Models of Treatment | Addiction Counselor Exam Review

Hi everybody and welcome to today's presentation of the addiction counselor exam review. We're going to be talking about models of treatment. Over the next little while we're going to review the premises of behavioral self control, dialectical behavior therapy, the matrix model, motivational enhancement, family behavior therapy, medication assisted therapy, relapse prevention and harm reduction approaches. Basically what we're talking about in this presentation are the psychological models of treatment. If you believe in the biological model, then obviously you're not going to be looking at behavioral self control, you're going to be looking at pharmacotherapy or something else. So what is the psychological model? Well, basically the premise of this model is that addiction and mental health issues result from deficits in learning. We don't learn the coping skills we need, we don't learn how to become aware of what we need, we don't learn effective communication skills, etc. Deficits in thinking, which are our cognitive errors, or deficits in emotion regulation where you go from 0 to 150 in no time flat. And it can be any combination of these things. So the psychological or self medication model basically posits that there are a bunch of different approaches. You can look at behavioral self control, you can look at individual and group counseling that have multiple evidence based practices. And then you can also look at pharmacotherapy, especially for mental health issues, but also in some cases for, for substances. Now we know that medication assisted. There are only medications that are out there right now for nicotine, alcohol and opiates. Some other medications have been shown to be moderately effective with some other drugs, but they're not FDA approved for that yet. So let's move on. So behavioral self control training is exactly what it sounds like. It helps people strengthen their internal mechanisms, their self awareness in order to control their behavior. It also helps them establish external controls. So when I feel this way, what can I do? What tools do I have in my toolbox to help me control this emotion, this urge, this feeling, this thought? So behavioral self control teaches coping skills, goal setting, it helps people develop behavioral contracts. So what kinds of things would you contract for? You would contract for, for helping people stay clean and sober. You would contract for when the person is feeling anxious, what will they do? Behavioral contracting is a lot like treatment planning. We're developing a, or relapse prevention planning. More like we're developing a contract. When adversity steps in your path, what are you going to do? But behavioral contracting can also be used for positive behaviors. So encouraging the person, they're going to make A contract with you that they are going to get adequate sleep every night, that they're going to eat a healthy diet, that they're going to keep their therapy appointments. All of those things can be contracted. And when there is a contract, it helps people stay a little bit more on target, if you will, or on task if they feel like they have made a promise or a, or they told somebody else that they were going to do something. Behavioral self control also helps people identify triggers that will cause a relapse. So we talk a lot about triggers in substance abuse counseling. People, places, things, yada, yada, yada. We also need to pay attention to mental health triggers because when somebody's depressed, they're going to be more likely to relapse. When somebody's anxious or angry, they're going to be more likely to relapse. So what things trigger those mental health issues? And this can be people, this can be situations, this can be times of day or holidays or just about anything that can trigger a substance relapse can trigger a mental health relapse. But we need to make sure that neither one relapses because if they relapse with their addiction, it's going to impact their mental health negatively. If they relapse with their mental health, it's going to set them up for a relapse in their addiction. So we need to deal with both. Behavioral self control also uses a tool called functional analysis. And when we do a functional analysis, what we're really doing is asking ourselves or asking the person what led up to this behavior and what is the function of this behavior. So if Johnny's in the, in the grocery store and he has a complete meltdown because he wants cocoa puffs and mom says no, you can't have cocoa puffs. Well, let's do a functional analysis. Or what was it that he wanted? Was he hungry? Did he want, you know, did he just want cocoa Puffs? What was it? What was the hoped for benefit of this behavior? And how did we get to this point where he's throwing a tantrum? Well, there may not be Cocoa Puffs in the house, but maybe somebody, maybe mom or grandma or somebody else has given in before and gotten him cocoa Puffs when he threw a tantrum, so it rewarded that behavior. So a functional analysis, remember, asks what is the function of this behavior and how did we get to this point? What led up to throwing a full out tantrum? So we can help figure out ways to intervene along the way. Because people's relapses, what they Identify as their relapse generally starts a long time before they pick up again or before they have their clinical depressive episode. So