

huge variation and what depression looks like so I want to look at that person

and what symptoms they’re prevent presenting with acceptance of new

treatment goals other than for example with with substance abuse or addictive

behaviors abstinence there are some addictions especially the behavioral

ones but even eating disorders that you cannot completely abstain from you can’t

not eat you could argue the point about sex addiction some people say well you

don’t have to ever have sex you know when we’re talking about the totality of

the human organism that’s a choice that each person has to make but those are

the things that we want to look at in in terms of what is the person willing to

do and what is going to help them lead the healthiest and happiest life what

does happiness look like for them for some people you know their definition of

recovery from depression may be very different from mine but I want to look

at what are their treatment goal adoption of a recovery paradigm away

from problem focused acute care model which means we want to help them figure

out how to achieve a rich and meaningful life not just eliminate depression but

we also want to look at a recovery paradigm a recovery network if you will

it’s not just your symptomatic right now we’re gonna treat it right now it’ll go

away when it comes back you come back for more treatment you know because we

know that people who have major depressive disorder for example will

have recurrences most likely what we’re looking at is okay let’s treat what

you’ve got going on right now let’s help you start feeling better and help you

continue to feel better ie not relapse and have another episode

so we want to make sure that we’re looking not just at eliminating the

present symptoms but keeping them away integration of addiction treatment in

multiple disciplines especially primary care mental health and addiction so we

want to make sure that addiction counselors know the basics about working

with clients with have mental health issues we want to under the primary care

physicians have an understanding of how to screen for substance use issues

evidently less than 20% of primary care physicians ever receive training in that

that was from the report that came out anyhow and we want to make sure that

each area is aware of the impact of the other areas so mental health

practitioners are aware of the impact of even behavioral addictions like we’re

talking about Internet addiction which is in the dsm-5

and other other sort of sorts of behaviors we also want to make sure

they’re aware of the impact of physiological problems like polycystic

ovarian syndrome and hypothyroid okay another trend is the use of

evidence-based practices and if you are in a clinic you’ve probably heard about

this if you are in individual practice you may not have but I do want to show

you this really cool little tool and I will Psychotherapy For Clients With Addictive Disorders.

deficit by saying evidence-based practices are awesome

however in many circumstances about 85% of them require you to get go through a

certain training curriculum or whatever that can be quite expensive which is why

a lot of agencies have difficulty adopting new EB T’s because it requires

that every staff member be trained on it and that training is often several

thousand dollars so the new mandate that we start using that came out that

treatment facilities start using evidence-based practices well that’s

wonderful we’ve been saying that for a long time but how how can we make it

effective and affordable for agencies to switch over so that being said little

soapbox may be a big one the National Registry of evidence-based programs and

practices by Samsa is great because you can find an intervention search by

keywords I love databases if you can’t tell let’s

look for major depression there we go we’re just running a little slow so

there are two programs that came up in the search results depression prevention

managing your mood and partners in care now this shows whether its promises

promising outcomes or effective outcomes the depression prevention program has

evident effective outcomes evidence of effective outcomes in research for

depression and depressive symptoms so you’re thinking to yourself well that

might be something we want to implement so then you can click on that la dee da

dee da and learn more about about it how to access that evidence-based practice

now let me go back here one more time because I think this is a useful tool

seeking safety which we’re going to talk about later is it an evidence-based

practice and that’s one you can get relatively inexpensively but you can

search by program type so let’s say a mental health treatment by age let’s say

we’re working with adolescents sure why not

outcome categories mental health race ethnicity so we’re getting to more

detail about what’s going to work with this population let’s say Hispanic or

Latino and LGBTQ I TS let’s just throw that one in there I don’t know if we’re

gonna get anything that matches all of those criteria but

yeah that pushed it over a little bit once I added the special population but

you can do based on the population you serve you know them best how old are

they what they’re presenting issues are what their gender is what kind of

setting you have whether it’s inpatient outpatient court school or classroom so

there’s a lot of stuff you can look at here and find the different

evidence-based practices so ebps are not going away they are really cool they are

awesome motivational interviewing is an EBP that a lot of us have gotten trained

in over the years but you see how many years it took for that to actually get

completely integrated into practice where most people had had some training

in it okay use of medications is a new current trend in practice when you read

a lot of the insurance guidelines for reimbursement on the level of care

guidelines one of the statements in every single provider that I’ve ever

worked for in the level of care guidelines is medication is used unless

contraindicated and I mean it may be contraindicated because the person says

you know I don’t want to be on psychotropics or pain meds or whatever

it is and that’s that’s cool but all of the insurance companies that I’ve ever

worked with actually have a line item in there that says you need to consider the

