Module 7 Treatment Knowledge - UI Health Care science, education and ... Self-Monitoring Feedback...
Transcript of Module 7 Treatment Knowledge - UI Health Care science, education and ... Self-Monitoring Feedback...
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Unifying science, education and service to transform lives
Toolbox Training: A Substance Abuse Educational Series 2 of 40 For Mental Health Professionals First Edition
Module 7 – Treatment Knowledge
Goals and Objectives Listed below are the goals and objectives of the module and the corresponding TAP 21 competencies.
Module 7 Goals and Objectives
SAMHSA CSAT TAP 21 Competencies
Treatment Knowledge Goal: Introduce treatment and recovery models from a co-occurring specific perspective to include counseling theory, techniques, and relapse prevention perspectives. Objectives: 1. Define Evidence Based, Consensus
Based, and Best Practice; 2. Discuss the impact of the therapeutic
relationship and treatment alliance; 3. Develop co-occurring skills in best
practices implementation to include: Behavioral, Cognitive Behavioral, Cue Exposure, Contingency Management, Coping Skills, Cognitive Restructuring, Relapse Prevention, Motivational Interviewing, Stages of Change, and Pharmacological Therapy.
Transdisciplinary Foundations (TF) B. Treatment Knowledge
1. Describe the philosophies, practices, policies, and outcomes of the most generally accepted and scientifically supported models of treatment, recovery, relapse prevention, and continuing care for addiction and other substance-related problems. 2. Recognize the importance of family, social networks, and community systems in the treatment and recovery process. 3. Understand the importance of research and outcome data and their application in clinical practice. 4. Understand the value of an interdisciplinary approach to addiction treatment.
C. Application to Practice 1. Understand the established diagnostic criteria for substance use disorders and describe treatment modalities and placement criteria within the continuum of care. 2. Describe a variety of helping strategies for reducing the negative effects of substance use, abuse, and dependence. 3. Tailor helping strategies and treatment modalities to the client’s stage of dependence, change, or recovery. 4. Provide treatment services appropriate to the personal and cultural identity and language of the client. 5. Adapt practice to the range of treatment settings and modalities. 6. Be familiar with medical and pharmacological resources in the treatment of substance use disorders. 7. Understand the variety of insurance and health maintenance options available and the importance of helping clients access those benefits. 8. Recognize that crisis may indicate an underlying substance use disorder and may be a window of opportunity for change. 9. Understand the need for and the use of methods for measuring treatment outcome.
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Toolbox Training: A Substance Abuse Educational Series 3 of 40 For Mental Health Professionals First Edition
Module 7 – Treatment Knowledge Pre-session Assignment
All participants to read: Bednar, S.G. (2003). Substance Abuse and Woman Abuse—A Proposal for Integrated
Treatment. Federal Probation, 67, 52-58.
Be prepared to reflect on and discuss this article at the training session. Elective article: Walton-Moss, & B., McCaul, M.E. (2006). Factors Associated with Lifetime History of Drug
Treatment Among Substance Dependent Women. Addictive Behaviors, 31, 243-253.
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Toolbox Training: A Substance Abuse Educational Series 4 of 40 For Mental Health Professionals First Edition
Module 7 – Treatment Knowledge Agenda
ADDICTION COUNSELOR TRAINING SERIES
Treatment Knowledge
AGENDA
14-Nov-07 8:30 AM registration 9:00 AM Treatment Knowledge 10:30 AM break 10:45 AM Treatment Knowledge noon lunch 1:00 AM Treatment Knowledge
2:15 AM Referral, Service Coordination, and Documentation
3:30 AM break
3:45 AM Referral, Service Coordination, and Documentation
4:30 AM close 15-Nov-07 8:30 AM registration
9:00 AM Referral, Service Coordination, and Documentation
11:00 AM break
11:15 AM Professional Readiness: Attitudes and Values
noon lunch
1:00 PM Professional Readiness: Attitudes and Values
2:45 PM break
3:00 PM Professional Readiness: Attitudes and Values
4:30 PM close
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Toolbox Training: A Substance Abuse Educational Series 5 of 40 For Mental Health Professionals First Edition
Module 7: Handout – A Review Module 4, 5, and 6 Clinical Evaluation: Screening, Assessment and Treatment Planning
Fill-in-the-Blank
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Toolbox Training: A Substance Abuse Educational Series 6 of 40 For Mental Health Professionals First Edition
Module 7: Handout – B Review Module 4, 5, and 6 Clinical Evaluation: Screening, Assessment and Treatment Planning
Unifying science, education and service to transform lives
Toolbox Training: A Substance Abuse Educational Series 7 of 40 For Mental Health Professionals First Edition
Module 7: Handout – C Review Module 4, 5, and 6 Clinical Evaluation: Screening, Assessment and Treatment Planning
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Toolbox Training: A Substance Abuse Educational Series 8 of 40 For Mental Health Professionals First Edition
Module 7 – Handout 1 Group Exercise:
Self-Monitoring Feedback Form
Example completed Self-Monitoring Feedback Form: Day Time What Who Where Thoughts Feelings Consequences
Sat 10:00 am
Beer Alone Bar I’m worthless
Sad Jail
Sun 9:30 am
Wine Alone Kitchen I hate people
telling me what to do.
Sad My family went to the park without
me.
For Exercise:
Divide into pairs.
Choose one person to role play a client in recovery. Consider modeling a client you have worked with ensuring confidentiality.
The alternate person will role play the clinician.
Client: take a few minutes to complete the Self-Monitoring Feedback Form on the next page. This form would have been discussed with the client in the previous session and completed as homework.
Initiate a face-to-face session reviewing the Self-Monitoring Feedback Form as a guide for discussion.