we want to look back and see what the steps were that kind of led up to where we're at right now. That way we can help the person identify early warning signs of relapse and intervene sooner. And behavioral self control takes all of this information, coping skills, goal setting, contracting, trigger management, and functional analysis, and puts it together to help people develop a relapse prevention plan, which will look very similar for mental health and for substances. If people are using substances or engaging in addictive behaviors, it's going to mess with their neurotransmitters and make it harder for them to be happy, make it harder for them to be emotionally balanced. If people are having difficulty with their mental health, it's going to be harder for them to stay clean and sober because they're feeling really lousy. So we want to look at the things like vulnerability prevention, making sure they're getting enough proper nutrition, remember, hungry, angry, lonely, and tired. We want to make sure that they've addressed all of those things. So behavioral self control is really a comprehensive system for helping the person develop the skills and tools they need, identify when and how to use them, and prevent as many problems as possible. Now, dialectical behavior therapy is newer, but a lot of us are really familiar with it. Why would you use dialectical behavior therapy? Well, clients may unintentionally reward ineffective treatment while punishing their therapists for effective therapy. So if we use dbt, we're going to be more aware of that. And if you think of when you've worked with a client before, when you start pushing those buttons, when you start getting into those tender emotional areas, they may withdraw, which punishes the therapist. The therapist goes, oh, you know, that makes me unhappy that this client withdrew from treatment because, you know, he was making progress, but it got too painful and they hit the road. Now how do they reward ineffective treatment? Because clients keep coming. If you are not pushing those hot buttons and making them uncomfortable occasionally, then they may keep coming because they're like, okay, you know, I can do this. This isn't so bad. DBT helps therapists become aware of when a client is sort of lulling them into a false sense of laziness, if you will, because, you know, things seem to be going swell for the patient. Quite honestly, if patients don't occasionally get grumpy with you, you're probably not pushing them or finding all of the buttons. So dialectical behavior therapy Encourages therapists to get together in a group once a week and do case staffing so you can get a fresh pair of eyes that may be saying that may be able to tell you, you know what? I think he's avoiding this path right here. Or I think this reaction of, you know, suddenly not showing up for appointments, maybe because you touched on this particular issue. And in dbt, there's a lot of functional analysis that goes on. You're going to see overlap in these theories, because DBT therapists really look at what's the function of this behavior? Is it they're not making progress and they're unhappy and they left? Is it because they left because they became too uncomfortable? What are the reasons for this behavior, and how can we maybe create environment that brings them back in or keeps them moving forward? The sheer volume and severity of problems presented by clients often makes it impossible to use the standard cognitive behavioral format. You know, some clients will present and they will have pain, they will have anxiety, they will have depression, they will have ptsd, they will have cocaine abuse, they will have a history of sexual abuse, they will have relationship issues. I could go on. And cognitive behavioral therapy is really awesome for addressing thoughts. But cognitive behavioral therapy doesn't help as much with some of the other biopsychosocial issues. So DBT can step in and help clients generalize some of those skills they're learning and develop more effective methods. Clients who have engaged in cognitive behavioral therapy found the focus on change invalidating because we're telling them what you're doing right now is wrong. In cognitive behavioral therapy, often our unhelpful thoughts are called irrational thoughts. Well, you know, that's kind of hurtful if somebody says, you're just being irrational, which is why I use the word unhelpful. But either way, in addiction, people may have difficulty with cognitive behavioral because addiction is a solution to a problem. It's a bad solution, but it's a solution to a problem. So if we're saying, you're not making the right choice here, the person's going, I've tried everything else, and it hasn't worked. So what am I supposed to do? Dialectical behavior therapy provides a lot of alternatives. Cognitive behavioral therapy often makes clients feel like their suffering is being underestimated or their therapists are overestimating their own helpfulness. So we need to make sure to validate the client's experience, help them understand the function of their reactions, their urges, their behaviors, their thoughts, and figure out a better way, a more helpful way to help them meet their goals, you know, and that means we have to define or help the client define what their goals are. Not all clients want to stay clean and sober forever, you know, so let's look at what can we do in this particular