use of medications for treatment and telehealth technologies are becoming

huge partly because it makes services more accessible and to a little extent a

little more affordable you’re still paying for the clinicians time and the

technology but there are a lot of other ways we can use telehealth such as

support groups in the rooms is an online chat room for people with substance

abuse issues people can log into daily virtual support groups or you can even

host one on your own website if it’s a support group you have less HIPAA issues

especially if you host it on website other than your own you create a

secondary arm that’s your aftercare support thing talk to your attorney

about HIPAA and hi-tech confidentiality issues there but there are a lot of

different things you can do you can provide chat support to your clients so

they can get more immediate in the moment support for something that’s

going on maybe there in the first month of recovery you can have forums

available forums have kind of gone by the wayside over the past 15 years or

whatever but they still get used some and it allows people to communicate

asynchronously and provide each other feedback one that I participate in spark

people it has an app is a nutrition and health and wellness app but there’s a

lot of really good interpersonal support that goes on on that in that chat room

so that’s a good place and oh there was another one I met the man the other day

that created pocket rehab is the name of the app and is only available on Apple

devices right now but pocket rehab and he has a really great program that

allows people to both do private journals as well as to receive lifeline

support from other people who are in recovery and he incorporates all

addictions not just substances but also shopping and in Internet addiction and

all those sorts of things so an online video psychoeducation

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if you have certain topics that you teach every single group that comes

through like when I when I was at the clinic in South in Florida there were

certain groups I did every single 30 days so you can record those and it

doesn’t have to be super fancy it can be like this or it can be super fancy

whatever you want and have those available online they can be password

protected so only your clients can get to them if you want to so they can watch

them at their leisure and and or you know they can participate in the group

and then they can go back and review the video

later if they need sort of a tune-up so how else can we make treatment more

available and that’s one of the things that’s going to kind of plague us

because there’s the balance between or struggle if you will between making

services available but we can make them available but we’ve making them

affordable is almost more challenging than making them available a lot of

people kind of shy away from groups especially face-to-face groups because

you know they don’t necessarily want to see their neighbor when they walk into a

room online groups have the benefit of people can’t see each other or you don’t

have to do video so people can see each other most of the time they can’t so

people feel like they maintain a little bit more anonymity online services

that’s another thing so I would encourage you to continue to think about

those principles of effective treatment duration and treatment for at least

three months is generally critical for substances definitely critical for

mental health you know really 12 weeks is not a long time for somebody who’s

struggling with major depressive disorder you know to really get some

traction in their recovery now if you’re dealing with some acute adjustment

issues obviously three months isn’t what we’re talking about but you know major

issues that are going on that’s really what we want to look at treatment plans

must be assessed continually and modified to assure that it meets the

person’s changing needs so you’re going along for three weeks and all of a

sudden the person loses their job or separates from their spouse or something

else happens or maybe even they get a promotion at work score that’s awesome

but you may still need to adjust the treatment plan based on what the

expectations were for that person to do how much time they have to devote to

treatment and the current pressures in their life if they get a promotion then

they also might have new added stressors if you will of this new job so you might

have to kind segue over and add that as an additional

treatment plan ischium treatment doesn’t need to be voluntary to be effective

what needs to happen is for us to effectively engage the person and

develop mutually agreeable goals whether you know if they’re seeing you for anger

management issues their boss said they’ve got to come to counseling for

anger management okay well they’re probably going to be pretty ticked off

but they’re having to go to these groups I don’t blame them so let’s talk about

what is it that you can get out of these groups how might this help you you know

your goal is to keep your job my goal is to help you with your anger management

how can we make these two goals kind of work together harmoniously and I used to

ask my involuntary clients my probation of parole clients what is it that you

always wanted to learn or what skill or tool might be useful in your life as

long as probation and parole is paying for it and you’re stuck with me for the

next 16 weeks what is it that I can help you work on might as well take advantage