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Toolbox Training: A Substance Abuse Educational Series 9 of 40 For Mental Health Professionals First Edition
Module 7 – Handout 1 (continued)
Self-Monitoring Feedback Form
Day
Time
What
Who
Where
Thoughts
Feelings
Consequences
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Toolbox Training: A Substance Abuse Educational Series 10 of 40 For Mental Health Professionals First Edition
Module 7 – Handout 2 Group Exercise:
Primary Locus of Care by Severity
Individually, write a short example from your therapeutic experiences of “one” of the four quadrants from the “Primary Locus of Care by Severity”
You will have ten minutes to complete this portion of the exercise.
In small groups of three share your example and discuss whether you believe your client was appropriate placed defending your assessment.
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Toolbox Training: A Substance Abuse Educational Series 11 of 40 For Mental Health Professionals First Edition
Module 7 – Handout 2 (continued) Group Exercise:
Primary Locus of Care by Severity
High
Sev
erity
Low Severity High Severity
A lco
hol a
nd o t
her d
rug a
buse
Mental Illness
High
Sev
erity
Low Severity High Severity
A lco
hol a
nd o t
her d
rug a
buse
Mental Illness
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Toolbox Training: A Substance Abuse Educational Series 12 of 40 For Mental Health Professionals First Edition
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Unifying science, education and service to transform livesUnifying science, education and service to transform lives
Toolbox Training: Toolbox Training: A Substance Abuse Educational Series for A Substance Abuse Educational Series for Mental Health ProfessionalsMental Health Professionals
Module 7 Module 7 –– Treatment KnowledgeTreatment KnowledgeModule 8 Module 8 –– Referral, Service coordination and Documentation Referral, Service coordination and Documentation Module 9 Module 9 –– Professional Readiness/Attitudes and ValuesProfessional Readiness/Attitudes and Values
November 14-15, 2007
Content guided : Candace Peters, MA, CADC
2007 SeriesSeptember 12-13October 17-18November 14-15December 12-13
Toolbox Training: A Substance Abuse Educational Series Module 7 – Treatment Knowledge Module 8 – Referral, Service coordination and Documentation Referral Module 9 – Professional Readiness/Attitudes and Values November 14-15, 2007 Content guided by: Candace Peters, MA, CADC
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Prairielands ATTC Toolbox Training: A Substance Abuse Series for Mental Health Professionals -- October 17-18, 2007
Welcome
Anne Helene Skinstad, PhD– Project Director
Candace Peters, MA, CADC– Director of Training
Ros Hayslett– Projects Coordinator
Duane Mackey, EdD– Native American Initiative Regional Coordinator
Peter Nathan, PhD– Faculty Consultant, University of Iowa
Ken Winters, PhD– Faculty Consultant, University of Minnesota
Welcome Prairielands Addiction Technology Transfer Center
Anne Helene Skinstad, PhD Project Director Candace Peters, MA, CADC Director of Training
Ros Hayslett Projects Coordinator
Duane Mackey, EdD Native American Initiative Regional Coordinator Peter Nathan, PhD Faculty Consultant Ken Winters, PhD Faculty Consultant
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Toolbox Training: A Substance Abuse Educational Series 13 of 40 For Mental Health Professionals First Edition
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Prairielands ATTC Toolbox Training: A Substance Abuse Series for Mental Health Professionals -- October 17-18, 2007
Announcements & Logistics
Logistics
Announcements: – Sign-in beginning of first day and sign-out end of second day– Lunch will be served at noon– Self-care
Course Expectations: Interactive participation– Small group discussion– Role play– Large group discussion– Journal article review– Module review exercises
Evaluation Forms– GPRA: Consent, Pre, Customer Survey, Follow-up– Iowa Consortium on Mental Health Evaluation
Announcements & Logistics
Logistics Announcements: Complete forms at beginning of session
Sign-in Consent ATTC National Pre-Event Form
Complete forms at end of session Sign-out ATTC Network Customer Survey—Training IA Consortium Evaluation
Participants will receive “Follow-up” survey within 30 days of session completion
ATTC Network Customer Survey—Training Follow-up
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Prairielands ATTC Toolbox Training Module 3 Clinical Eval: Screening
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This Series is Designed To:Prepare participants for the certification examinationEnhance knowledge for existing addiction counselorsImprove overall counselor competence and treatment outcomeIntroduce Technical Assistance Publication (TAP) #21
LimitationsThis Training Series is designed as a broad overview.Previous education or training is necessary in order to pass the certification exam.Each module covers a wide range of concerns issues.Some topics are addressed only briefly.You are responsible to seek additional preparatory help if necessary.
Series Design This Series is Designed To:
Enhance participant co-occurring substance abuse and mental health knowledge
Enhance knowledge for existing addiction counselors
Improve overall counselor competence and treatment outcome
Introduce Technical Assistance Publication (TAP) #21 Introduce the National Institute on Drug Abuse’s
(NIDA) Principles of Drug Addiction Treatment: A Research-Based Guide
Limitations
This Training Series is designed as a broad overview. Previous education or training is necessary Each module covers a wide range of topics and
some topics are addressed only briefly. You are responsible to seek additional preparatory
help if necessary.
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Toolbox Training: A Substance Abuse Educational Series 14 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Prairielands ATTC Toolbox Training: A Substance Abuse Series for Mental Health Professionals -- October 17-18, 2007
Module Series
1. The Addiction Complex Simplified2. Basic Counseling Skills 3. Professional and Ethical Responsibilities4. Clinical Evaluation: Screening 5. Clinical Evaluation: Assessment 6. Clinical Evaluation: Treatment Planning 7. Treatment Knowledge 8. Referral, Service Coordination, and Documentation 9. Professional Readiness: Attitudes and Values 10. Counseling Families, Partners, & Significant Others 11. Group Counseling 12. Client, Family, and Community Education
Toolbox Training Module Series
1. The Addiction Complex Simplified: A New Understanding
2. Basic Counseling Skills 3. Professional and Ethical Responsibilities
4. Clinical Evaluation: Screening 5. Clinical Evaluation: Assessment 6. Clinical Evaluation: Treatment Planning
7. Treatment Knowledge 8. Referral, Service Coordination, and
Documentation 9. Professional Readiness: Attitudes and Values
10. Group Counseling 11. Counseling Families, Couples, and Significant
Others 12. Client, Family, and Community Education
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Prairelands ATTC Toolbox Training Module 4 Clinical Eval: Assessment
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Message from SAMHSAEvery day, countless lives are enriched or saved
because of the work carried out by addiction counselors.