situation. Overriding themes in DBT mindfulness. Helping people become aware of what they need, what their thoughts are, what their feelings are, and be aware of the difference between being in the emotional mind, which is the impulsive mind that typically reaches out for numbing, and the wise mind that can make more cognitive decisions based on facts that are before them. DBT teaches distress tolerance and urge surfing so people can get through those cravings. They can get through the emotional surges that may make them want to go use. It teaches emotion regulation so people learn how to dampen some of those surges a little bit by living healthier, getting enough sleep, getting proper nutrition, having positive social supports, etc. And finally, it teaches interpersonal effectiveness and problem solving, recognizing that a lot of people who have emotional dysregulation, who have, you know, emotional upheaval, have pushed away or overwhelmed people or felt like they have been abandoned by other people in the past. So we need to help them learn how to identify what they need and effectively communicate their needs so it's not overwhelming to the other person, but so the other person can understand what's going on and can help them problem solve. The next model we're going to talk about is the matrix model for stimulant use. Now this one has been generalized, I believe, for cannabis use as well. It's completely manualized. It's on the SAMHSA website. It is a 45 session treatment program. That's a long treatment program. Even if you're going five days a week, that's nine weeks every single day. So 45 session treatment program that teaches people about issues critical to addiction and relapse. People receive direction and support from a trained therapist and become familiar with self help programs. The therapist in the matrix model functions simultaneously as teacher coach, both fostering a positive and encouraging relationship and empowering the person to make the next right step. Motivational enhancement therapy is the next technique and you're going to be kind of surprised with this one. It's designed to help resolve ambivalence about treatment and abstinence. Now, motivational enhancement therapy is different than motivational interviewing. Now you use some motivational interviewing techniques when you do motivational enhancement therapy, but motivational enhancement therapy itself is a three to five session treatment program. That's it. Not 45, not a year, three to five sessions. It helps resolve ambivalence about treatment and abstinence and empower people to make the next right choice for them. Therapy consists of an initial assessment battery followed by two to four individual sessions with the therapist. So obviously you're not probably doing weekly sessions here. You're going to do an assessment and then a follow up and then probably your next appointment two weeks later, then your next appointment a month later, etc. That way you're staggering the time. Motivational enhancement therapy. Your first treatment session consists of something called the frames approach. The person is provided feedback about the initial assessment. They're encouraged to take responsibility for their own actions, thoughts and behaviors. We encourage them to elicit some self motivational statements. So recognizing what parts of this they have the ability and desire to change and it strengthens motivation and builds a plan for change. So we're working with the client. We're not telling them, you need to do this. We're saying, okay, now that you've heard the good, the bad and the ugly with the initial assessment, where is it that you want to go from here and let's work together to make a plan. I'm not going to force you to do anything. We provide advice. You know, when you're making that plan, the client may not have all the tools that they need or may not be thinking of creative ways to use the tools they have. So we can provide information or advice about coping strategies for high risk situations. We then provide a menu of options. We help them figure out, you know, in this big scheme of things, to address your goals, what is it that you need to do? You know, it's kind of like going to a restaurant and reading a menu and picking your first course, your second course, etc. Same thing is true here. We can say, all right, well, the first step you want to do is what? You have all these options out here. You can do self help, you can do outpatient, intensive, outpatient, residential, what is it that you need? But we want to focus on things other than just treatment. We want to say, what are your options for overcoming your obstacles? Notice I say obstacles, not barriers. You can scale obstacles, barriers you can't get around. So what can you do? What are your options for working around the fact that you're an hourly employee and if you're not at work, you don't get paid, so you can't be taking a whole lot of time off for treatment. What can you do to work around the obstacle of finances or childcare or whatever it is so we help them identify the options and the resources they need. We provide empathy. This is a big step. No matter what problem they're addressing, this is a big step. Crisis causes change, and change causes crisis. Whether you're trying to lose 20 pounds or get clean and sober or address your depression, you're going to be uncomfortable. You're going to have to address some things that