of it because you’re stuck with me so that helps a little bit also putting

the power back in their court and empowering them to identify their

treatment goals and let you know again what they’re gonna do instead hopefully

you have the flexibility so if they say I’m not going to 12-step meetings for

example you can say okay well you need some you need a support group or you

need some sort of pro-social activity so many hours a week what are you going to

do instead the medical model of treatment looks at these issues mental

health and substance abuse more as a chronic disease issue with mental health

we’re looking at neurotransmitter imbalances with and we also have

neurotransmitter imbalances with addiction these treatments are often

hospital or doctor’s office based so you may be working with somebody it’s likely

that you’re working with somebody who is also seeing their primary care physician

or a psychiatrist for psychotropics okay so if you are

that’s fine but we need to look at it and say okay that person is addressing

this aspect of the depression or the anxiety or the addiction I’m going to

address this aspect over here we’re not really going to overlap but as the

clinician we probably are the single point of contact so we need to make sure

everything is merging together well the medical model does use a biopsychosocial

approach with an emphasis placed on physical causes and pharmacotherapy but

they do look at the psychological and social aspects a little bit and the

doctor may make some recommendations but he’s not gonna do counseling and he’s

not gonna do life skills training you may see people get detoxification

medication for symptom reduction medication for a version like antabuse

which is what they used to give alcoholics and they do still some and

medical maintenance or medication assisted therapy the spiritual model

views mood issues and addiction as being caused by spiritual emptiness which

leads to character defects such as pride resentment and anger

now the 12-step models are largely based in the spiritual model but you also

might be working with somebody who’s been working with their spiritual guide

or their spiritual leader so we want to be able to understand where that person

has been telling the client this is probably what’s causing your your issues

right now less weight in the spiritual model is given to causation and more of

an emphasis is put on a spiritual path to recovery development of values and a

sense of meaning and purpose so what we’re looking at developing hope faith

courage discipline those sorts of things which really won’t hurt anybody the

12-step models which are mutual help and many people aren’t real familiar with

twelve steps they’ve heard about them they know well if somebody has a

substance use issue they go to a a or NA well there’s a lot of a programs out

there a lot of Anonymous they emphasize that one cannot help once

self and recovery requires surrender of one’s will to a higher power now for

some people as soon as they hear that their skin starts to crawl and they’re

like oh heck to the no and for other people they embrace that and go you know

what you’re right I’ve been trying and trying and trying and I can’t do it on

my own so one of the challenges we have if we’re working with somebody who

either doesn’t believe in a higher power or who is angry at their higher power

how do we help them embrace that and one tool and I’m going to ask you to think

about other ways we can help people integrate into 12-step communities if

they don’t believe in a higher power but one tool that I’ve always been taught is

to view God as good orderly direction that is to get to your goals to get a

reaching meaningful life always think first before you act is what I’m getting

ready to do going to help me move in a good orderly direction towards my goals

or is it gonna you know throw me off track so if we’re thinking about good

orderly direction in terms of a higher power or a higher direction sometimes

that can help people deal with 12-step meetings if they were a bit resistant

because sometimes the court just requires 12-step meetings and you can’t

you have no way to get around it you can advocate till you’re blue in the face

and it ain’t gonna help so one thing that I do want to point out with that is

emotions Anonymous I said there’s a lot of eyes out their emotions Anonymous is

designed for people basically who have emotional dysregulation issues where

their emotions they go from 0 to 240 and 1.2 seconds and they feel like they’re

not able to control their anger their depression their anxiety any of those

dysphoric feelings if they’re willing to explore a 12-step sort of approach ei is

a good activity for them they have their own literature they have their own books

the meetings are not nearly as plentiful as

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there are aana meetings around but they’re always open to people starting