In a myriad of settings, competent, well-trained counselors form the relationships and carry out the strategies that help their clients move from life-threatening addiction to life-affirming recovery…
We can state with certainty that thousands of addiction counselors accomplish their missions with distinction.
Message from SAMHSA Every day, countless lives are enriched or saved
because of the work carried out by addiction counselors.
In a myriad of settings, competent, well-trained counselors form the relationships and carry out the strategies that help their clients move from life-threatening addiction to life-affirming recovery…
We can state with certainty that thousands of addiction counselors accomplish their missions with distinction.
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Toolbox Training: A Substance Abuse Educational Series 15 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Today’s Presenter’s Anne Helene Skinstad, PhD Project Director, Prairielands ATTCFaculty, The University of Iowa(319) 335 [email protected]
Candace Peters, MA, CADCDirector of Training, Prairielands ATTC(319) 335 [email protected]
Shanita Eze, MA, ADNKirkwood Community College, Iowa City, IA [email protected] Eze is a registered nurse, who also holds a Bachelor of Arts Degree in Psychology and a
Masters of Arts in Education with specialization in Substance Abuse Counseling from the University of Iowa. Shanita has extensive experience working in a variety of settings as a nurse, including the specialties of virology, hematology, and oncology. Shanita has provided Counselor/Case Manager services in office and street environments. She provided service in multiple areas: homeless outreach and case management, women and children, intake/assessment, outpatient, adolescents, group and individual counseling, and residential. In 2004, Shanita was appointed adjunct professor at Kirkwood Community College where she provides instruction to nursing students.
Today’s Presenter Anne Helene Skinstad, PhD Project Director, Prairielands ATTC Faculty, The University of Iowa (319) 335 5368 [email protected] Candace Peters, MA, CADC Director of Training, Prairielands ATTC (319) 335 5368 [email protected] Shanita Eze, MA, ADN Kirkwood Community College, Iowa City, IA [email protected] Shanita Eze is a registered nurse, who also holds a Bachelor of Arts Degree in Psychology and a Masters of Arts in Education with specialization in Substance Abuse Counseling from the University of Iowa. Shanita has extensive experience working in a variety of settings as a nurse, including the specialties of virology, hematology, and oncology. Shanita has provided Counselor/Case Manager services in office and street environments. She provided service in multiple areas: homeless outreach and case management, women and children, intake/assessment, outpatient, adolescents, group and individual counseling, and residential. In 2004, Shanita was appointed adjunct professor at Kirkwood Community College where she provides instruction to nursing students.
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Toolbox Training: A Substance Abuse Educational Series 16 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 4 Clinical Eval: Assessment
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Module 7 – Treatment KnowledgeAgenda
14-Nov-078:30 AM registration9:00 AM Treatment Knowledge10:30 AM break10:45 AM Treatment KnowledgeNoon lunch (served)
1:00 AM Treatment Knowledge2:15 AM Referral, Service Coordination, and Documentation3:30 AM break3:45 AM Referral, Service Coordination, and Documentation4:30 AM close
15-Nov-078:30 AM registration9:00 AM Referral, Service Coordination, and Documentation11:00 AM break11:15 AM Professional Readiness: Attitudes and Valuesnoonlunch1:00 PM Professional Readiness: Attitudes and Values2:45 PM break3:00 PM Professional Readiness: Attitudes and Values4:30 PM close
Agenda See Agenda Handout for more information. 14-Nov-07 8:30 AM registration 9:00 AM Treatment Knowledge 10:30 AM break 10:45 AM Treatment Knowledge noon lunch 1:00 AM Treatment Knowledge
2:15 AM Referral, Service Coordination, and Documentation
3:30 AM break
3:45 AM Referral, Service Coordination, and Documentation
4:30 AM close 15-Nov-07 8:30 AM registration
9:00 AM Referral, Service Coordination, and Documentation
11:00 AM break
11:15 AM Professional Readiness: Attitudes and Values
noon lunch
1:00 PM Professional Readiness: Attitudes and Values
2:45 PM break
3:00 PM Professional Readiness: Attitudes and Values
4:30 PM close
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Review Activity
Review Activity: Fill-in-the-blank Module 6: Clinical Evaluation: Treatment Planning Presenter will provide instructions. Refer to Handout A-C.
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Toolbox Training: A Substance Abuse Educational Series 17 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Goals and ObjectivesModule 7: Treatment Knowledge
Goal: Introduce treatment and recovery models from a co-occurring specific perspective to include counseling theory, techniques, and relapse prevention perspectives.
Objectives:1. Define Evidence Based, Consensus Based, and Best
Practice; 2. Discuss the impact of the therapeutic relationship and
treatment alliance; 3. Develop co-occurring skills in best practices
implementation to include: Behavioral, Cognitive Behavioral, Cue Exposure, Contingency Management, Coping Skills, Cognitive Restructuring, Relapse Prevention, Motivational Interviewing, Stages of Change, and Pharmacological Therapy.
Module 7: Treatment Knowledge Goals and Objectives: Goal: Introduce treatment and recovery models from a co-occurring specific perspective to include counseling theory, techniques, and relapse prevention perspectives. Objectives: 1. Define Evidence Based, Consensus Based, and Best
Practice; 2. Discuss the impact of the therapeutic relationship and
treatment alliance; 3. Develop co-occurring skills in best practices
implementation to include: Behavioral, Cognitive Behavioral, Cue Exposure, Contingency Management, Coping Skills, Cognitive Restructuring, Relapse Prevention, Motivational Interviewing, Stages of Change, and Pharmacological Therapy.