may make you uncomfortable for a little while, and it can be scary. A lot of people when they start substance abuse treatment are afraid they're going to relapse because that's what they hear everywhere. You know you're going to relapse. You can't just start and work all the way through. Well, I'm here to dispel the myth that you cannot get through treatment without a relapse. People have done it. Does it happen a lot? No, but people have done it. We want to provide empathy for people because it's scary. We want to help them understand, you know, what, if you relapse, if you slip, that's a learning opportunity, and we can figure out how to prevent that in the future. And as you get healthier and happier, those slips and those regressions will be fewer and farther between. And we want to provide self efficacy. That is, we want to encourage the client to believe they can make this change. When I work with people who are trying to quit smoking, a lot of times they're looking at me like, doc, I don't know that I can do this. I've tried 17 times before and I failed every single time. What's going to make this time different? And so we want to inspire self efficacy. We want to help them see how their motivation is different. We want to help them see how this situation is different than the past. But we also want them to look back over the past and realize how much strength they actually have. Maybe they stayed clean. They didn't smoke for six months. Well, that's great. You know, that was really hard. So, you know, you can do it. It's just a matter of building on what you've learned from past attempts to quit in subsequent sessions. So this all takes place in the first session after the assessment. In subsequent sessions, the therapist monitors change, reviews the change strategies being used, and continues to encourage change. This is a lot of coaching here. You're not going to be delving into deep, dark issues that may be underlying behavior. Motivational enhancement therapy is not psychodynamic. You know, we're not going to be looking at how your childhood is impacting your present or resolving Issues from childhood. We're going to be talking about focusing on behavior change and helping you see, or helping the client see positive forward progress in achieving that goal. And there may be some things that are needed with that, There may be some counseling that goes with it. But remember, you've only got like four sessions to work with, so you're not going to be spending a lot of time like we do. In humanistic or psychoanalytic approaches, family behavior therapy has demonstrated positive results in both adults and adolescents. So score. This one works with both age groups, addresses not only substance use and mental health problems, but also other co occurring issues such as conduct disorder, child mistreatment, family conflict, unemployment, chronic pain. The list can go on. Family behavior therapy involves having the patient, along with at least one significant other, such as a cohabitating partner or parent, work together so you don't have to have the whole family together. And a lot of times in addiction it is not possible to get that whole family together because there are too many people who are hurting. And you know, there are going to be some people who have their own stuff and they're not able to come to the table right now. But so it's the patient and at least one other person. Family behavior therapy combines behavioral contracting with contingency management. So you have the patient who says, I'm going to stay clean and sober, I'm going to start doing these positive health behaviors, yada, yada, yada, makes the contract and then you have the family member who is going to basically be the holder of that contract. And when things go well, you know, there are going to be contingencies that are applied, either additional privileges or rewards or whatever the case may be, whatever that person decides. When I work with families and we do family behavior therapy, I generally have the contract go both ways. So the person who's the identified patient also holds a contract on the loved one, because loved ones are going to have to change their behavior too. When people are in dysfunctional relationships, you have one person who may kind of start it if you will, but other people change their behavior in a way to try to maintain balance in the family. So we need to help the enabler, the codependent, the mascot, the hero, whatever role this person takes, we need to help them change their behavior. Generally it revolves around open communication and not nagging and some other things. But I want the identified patient to feel like they've got some element of control as well. I don't want them to feel like they're being ganged up on. So both Parties have contracts and both parties have rewards for maintaining those contracts and consequences for not maintaining those contracts. In family behavior therapy, therapists seek to engage families in applying behavioral strategies taught in sessions and acquiring new skills to improve the home environment. So we're talking about communication and boundary setting and forgiveness and acceptance and mindfulness and all those things. And we're helping the family take these skills and figure out how to apply them to create a more harmonious family environment. Seeking Safety Now I love this curriculum, and that's just a personal statement that's