new meetings so if you’re interested in learning more about it maybe starting a

meeting at your facility that could be an avenue that you go down okay so how

can you use a spiritual model with clients who don’t believe in a higher

power and for me it comes down to working with them to define what

spirituality means to them and in what way they think spirituality or lack

thereof or spiritual roadblocks are contributing to their unhappiness right

now and so we get into a much more abstract conversation about what’s going

on and talking about what does recovery look like and if you’re recovering

spiritually if you were a coverage spirit spiritually what would be

different what do you need to enhance are we talking virtues or what behaviors

and we kind of pick that apart for a little while to develop their ultimate

goal plan

okay the psychological and self-medication model says that

addiction and mental health issues result from deficits in learning

thinking or emotion regulation so this is the stuff we were all taught in grad

school treatments can be ranged from behavioral self-control to individual

and group counseling to pharmacotherapy I mean we’re not opposed to helping

people figure out what may need to be addressed and advocate for them or

encourage them to advocate for themselves with their physicians in

order to access pharmacotherapy that might help them so the goals will start

with behavioral self-control training behavioral self-control is you know

think back basic behaviorism strengthen internal mechanisms so increased

self-awareness of what’s going on what you need what your triggers are or your

stimuli and establish external controls so you can implement coping skills help

people start learning how to set goals so they have something out there that

they see I need to accomplish this this week or this this month or whatever it

is and they have this external plan that’s helping them monitor and shape

their behavior you can use behavioral contracting so for example what would

you contract for with somebody who has major depression who has difficulty

getting out of bed we may contract for having the person get up by a certain

time each day and you put in rewards for achieving that and if they don’t achieve

it then we want to look at you know what what’s going on what happened there but

each day just like with standard behavioral interventions if they do what

they’re supposed to do or trying to do we need to make sure that it’s rewarding

so if they do get out of bed at whatever time you you identify

we need to make sure they have access to some sort of rewards trigger management

so encouraging people to be aware of what their triggers are I’ve told you

before one of my four as far as mental health mood triggers is the commercials

for the ASPCA and I was at the gym the other day and I looked up and they had

this poor little shivering dog in in the video and it just broke my heart I was

like okay no not even watching that but what are people’s triggers for their

mental health stuff it could be a meeting that they have to go to at work

it could be a person it could be a place but helping them identify what those

triggers are and figuring out how to work with and or through them functional

analysis of the behaviors not the diagnosis so if somebody has symptoms of

depression they meet the criteria for major depression whatever you want to

say all right we’re not going to look at what is the function of depression well

depression looks different for different people what is the function of not being

able to get out of bed not feeling you know they just don’t want to get out of

bed in the morning that’s the behavior so what’s motivating that well they may

not be sleeping well they may feel fatigued and exhausted okay let’s look

at what’s causing that because then we can figure out something to address the

underlying issue that’s causing the targeted behavior the behavior you want

to eliminate so conducting those functional analyses if somebody stress

eats okay so that’s a specific behavior so what

purpose does it serve and what else could you put in its place to satisfy it

this need instead of stress eating relapse prevention so we want to look at

relapse prevention strategies for both mental health and addiction and they’re

basically going to be the same good sleep good nutrition good social support

mindfulness relaxation and recreation you know regularly I won’t say every day

because some people just they work too jobs have six kids can’t do it okay

that’s fine but we want to make sure that these people are living or trying

to live a happy healthy life so that’s what relapse prevention is is helping

the person prevent those conditions prevent it stuff that caused the

neurochemical imbalances that led to their depression which may have led to

their unhelpful thinking so you know wherever the unhelpful thinking came in

the process you know it doesn’t really matter we end up needing to treat or

address everything but realizing that relapse prevention means preventing

those conditions from occurring again just like when there’s a hurricane

there’s a certain set of conditions that have to happen for hurricane to form

well there’s a certain set of conditions for each person that need to kind of

occur for them to have a recurrence of their major depressive episode in most

cases like 99% of the cases so we want to know what those are so we can try to

prevent them and we don’t want to know what those are and what the symptoms are

of the beginning of an episode so people can intervene early if they notice you

know what I’m starting to feel kind of wonky then they can start saying I need

to back off maybe I need to take this weekend off and rest and relax because

I’m starting to get burned out and I’m starting to feel blue and I really don’t

want to go into a whole depressive episode that’s relapse prevention so

preventing an early intervention dialectical behavior therapy came as a

response to people who weren’t doing well with traditional cognitive

behavioral clients in traditional cognitive behavioral often and

traditional therapy often unintentionally reward ineffective

treatment while punishing therapists for effective therapy with a lot of clients

when we start digging when we start pushing buttons when we start helping

them move through those stuck points it hurts and they don’t like it so in

certain circumstances among certain groups of people they

symptoms escalate so much that the therapist has to back off every time

they start to get to a point the client either discharges or rapidly escalates

or decompensates so cognitive behavioral wasn’t helping to deal with the distress