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Evidence-Based -- Best Practices
Title Slide: Evidence-Based -- Best Practices
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s. Evidence-Based -- Best Practices
The use of current and best research evidence in making clinical and programmatic decisions about the care of the client.
Evidence-Based -- Best Practices Evidence-Based:
- The use of current and best research evidence in making clinical and programmatic decisions about the care of the client
- Interventions that show consistent scientific evidence being related to preferred client outcomes.
- The use of current and best research evidence In making clinical and programmatic decisions about
the care of the client.
Consensus-based: - Agreement regarding treatment practice
achieved through the general concurrence of treatment practitioners, researchers, clients, and other experts.
- Example— Practice Guidelines in Treating Clients with Co-Occurring Disorders; TIP Manuals
- Determine the strength of available research evidence
- Integrate clinician expertise and client values in development of recommendations
Often times the term “evidence-based” and/or “consensus-based” are utilized when speaking about “best practices” and vice-a-versa.
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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What Is Our Goal for Substance Abuse Treatment?
To provide an optimum opportunity for change.
To provide persistent, incremental improvements in the quality and effectiveness of substance abuse treatment which results in better quality recovery for more people.
What Is Our Goal for Substance Abuse Treatment? – Not unlike our goal for Mental Health Treatment!
To provide an optimum opportunity for change.
To provide persistent, incremental improvements
in the quality and effectiveness of substance abuse treatment which results in better quality recovery for more people.
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What Does All This Mean?
We have an opportunity to improve treatment services.There are effective and cost-efficient treatments available for alcohol and drug dependence.
(Institute of Medicine, 1998. Bridging the Gap Between Practice and Research. Washington, DC: National Academy Press)
What Does All This Mean? We have an opportunity to improve treatment
services. There are effective and cost-efficient treatments
available for alcohol and drug dependence. Our challenge is to integrate substance abuse
and mental health services to enhance the opportunity for change in those we serve.
(Institute of Medicine, 1998. Bridging the Gap Between Practice and Research. Washington, DC: National Academy Press)
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Evidence-Based Practice for Addiction Treatment
Cognitive–behavioral interventionsCommunity reinforcementMotivational enhancement therapy12-step facilitationContingency management Pharmacological therapies
1. L. Onken (2002). Personal Communication. National Institute on Drug Abuse.2. Principles of Drug Addiction Treatment: A research-based guide (1999). National Institute on Drug
Abuse
Evidence-Based Practice for Addiction Treatment
Cognitive–behavioral interventions Community reinforcement Motivational Enhancement Therapy 12-step facilitation Contingency Management Pharmacological therapies
1. L. Onken (2002). Personal Communication.
National Institute on Drug Abuse. 2. Principles of Drug Addiction Treatment: A
research-based guide (1999). National Institute on Drug Abuse
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Evidence-Based Practices for Alcohol Treatment
Brief InterventionSocial Skills TrainingMotivational Enhancement and Motivational InterviewingCommunity ReinforcementBehavioral ContractingPharmacological
Miller et al., (1995) What works: A methodological analysis of the alcohol treatment outcome literature. In R. K. Hester & W. R. Miller (eds.) Handbook of Alcoholism Treatment Approaches: Effective Alternatives. (2nd
ed., pp 12 – 44). Boston: Allyn & Bacon.
Evidence-Based Practices for Alcohol Treatment
Brief Intervention Social Skills Training Motivational Enhancement and Motivational
Interviewing Community Reinforcement Behavioral Contracting Pharmacological
Miller, W.R, Brown, J. M., Hester, R.K., Wilbourne, M.S. (1995). What
works: A methodological analysis of the alcohol treatment outcome literature. In Hester, R.K., & Miller, W.R. (Eds.). (2000). Handbook of Alcoholism Treatment Approaches: Effective Alternatives. (2nd ed., pp. 12 – 44). Boston: Allyn & Bacon.
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Evidence Based Practices for Adolescents
Parent Training: Family Check-up Model (Kavanaugh, K., and Dishion, T.J., 2002)
Family TherapyCognitive Behavioral TherapyOut-of-Home CareWhat Doesn’t Work
Evidence Based Practices for Adolescents
Parent Training: Family Check-up Model (Kavanaugh, K., and Dishion, T.J., 2002)
Family Therapy Cognitive Behavioral Therapy Out-of-Home Care
What Doesn’t Work
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Bio-Psycho-Social Model
Assessment– Biological: illness, head injury, allergy,
medications, chronic pain, dental, optical, lice, skin irritations, hearing, physical abuse, liver disease
– Psychological: DSM-IV, domestic abuse
– Social: housing, child care, transportation, legal, family, culture
Bio-Psycho-Social Model Assessment
– Biological: illness, head injury, allergy, medications, chronic pain, dental, optical, lice, skin irritations, hearing, physical abuse, liver disease
– Psychological: DSM-IV, domestic abuse
– Social: housing, child care, transportation,
legal, family, culture
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Therapeutic Relationship
Title Slide – Therapeutic Relationship
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Therapeutic Relationship
Therapeutic Alliance– Definition– Ethical Responsibilities– Power distribution
Therapeutic Relationship Therapeutic Alliance
– Definition – Ethical Responsibilities – Power distribution
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Nature of the Therapeutic Relationship
Experience of working in a team effort: collaboration between client and therapistExperience of Therapist as an opportunity for changeExperience of having an advocate
Nature of the Therapeutic Relationship
Experience of working in a team effort: collaboration between client and therapist
Experience of Therapist as an opportunity for change
Experience of having an advocate
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s. Therapeutic Relationship: Function
Allows the patient to express previously undisclosed emotions and thoughtsInfluences the patient through reinforcement, suggestions, etcProvides the patient with supportModels adaptive interpersonal functioning
Therapeutic Relationship: Function Allows the patient to express previously
undisclosed emotions and thoughts Influences the patient through reinforcement,
suggestions, etc Provides the patient with support Models adaptive interpersonal functioning
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Therapeutic Relationship: Client’s Development
Feeling heard, understood, accepted, respected, and empoweredFeeling the therapist is concernedFeeling the therapist is working with him or her
Therapist realistically optimisticFeeling that positive change is occurringGender and Cultural Effects: Stigma, Primary Parental Role, Domestic Abuse Cycle
Therapeutic Relationship: Client’s Development
Feeling heard, understood, accepted, respected, and empowered
Feeling the therapist is concerned Feeling the therapist is working with him or her
Therapist realistically optimistic Feeling that positive change is occurring Gender and Cultural Effects: Stigma, Primary
Parental Role, Domestic Abuse Cycle
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Therapeutic Relationship: Therapist’s Contributions
EmpathyPositive view of the patient’s motivationMaintaining trust and confidentiality
Therapeutic Relationship: Therapist’s Contributions
Empathy Positive view of the patient’s motivation Maintaining trust and confidentiality
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Group Exercise: Journal Article Review
Group Exercise: Journal Article
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Toolbox Training: A Substance Abuse Educational Series 23 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Journal Article Review
Required Reading:Bednar, S.G. (2003). Substance Abuse and Woman Abuse—A Proposal for Integrated Treatment. Federal Probation, 67, 52-58.