not saying it's necessarily going to be right for your particular caseload. Seeking Safety is a great curriculum for clients who have issues with trauma, ptsd, and addiction. It's present focused, so they're not going back there. You know, they're focusing on what can I do to make my environment safe right now? If you think of mindfulness and DBT and ACT and a lot of other theories that are out there, then encourage the person to be aware of how they feel and what their thoughts are right now. And instead of fighting with it, saying I shouldn't be scared, I shouldn't be anxious, I shouldn't be this just accepting I am. This is how I feel now. I how can I improve the next moment? And Seeking Safety helps people learn how to become self aware and identify ways to improve the next moment while still being compassionate with themselves and saying, you know what, you've been through a lot and you're doing good. Seeking Safety is available as a book with guidance for clients and clinicians and can be done in individual or group. So it gives you a lot of latitude. Now on your addiction counselor exam review, I really seriously doubt that they're going to ask you about each topic of Seeking Safety, but just to give you an idea of some of the really awesome things that it can help you give you ideas for topics to cover in group or individual. The book goes over case management, taking back your power when substances control you, using honesty and asking for help, setting boundaries, getting others to support your recovery, community resources, creating meaning out of what's happened, integrating the split self, detaching from emotional pain and grounding and coping with triggers, just to name a few. Like I said, There's 25 topics in seeking Safety and not all of them are going to be appropriate for every single group. You don't have to go through all 25, but it gives you a lot of stuff to work with. The next model is the sociocultural model. In this model, emphasis is placed on the socialization process, culture Observational learning and reinforcement of behaviors. So this model says, where are you learning this stuff? Who taught you? Or where did you learn that to cope with stress, this is the best way to act or react. Recovery involves building new social and family relationships. Now, that doesn't necessarily mean discarding everybody, but it does mean learning how to set healthier boundaries. Some cultures are not going to be as responsive, or this won't work as well with some cultures where respect for elders and following the edicts of the elders is expected, no questions asked. But for a lot of cultures, this can help people. They need to learn how to build new relationships in terms of quality and what those relationships look like. They need to develop social competency and interpersonal effectiveness so they're able to identify and communicate their needs and effectively get them met. And it also teaches working within their cultural infrastructure. Remember I said culturally, some cultures are not going to be okay with just upheavaling, whatever, turning family relationships upside down. You know, they're going to say, there is a hierarchy in this family, so we need to help people identify. All right, within the bounds of your cultural infrastructure, what can you do to have healthier relationships and feel more supported, empowered, and happy? The next model we're going to talk about is relapse prevention, and I think most of us are really familiar with that. In relapse prevention therapy, we help clients adopt strategies designed to help them become aware of cues or triggers that make them more likely to abuse substances or become symptomatic with mental health issues, etc. So these triggers can be any of the smell, taste, sight, sound, touch. It can be times of day, it can be places, it can be different people. There are a ton of things, and you're not going to be able to help clients identify every single particular trigger. What we want them to do is become aware of the big ones, but also become aware of, how do I feel when I'm being triggered? When I feel like something's triggering me, what sensations do I notice? When they start becoming more aware of that? Then, regardless of what the trigger is, and it could be a new trigger, they recognize it and go, okay, I'm feeling triggered right now. And then they can take the next step, which is to engage some of those more effective alternate coping responses. Now, medication assisted therapy, like I said, there are only a few medications out there, and they really only right now address opiates and alcohol and to a certain extent, nicotine. They're working on more. The ones that you need to know about more than anything are methadone you know, methadone is used for pain management in some people, but it's also a substitute or a medication assisted. I shouldn't say substitute because it doesn't. People don't get high on methadone. The dose is very controlled. But it's a medication that can be used to help people who are trying to recover from an addiction to opiates. Suboxone is another one and a lot of people are really familiar with it. Suboxone is a combination of buprenorphine and naltrexone or which people take sublingually. They take in their mouth. Now the Suboxone, if they try to crush it, inject it, you know, get it some other way, that's going to get into their system faster. The naltrexone kicks in and it