that was caused by pushing on those buttons and dealing with those old

wounds the sheer volume and severity of problems presented by clients makes it

impossible to use the standard cognitive behavioral format in many cases because

they would be doing ABC worksheets until doomsday so we need to help them figure

out how to moderate some of this distress and how to figure out what the

root causes are clients found the focus on change inherent to CBT in validating

because cognitive behavioral was often saying again this is your problem is

caused by unhelpful cognitions and behaviors that’s what you need to change

let’s you know it’s very practical very pragmatic but clients who are struggling

and who are extremely emotionally raw often felt very invalidated

so the overriding themes in DBT our mindfulness using that wise mind getting

out of the emotional reactive mind distress tolerance sometimes life is

going to be unpleasant and you can’t necessarily make it stop so what do you

do how can you address it emotion regulation and interpersonal

effectiveness and problem solving a lot of people who have emotional

dysregulation have difficulty managing those emotions and not going from 0 to

240 and 1.2 seconds they’ve had struggles with interpersonal

relationships a lot of people with borderline personality disorder

characteristics also struggle with relationships because of their lack of

internal sense of self their need for external validation so more

interpersonal effectiveness skills need to be taught but they also need to be

able to regulate their emotions and their distress another model that you

might not be familiar with but has a lot of really awesome units for straight-up

mental health is the matrix model for stimulant use now if you’re going to use

it as an evidence-based practice obviously you’re using it with stimulant

abusers but this manual for the matrix model provides you with worksheets I

mean it’s it’s a clinicians manual for identifying triggers body chemistry and

recovery thinking feeling and doing work in recovery guilt and shame sex and

recovery truthfulness trust being smart not strong talking about asking for help

so there are a lot of really awesome things that you can get some ideas off

of to do group if nothing else the goals of the matrix model are to learn about

issues critical to addiction and relapse receive direction and support from a

trained therapist and become familiar with self-help programs not just 12-step

but that can include celebrate recovery and some of those others the therapist

functions simultaneously as teacher and coach fostering a positive encouraging

relationship so a lot of this is psycho-educational like I said it a lot

of the groups are applicable to people who don’t have any addiction issues at

all motivational inherent enhancement

therapy is unique because it usually only consists of three to five sessions

period and a story it’s used to help resolve ambivalence about treatment and

abstinence or change whatever the change may be and that can be relationship

issues or whatever the therapy consists of initial and assessment battery

because you want to get an understanding of what’s going on in this person’s life

so you can provide them feedback followed by two to four individual

sessions with the therapists and they’re not usually weekly they’re spaced out

where you develop goals and you empower the person to make

Changez on their own the first treatment you want to provide feedback about the

initial assessment place the responsibility for change directly on

the shoulders of that person saying you know what you got this but I can’t do it

for you I am here to advise as much as I can but ultimately if you’re going to

change it’s the balls in your court so we want to elicit self motivational

state statements identifying the reasons they want to do it and examples of how

they’ve succeeded in the past so self motivation and self-efficacy we want to

strengthen motivation and build a plan for change so this is still the first

session it’s a long one we provide advice such as coping strategies for

high-risk situations then we provide a menu of options so here’s some advice

about you know different directions you could go here’s a menu of options for

different types of treatment different books you could read you know these are

things I think would help you here’s a laundry list now let’s figure out what

looks good to you we want to provide empathy and enhance self efficacy

so feedback responsibility advice menu of options empathy and self-efficacy in

the subsequent sessions the therapist monitors change reviews the change

43:51strategies being used and encourages change you’re the cheerleader at that

point so this is very behavioral in nature and motivational in nature and

puts a whole lot of responsibility on the person which means it’s really good

for some people who are really high functioning and really motivated family

behavior therapy I really like it’s demonstrates positive results in both

adults and adolescents it addresses not only substance use and mental health

problems but other co-occurring issues because it’s family behavior therapy not

identified patient behavior therapy so we’re looking at a whole family going

alright what’s going on here it can start addressing conduct disorders child

mistreatment family console unemployment you know the range of

things goes on we figure out what are the weak links if you will or the

trigger points in this family that are causing the identified behaviors what

they want to get rid of and how can we help them meet those goals it involves

the patient along with at least one significant other such as a cohabitating

partner or a parent so it doesn’t have to be the whole family ideally it is

everybody living in that household but it requires at least one other person

FBT combines behavioral contracting with contingency management so you set up a

contract you agree to do these things if you do there are certain rewards that

you can get and they set up the rewards therapists seek to engage families in

applying the behavioral strategies taught in sessions and acquiring new

skills to improve the home environment such as you know how do you deal with

the toddler if you know there are difficulties with child neglect or child

maltreatment you know some education about how to do that and okay when Sally

starts asking why is this blue or why is this green for the 700th time and you

just want to pull your hair out what do you do instead of losing your temper

so basically providing these tools but it’s set up in a contract with rewards

for successful completion and it does in contrast to the other things it looks at