Optional Reading:Walton-Moss, B., McCaul, M.E. (2006). Factors Associated with Lifetime History of Drug Treatment Among Substance Dependent Women. Addictive Behaviors, 31, 243-253.
Journal Article Review Required Reading:
Bednar, S.G. (2003). Substance Abuse and Woman Abuse—A Proposal for Integrated Treatment. Federal Probation, 67, 52-58.
Optional Reading:
Walton-Moss, B., McCaul, M.E. (2006). Addictive Behaviors, 31, 243-253.
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Evidence Based – Best Practices (cont)
BehavioralCognitive BehavioralCue ExposureContingency ManagementCoping SkillsCognitive RestructuringRelapse PreventionMotivational InterviewingStages of ChangePharmacological
Evidence Based – Best Practices Behavioral Cognitive Behavioral Cue Exposure Contingency Management Coping Skills Cognitive Restructuring Relapse Prevention Motivational Interviewing Stages of Change Pharmacological
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Behavioral and
Cognitive Behavioral
Title Slide - Behavioral and Cognitive Behavioral
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Toolbox Training: A Substance Abuse Educational Series 24 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Behavioral
Substance abuse is an interplay of internal states, behaviors, and environment
Nothing is entirely “biological”
Looking at behavior and environment leads to optimism about treatment
Behavioral Substance abuse is an interplay of internal states,
behaviors, and environment
Nothing is entirely “biological”
Looking at behavior and environment leads to optimism about treatment
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Prairelands ATTC Toolbox Training Module 4 Clinical Eval: Assessment
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1 Ounce of Behavior Change
is worth
10,000 Pounds of Insight
1 Ounce of Behavior Change
is worth
10,000 Pounds of Insight
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Behavioral Conditioning
Classical Conditioning– Particular stimuli related to the addictive
behavior
Operant Conditioning– Past addictive behavior produced positive
consequences
Behavioral Conditioning Classical Conditioning
– Particular stimuli related to the addictive behavior become paired with the behavior
– Further contact with such stimuli produce conditioned response
Operant Conditioning – Past addictive behavior produced positive
consequences – Future use in presence of discriminative
stimuli – Addictive behavior is more rewarding than
alternatives
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Toolbox Training: A Substance Abuse Educational Series 25 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Self-Control
• Self-Monitoring provides a functional analysis of addictive behavior.
• Assesses self-defeating thinking, high risk situations, skill deficits, consumption patterns, emotional states, cues and risks for relapse.
• Helps clients develop alternative coping skills
Self-Control • Self-Monitoring provides a functional analysis of
addictive behavior.
• Assesses self-defeating thinking, high risk situations, skill deficits, consumption patterns, emotional states, cues and risks for relapse.
• Helps clients develop alternative coping skills
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Behavioral: Self-Monitoring
• As little as 2 weeks of self-monitoring before treatment can often highlight the situational antecedents and skills deficits that underlie an addictive behavior pattern.
Roger H. Peters PhD, Richard K. Sherman, MS, Richard Sandberg, and Alan Marlatt
Behavioral: Self-Monitoring • As little as 2 weeks of self-monitoring before
treatment can often highlight the situational antecedents and skills deficits that underlie an addictive behavior pattern.
Roger H. Peters PhD, Richard K. Sherman, MS, Richard Sandberg, and Alan Marlatt
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Self-Monitoring Feedback Form
My family went to the park without me.
SadI hate people telling me what to do.
KitchenAloneWine9:30 amSun
JailSadI’m worthless
BarAloneBeer10:00 amSat
ConsequencesFeelingsThoughtsWhereWhoWhatTimeDay
Self-Monitoring Feedback Form See Module 7 – Handout 1 for details.
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Toolbox Training: A Substance Abuse Educational Series 26 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Group Exercise: Self-Monitoring Feedback Form
Title Slide - Group Exercise: Self-Monitoring Feedback Form
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Group ExerciseDivide into pairs.Choose one person to role play a client in recovery. Consider modeling a client you have worked with ensuring confidentiality.The alternate person will role play the clinician.Client: take a few minutes to complete the Self-Monitoring Feedback Form. This form would have been discussed with the client in the previous session and completed as homework.Initiate a face-to-face session reviewing the Self-Monitoring Feedback Form as a guide for discussion.
9:45 am
Group Exercise See Module 7 – Handout 1 for details.
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Cue Exposure
• Urges and cravings are often triggered by emotional states and external events
• Reduce and eliminate exposure to cues or high risk situations.
• Teach clients that cues are early warning signals to develop immediate alternative activities.