the family system it looks at the environment and addresses

biopsychosocial spiritually environmentally the trigger points that

may be prompting the behaviors you want to eliminate seeking safety love this

one is a present focus therapy for trauma PTSD and addiction it is

available as a book with guidance for clients and clinicians and you can get

it on Amazon and it can be done in individual or group I had two clinicians

where I used to work that used to run this program or different instances of

this program and the clients loved it and did super super well as far as their

their outcomes the topics not going to go into huge

depth you can look at it on Amazon but they range from introduction to safety

PTSD and taking it taking back your power compassion creating meaning

detaching from emotional pain and grounding identifying red and green

flags and self nurturing and again you can conduct these in any order so your

particular group may need a different order and maybe you don’t work with

people who have active substance use issues so you can take that substance

group kind of out of it because this is really looking at PTSD recovery and

creating safety the socio-cultural model emphasizes the socialization process

culture observational learning and reinforcement of behaviors so somebody

using this model is really going to look at the social and family relationships

and in substance abuse recovery we often say that people need to change people

places and things well that’s easy to say but it is almost impossible to do

for most people they’re going to go back to that same environment out of which

they came because that’s the only place they have to go they don’t they can’t

afford to go to a sober-living facility that may charge $1500 a month or

something so they’re going back home so changing the culture that they live in

they live in the same neighborhood you know whatever that’s not so easy but we

can help them develop skills and tools to deal with the stressors in their

family and social relationships in their environment we can help them develop

social competency and interpersonal effectiveness playing on the

observational learning if they see John and he’s doing he’s he goes drinking

when he’s had a bad day and it seems to help him feel better and your client

says well maybe I had a when I have a bad day go out drinking we want to

encourage him to think what are your ultimate goals and is following what

John does even though it looks like it might help is that really going to help

you is that going to be the solution that you’re looking

and encourage people to work within their own cultural infrastructure to

find a safe place you know what is it that I can do where so I’m remaining

true to my culture as I define it but I’m also happy and healthy and all those

sorts of things relapse prevention is a really basic

approach and it adopts strategy is designed to help clients become aware of

cues or triggers that make them more likely to abuse substances or become

symptomatic triggers and I’ve told you before that um you know it can be

holidays it can be seasons it can be smells it can be there are a variety of

things I know for me there are certain smells that trigger really positive

memories and certain smells that trigger trauma and I’ve learned how to deal with