10:30 am
Cue Exposure • Urges and cravings are often triggered by
emotional states and external events that have been paired with addictive behavior.
• Reduce and eliminate exposure to cues or high
risk situations. (Covert Sensitization Strategies)
• Teach clients that cues are early warning signals to develop immediate alternative activities that reduce and eliminate exposure to the cue.
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Toolbox Training: A Substance Abuse Educational Series 27 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Contingency Management
• Providing reinforcement for abstinent behavior
• Clean urines are given vouchers worth money
• Clean urines guaranteed homeless a work program and therapeutic housing
• Rewarding the target desired behavior
Contingency Management • Providing reinforcement for abstinent behavior • Clean urines are given vouchers worth money • Clean urines guaranteed homeless a work
program and therapeutic housing • Rewarding the target desired behavior
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Coping Skills
• Teach clients skills to successfully cope with interpersonal, social, emotional and personal problems (Monti, et. al, 2001)
• While some clients are skill deficient,others can’t execute skills because of anxiety, maladaptive beliefs and/or depression
Coping Skills • Teach clients skills to successfully cope with
interpersonal, social, emotional and personal problems (Monti, et. al, 2001)
• While some clients are skill deficient, others can’t
execute skills because of anxiety, maladaptive beliefs and/or depression
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Toolbox Training: A Substance Abuse Educational Series 28 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Cognitive Behavioral
Cognitive behavior therapy (CBT) combines
Behavior therapy helps you weaken the connections between troublesome situations and your reactions to them.
Cognitive therapy teaches you how certain thinking patterns are causing your symptoms.
Very simply put, CBT attempts to help patients recognize, avoid, and cope.
Cognitive Behavioral Cognitive behavior therapy (CBT) combines two very effective kinds of psychotherapy — cognitive therapy and behavior therapy.
Behavior therapy helps you weaken the connections between troublesome situations and your reactions to them. Reactions such as fear, depression or rage, and self-defeating or self-damaging behavior. It also teaches you how to calm your mind and body, so you can feel better, think more clearly, and make better decisions.
Cognitive therapy teaches you how certain
thinking patterns are causing your symptoms — by giving you a distorted picture of what's going on in your life, and making you feel anxious, depressed or angry for no good reason, or provoking you into ill-chosen actions.
Very simply put, CBT attempts to help patients recognize, avoid, and cope. That is, RECOGNIZE the situations in which they are most likely to use cocaine, AVOID these situations when appropriate, and COPE more effectively with a range of problems and problematic behaviors associated with substance abuse.
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Relapse Prevention
Functional AnalysisIdentify High Risk SituationsCoping Skills TrainingEnhance Self-EfficacyRelapse Reframed as teachable momentChallenge Positive Alcohol ExpectanciesLifestyle Balance
Relapse Prevention Functional Analysis Identify High Risk Situations Coping Skills Training Enhance Self-Efficacy Relapse Reframed as teachable moment Challenge Positive Alcohol Expectancies Lifestyle Balance
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Toolbox Training: A Substance Abuse Educational Series 29 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Stages of Change Model
Pre-ContemplationContemplationPreparationActionMaintenance
Stages of Change Model Pre-Contemplation Contemplation Preparation Action Maintenance
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Cognitive Restructuring
• “It would be too hard to stop drinking. I’d lose all my friends, be bored, and never be comfortable”
• Cognitive restructuring requires assessment of client’s maladaptive alcohol and other drug beliefs
• Use socratic questioning to help clients test the accuracy of their beliefs
Cognitive Restructuring • “It would be too hard to stop drinking. I’d lose all
my friends, be bored, and never be comfortable”
• Cognitive restructuring requires assessment of client’s maladaptive alcohol and other drug beliefs
• Use socratic questioning to help clients test the
accuracy of their beliefs
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s. Motivational Enhancement Therapy
“This approach provokes less resistance and encourages clients to progress at their on pace toward deciding about, planning, making, and sustaining positive behavioral change”
Enhancing Motivation for Change in Substance Abuse Treatment, 1999, p. 21
Motivational Enhancement Therapy “This approach provokes less resistance and encourages clients to progress at their on pace toward deciding about, planning, making, and sustaining positive behavioral change”
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Toolbox Training: A Substance Abuse Educational Series 30 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Motivational Enhancement Therapy:Assessment and Feedback
• Substance use patterns• DSM-IV substance
dependence/abuse diagnosis
• Life functioning problems• Functional Analysis
• Biomedical Effects• Neuropsychological
Effects• Family History• Psychological Problems• Personalize/Interpret
Results
Motivational Enhancement Therapy: Assessment and Feedback
• Substance use patterns • DSM-IV substance dependence/abuse diagnosis • Life functioning problems • Functional Analysis • Biomedical Effects • Neuropsychological Effects • Family History • Psychological Problems • Personalize/Interpret Results
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Motivational Enhancement Therapy Strategies
• Reflective Listening• Double Sided Reflection • Rolling with Resistance• Reframing • Empathy• Reduce Resistance by
Shifting Focus
• Circular Questioning• Co-creating success• Measuring motivation or
scaling• Note taking• Open ended questions• Empathy• Encourage client choice• Summarizing
Motivational Enhancement Therapy Strategies
• Reflective Listening • Double Sided Reflection • Rolling with Resistance • Reframing • Empathy • Reduce Resistance by Shifting Focus • Circular Questioning • Co-creating success • Measuring motivation or scaling • Note taking • Open ended questions • Empathy • Encourage client choice • Summarizing
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Toolbox Training: A Substance Abuse Educational Series 31 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Motivational Interviewing Principles
William R. Miller, PhD and Stephen Rollnick, PhDRationale & Basic Principles: Implementation of Skills
Express Empathy!Develop Discrepancy Roll with Resistance -- Avoid Argumentation!Elicit-Efficacy!
Motivational Interviewing Principles William R. Miller, PhD and Stephen Rollnick, PhD Rationale & Basic Principles: Implementation of Skills
Express Empathy!
Develop Discrepancy
Roll with Resistance -- Avoid Argumentation!
Elicit-Efficacy!
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Motivational Interviewing: Rationale
What makes Motivational Interviewing a unique counseling approach is how its skills are employed by clinicians.
Motivational Interviewing requires attention to timing issues, specific strategize and application methods, and maximizing the effectiveness of these skills.
Motivational Interviewing: Rationale
Clinicians commonly think that they are already practicing Motivational Interviewing since most clinical training encompasses basic counseling skills such as active listening, use of open-ended questions, use of affirmation, and summarizing.
What makes Motivational Interviewing a unique
counseling approach is how its skills are employed by clinicians.
Motivational Interviewing requires attention to
timing issues, specific strategize and application methods, and maximizing the effectiveness of these skills.
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Co-Occurring Substance Use and Mental Health
Title Slide – Co-Occurring Substance Use and Mental Health
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Co-Occurring Substance Use and Mental Health Disorders
Mental Health Disorders
Substance Use Disorders
Co-Occurring Substance Use and Mental Health Disorders
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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What are “Co-occurring Disorders”?
The presence of at least two disorders:
One being substance abuse or dependence
The other being a DSM-IV major mental disorder, usually:– Major Depression – Bipolar Disorder– Schizophrenia
What are “Co-occurring Disorders”? The presence of at least two disorders:
One being substance abuse or dependence
The other being a DSM-IV major mental disorder, usually:
– Major Depression – Bipolar Disorder – Schizophrenia
Mental Health Disorders
Substance Use Disorders
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Characteristics of Co-occurring Disorders (General)
Repeatedly cycle through treatment, probation, jail, and prison • More likely to re-offend or to receive
sanctions when: Not taking medication, not in treatment, experiencing mental health symptoms, using alcohol or drugs
• Use of even small amounts of alcohol or drugs may trigger recurrence of mental health symptoms
Characteristics of Co-occurring Disorders (General) Repeatedly cycle through treatment, probation, jail, and prison
• More likely to re-offend or to receive sanctions when: Not taking medication, not in treatment, experiencing mental health symptoms, using alcohol or drugs
• Use of even small amounts of alcohol or drugs may trigger recurrence of mental health symptoms
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Differentiation Between Axis I and Axis II Disorders
Axis I: for reporting all the various disorders or conditions in the Classification except for the Personality Disorders and Mental Retardation.
Axis II: Personality Disorders; Mental Retardation: for reporting Personality Disorders and Mental Retardation. – It may also be used for noting prominent maladaptive
personality features and defense mechanisms.
Differentiation Between Axis I and Axis II Disorders
Axis I: for reporting all the various disorders or conditions in the Classification except for the Personality Disorders and Mental Retardation. Also reported on Axis I are Other Conditions That May be a Focus of Clinical Attention. If more than one Axis I disorder is present, the principal diagnosis or the reason for visit should be indicated by listing it first.
Axis II: Personality Disorders; Mental Retardation:
for reporting Personality Disorders and Mental Retardation. It may also be used for noting prominent maldaptive personality features and defense mechanisms. The listing of personality Disorders and Mental Retardation on a separate axis ensures that consideration will be given to the possible presence of Personality Disorders and Mental Retardation that might otherwise be overlooked when attention is directed to the usually more florid Axis I disorders.
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Toolbox Training: A Substance Abuse Educational Series 34 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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General Assessment Approach for Co-occurring Disorders
1. Assess the significance of the substance use disorder *Obtain longitudinal history of Mental Health
and Substance Abuse symptom onset: Primary and Secondary occurrence
*Analyze whether Mental Health symptoms occur only in the context of Substance Abuse
*Determine whether sustained abstinence leads to rapid and full remission of Mental Health symptoms
General Assessment Approach for Co-occurring Disorders 1. Assess the significance of the substance use disorder
Obtain longitudinal history of Mental Health and Substance Abuse symptom onset: Primary and Secondary occurrence
Analyze whether Mental Health symptoms occur only in the context of Substance Abuse
Determine whether sustained abstinence leads to rapid and full remission of Mental Health symptoms
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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General Assessment Approach for Co-occurring Disorders
2. Determine the length of current abstinence
3. Reassess Mental Health symptoms at end of 4-6 weeks of abstinence
4. If Mental Health symptoms resolve, potential referral for Substance Abuse services
5. Assess Social Needs: family issues, work related issues, housing status
General Assessment Approach for Co-occurring Disorders 2. Determine the length of current abstinence
If not 4-6 weeks in duration, delay diagnosis until abstinence has been achieved
3. Reassess Mental Health symptoms at end of 4-6 weeks of abstinence 4. If Mental Health symptoms resolve, potential referral for Substance Abuse services; if not, potential referral for Mental Health or specialized Developmental Disability services 5. Assess Social Needs: family issues, work related issues, housing status (homelessness)
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Characteristics of Co-occurring Disorders (Treatment-related)
• More rapid progression from initial use to substance dependence
• Poor adherence to medication• Decreased likelihood of treatment
completion• Greater rates of hospitalization• More frequent suicidal behavior• Difficulties in social functioning• Shorter time in remission of symptoms
Characteristics of Co-occurring Disorders (Treatment-related)
More rapid progression from initial use to substance dependence
Poor adherence to medication Decreased likelihood of treatment completion Greater rates of hospitalization More frequent suicidal behavior Difficulties in social functioning Shorter time in remission of symptoms
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Characteristics of Co-occurring Disorders (Behavioral)
• Difficulty comprehending or remembering important information (e.g., verbal memory)
• Not recognize consequences of behavior (e.g., planning abilities)
• Poor judgment • Disorganization • Limited attention span • Not respond well to confrontation
Characteristics of Co-occurring Disorders (Behavioral)
Difficulty comprehending or remembering important information (e.g., verbal memory)
Not recognize consequences of behavior (e.g., planning abilities)
Poor judgment Disorganization Limited attention span Not respond well to confrontation
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Co-Occurring Conditions in Adolescence
Ninety Percent w/Lifetime Co-Occurring Disorder had one MH Disorder prior to Onset of Substance Abuse. Median onset MH Disorder at Age 11 years.Onset Substance Abuse between 16 and 21 years.