those triggers through practice and experience but it’s important for

clients to be able to recount if they have a smell for example that triggers a

traumatic memory for them to be able to stay in the present and not you know go

back there wherever back there was so relapse prevention helps people be a lot

more cognizant of their environment and more mindful one of the things that we

don’t we don’t usually use the words mindfulness and relapse prevention

together but you can’t have one without the other

mindfulness helps clients identify when they start feeling that queasy little

feeling that pit of their stomach that says this is not a good place for me to

be or this is gonna be stressful so they can address it early that early

intervention and it helps them look around and eliminate as many triggers as

possible so they can have positive things around

if they’re say particular you know billboard on their way to work that

triggers them they can go a different route if they see maybe they’re driving

past the neighborhood where they used to live with their expose and that just

devastates them every time they drive by it or it makes them really angry well

maybe they can find a different to work so monitoring and managing those

triggers so they’re not intentionally putting themselves in stressful or

51:24

dangerous high-risk situations and helping them develop alternative coping

responses to those cues all right so you have to drive by your old neighborhood

you get enraged when you drive by there and you’re thinking about what happened

and I can’t stand it what can you do how can you get out of that flurry of

adrenaline and get yourself to a place that’s more helpful for you for some

people you know one thing I might suggest for a client who has to do that

is to think alright if they know ahead of time they’re gonna have to drive by

that place what can they do leading up to it positive self-talk leading up to

it and distraction techniques as they pass it so maybe having their favorite

song really loud on the radio or the comedy channel on or something that can

help so they get so they get past it or if they have an unreasonable fear of

bridges what can you do if you know you’ve got to go over a bridge to get

through it so it doesn’t throw you for for a loop

now obviously those are acute responses but enough stressors could potentially

trigger a full-blown relapse of anxiety or depressive major depressive symptoms

medication assisted therapy which allegedly is supposed to be becoming

available at all treatment facilities and I’ll wait to see that happen

includes methadone suboxone vivitrol antabuse and some SSRIs you’re selective

serotonin reuptake inhibitors they’ve been found to help with certain

compulsive behaviors certain antidepressants especially zoloft it’s

53:12

been found to be really helpful with people with bulimia so there is some

evidence out there that SSRIs can help with some compulsive behaviors in

addition to mood issues vivitrol is helpful for alcohol and opiate abuse

antabuse is the thing that people take then makes them throw up and really

really sick actually it increases the rate at which they get alcohol poisoning

is technically what happens if they drink so there’s a lot of different

types of medication assisted therapy out there it’s not necessarily meant to have

somebody on it indefinitely I help start a methadone clinic where I

came from in Florida and our psychiatrist really looked at it as an

18-month treatment program get people on you know get them to the point where

they’re not having cravings to use then they had in methadone clinics you are

required by the Food and Drug not food and drug by the DEA there are all kinds

of requirements for counseling that have to take place in a methadone clinic not

in the patient not in the doctor’s offices where people go and get suboxone

that’s generally just getting them suboxone but in methadone clinics people

have to undergo pretty intensive therapy in addition to it and a lot of clinics

will only maintain people on it unless there is an overriding reason not to

discharge them for about 18 months to two years you have to present to the

powers that be at the DEA or wherever compelling reasons to keep somebody on

methadone more than two years now some of the people that I worked with that

were veterans did have chronic pain they had opiate addiction issues methadone

was being used to help monitor manage their pain you know there were some

outstanding outliers or whatever but understand that methadone really for the

most part is not meant to be something that people get on and stay on for the

rest of their lives it’s not replacing one addiction with another it’s supposed

to help them get through that period until their neurotransmitters can kick

back in and they develop the skills they can they need to develop to deal with

life on life’s terms medication assisted therapy for mental health issues are

your SSRIs SNR is your atypical antipsychotics your

antipsychotics some people need those obviously if

somebody has a psychotic disorder or a bipolar disorder they’re probably going

to have to be on medication people with a generalized anxiety and major

depressive disorder and some of your mood disorders may not have to be but it

may help them get through until they start getting some treatment traction

harm reduction is the acceptance that drug use and mental health issues are

just a reality the goal is to prevent harm caused by severe mental health

issues you know not being able to get out of bed losing your job relationship

problems you can have a lot of problems from mental health even if you don’t

have an addiction when we talk about these we talked about the for ELLs just

to make it easier to remember liver lover livelihood and law so we

want to prevent health problems we want to prevent relationship problems we want

to keep people employed and keep them from getting involved with the law

interventions for harm reduction include low threshold pharmacological

interventions so like what we just talked about if we’re talking about

drugs needle exchange programs emphasis on non-injection routes of

administration such as oral tablets and even smoking and inhalation but

injection int’l a ssin and smoking are the three fastest ways to get high and

three most potent so we want to steer people away from those as much as

possible lead more towards oral as as needed and if you’ve got somebody on

other medications you know for some sort of mental health issue I know some of my

clients who had psychotic disorders would have injectable antipsychotics but

we don’t want people ideally injecting themselves every single day unless it’s

inevitable but with the antipsychotics a once-a-month injection of the of the

antipsychotic would keep the person going so they didn’t have to remember to

take it so we want to look at harm reduction what can we do to help this

purse an involvement of those with a history

of use or distress in program development so to develop a harm

reduction program we need to ask people who have the problem what is going to

help you out what can minimize the ancillary problems caused by this

behavior condition or addiction multidisciplinary psychotherapeutic

interventions for co-occurring issues medication assisted therapy for both

addictive and mental health issues wraparound services including legal and

child care and social services to ensure people have access to necessary

resources to achieve their goals and family therapy to improve the

interpersonal environment of the person now if you can get all those in the same

facility awesome but these are all things that we need to consider when

we’re looking at providing a comprehensive treatment program there

are many approaches to dealing with mental health and addiction issues since

co-occurring issues are the expectation not the exception it makes sense to be

aware of strategies to address both or all issues or at least where to find

those evidence-based and promising practices current trends and practices

are steering clinicians to use more individualized strengths-based

biopsychosocial spiritual approaches are there any questions

you

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