Co-Occurring Conditions in Adolescence
Ninety Percent w/Lifetime Co-Occurring Disorder had one MH Disorder prior to Onset of Substance Abuse.
Median onset MH Disorder at Age 11 years. Onset Substance Abuse between 16 and 21
years.
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Prairelands ATTC Toolbox Training Module 4 Clinical Eval: Assessment
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Primary Locus of Care by Severity
High
Sev
erity
Low Severity High Severity
Alco
hol a
nd o t
her d
rug a
buse
Mental Illness
IIISubstance abuse
system
IPrimary healthcare settings
IIMental health
system
IVState hospitals,
jails/prisons,emergency rooms, etc.
Primary Locus of Care by Severity See Module 7 – Handout 2 for details.
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Toolbox Training: A Substance Abuse Educational Series 36 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Group Exercise:Primary Locus of Care by Severity
Title Slide – Group Exercise
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Group Exercise
Individually, write a short example from your therapeutic experiences of “one” of the four quadrants from the “Primary Locus of Care by Severity”You will have ten minutes to complete this portion of the exercise.In small groups of three share your example and discuss whether you believe your client was appropriate placed defending your assessment.
12:00-12:15 pm
Group Exercise Individually, write a short example from your Co-
occurring therapeutic experiences of “one” of the four quadrants from the “Primary Locus of Care by Severity”
You will have ten minutes to complete this portion of the exercise.
In small groups of three share your example and discuss whether you believe your client was appropriate placed defending your assessment.
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Evidence-Based Best Practices(continued)
Pharmacotherapy
12:15pm
Title Slide - Pharmacotherapy
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Pharmacotherapy
DetoxificationCravings for AlcoholReplacement AversiveAntagonistMixed (Agonist-antagonist)
Pharmacotherapy
Detoxification Cravings for Alcohol Replacement Aversive Antagonist Mixed (Agonist-antagonist)
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Medications for Relapse Prevention: Alcohol
Naltrexone (1994)
Disulfiram (1950)
AcamprosateNalmefeneSerotonin re-uptake inhibitors
Medications for Relapse Prevention: Alcohol
Naltrexone (1994) Disulfiram (1950) Acamprosate Nalmefene Serotonin re-uptake inhibitors
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Neurotransmitters and Alcohol Dependence
DopamineOpioidsGlutamate GABASerotonin
Neurotransmitters and Alcohol Dependence
Dopamine Opioids Glutamate GABA Serotonin
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Toolbox Training: A Substance Abuse Educational Series 38 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Pharmacological Treatment for Opiate Addiction
Methadone Replacement
Levo-alpha-acetyl-methadol(LAAM)
Buprenorphine
Pharmacological Treatment for Opiate Addiction
Methadone Replacement: a narcotic agonist, which means that it is a drug that stimulates an opioid receptor, producing morphine-like actions.
Levo-alpha-acetyl-methadol (LAAM): an oral
narcotic analgesic used to treat opiate dependencies. Has been removed from the market by the FDA
Buprenorphine: a mixed agonist-antagonist.
Antagonists block the effects of opiates by binding to receptors without stimulating them. Buprenorphine produces a long-lasting effect, and can be prescribed by qualified physicians in a doctors office. For more information: http://www.nida.nih.gov/NIDA_Notes/NNVol16N2/Buprenorphine.html
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Treatment for Nicotine Dependence
Nicotine Replacements are available as gum and patches over-the-counter.They can be used by people outside formal stop-smoking programs, but they're less effective when used that way. Also available by prescription as a nasal spray and as a puffer ("inhaler").
American Heart Association, July 12, 2004, Nicotine Substitutes/Nicotine Replacements
Treatment for Nicotine Dependence
Nicotine Replacements are available as gum and patches over-the-counter.
Nicotine replacement therapy has been shown to be safe and effective in helping people stop using cigarettes when used as part of a comprehensive smoking cessation program.
They can be used by people outside formal stop-smoking programs, but they're less effective when used that way.
Nicotine Replacement Therapy is also available by prescription as a nasal spray and as a inhaler.
American Heart Association, July 12, 2004, Nicotine Substitutes/Nicotine Replacements
Unifying science, education and service to transform lives
Toolbox Training: A Substance Abuse Educational Series 39 of 40 For Mental Health Professionals First Edition
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Summary
Title Slide – Summary
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Prairelands ATTC Toolbox Training Module 7: Treatment Knowledge
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Summary and Questions
Goal: Introduce treatment and recovery models from a co-occurring specific perspective to include counseling theory, techniques, and relapse prevention perspectives.
Objectives:1. Define Evidence Based, Consensus Based, and Best Practice; 2. Discuss the impact of the therapeutic relationship and treatment
alliance; 3. Develop co-occurring skills in best practices implementation to
include: Behavioral, Cognitive Behavioral, Cue Exposure, Contingency Management, Coping Skills, Cognitive Restructuring, Relapse Prevention, Motivational Interviewing, Stages of Change, and Pharmacological Therapy.
12:45
Summary and Questions Goal: Introduce treatment and recovery models from a co-occurring specific perspective to include counseling theory, techniques, and relapse prevention perspectives. Objectives: 1. Define Evidence Based, Consensus Based, and Best
Practice; 2. Discuss the impact of the therapeutic relationship and
treatment alliance; 3. Develop co-occurring skills in best practices
implementation to include: Behavioral, Cognitive Behavioral, Cue Exposure, Contingency Management, Coping Skills, Cognitive Restructuring, Relapse Prevention, Motivational Interviewing, Stages of Change, and Pharmacological Therapy.