actually prompts an almost immediate detox from the opiates and they start feeling really crappy, really fast. So Suboxone is, has some of the benefits of methadone. One of the main benefits of Suboxone is it can be dispensed from a doctor's office. You don't have to go to a methadone clinic. Vivitrol is another medication that's out there. And Vivitrol can be injectable as well as taken a variety of other ways. Vivitrol is actually very useful not only for methadone or not methadone, but for opiates, but also for alcohol. And they found that people can get an injection once a month and it helps with alcohol abuse. Antabuse is the long standing drug for people who abuse alcohol. And Antabuse basically keeps your body from processing alcohol in the same way. So you get to toxic levels of alcohol byproducts in your system a lot faster, which is why people get so deathly ill on if they drink subs, if they drink alcohol, when they're on Antabuse. SSRIs have also been found to assist people with reducing some of their compulsive behavior, some of their desire to use, reduce the urges to go out and use substances. SSRIs, which are your selective serotonin reuptake inhibitors and your Snris selective norepinephrine reuptake inhibitors, your antidepressants typically is what they're referred to. But these drugs are really helpful for both anxiety. Well, for anxiety and depression. They found that SSRIs tend to be more helpful with anxiety than depression. And they're not all created equal. There are bunches of SSRIs out there. And depending on your client, each client will respond differently to each ssri. So depending on what is not in balance in their neurotransmitters, one SSRI may work better than another. So encourage them to be open with their doctor and communicate about side effects so they can find the right medication. Atypical antipsychotics and tricyclic antidepressants are also out there and can help with moderating anxiety, depression, and in some cases, bipolar disorder. Now, if somebody has bipolar disorder and they start taking an ssri, it may trigger a manic episode, which is why some doctors will put them on a mood stabilizer and an ssri. What's the take home message here? The take home message is that if we want somebody to stay clean and sober, we need to make sure that they are not clinically depressed or anxious, out of their mind. So we need to help them feel content. I mean, we don't need to make them feel elated, but we need to make them feel like they don't want to crawl out of their own skin. And there are drugs out there that can help with the withdrawals and help with the urges and cravings for certain substances, which can make the recovery period. While the brain is rebalancing the neurotransmitters and the body is recovering, it can make that recovery period a little easier, which reduces the risk of relapse and finally harm reduction. Harm reduction recognizes that drug use and mental health issues are reality. The goal of harm reduction is to prevent harm caused by them in the four L's and that's L as in liver lover, livelihood and law. So we want to prevent physical problems from use and with alcohol, that's cirrhosis of the liver. But we also are talking about injectables and other things. So we want to prevent physical harm. Lover. We want to prevent harm in interpersonal relationships. And that can be friends, that can be family, that can be spouses, that can be children. But they had to find an L. So lover, liver and lover. The third one is livelihood. We want to make sure that people don't lose their job because of their substance use and their gainfully employed and hopefully thriving at their job. And the fourth one is the law. We don't want people to start acquiring a rap sheet because of their substance use. And the law is not just criminal, the law is also civil. So if they're filing bankruptcy, if they are getting judgments against them, so their credit score is like way down in the toilet, that is going to negatively impact them. So we want to prevent harm biopsychosocially, we need to look at how to help this person thrive in their present situation. Interventions in harm reduction include low threshold pharmacological interventions. Like we just talked about, needle exchange programs. You might be saying, well, doesn't that encourage it? Well, if people are going to use, you know, let's look at preventing them getting from, preventing them from getting hiv. Let's look at preventing them from getting hepatitis. You know, let's try to help them as much as we can and then we can start working on the use issues. Provide an emphasis on non injection routes. Yes, it's not ideal, but the problems caused by inhalation or oral administration are often less problematic than through intravenous drug use and involvement of those with a history of use or distress in program development. So we want to get people in recovery to put in their two cents and say, all right, what are the biggest challenges to staying clean and sober? What are the things that would help reduce some of these over other secondary effects with health relationships, livelihood and legal or to use the four Ls, which you'll probably need to know for your test? Liver lover, livelihood and law. The multidisciplinary approach kind of takes everything and lumps it together and it provides psychotherapeutic interventions for co occurring issues. So each issue, like PTSD, may need to be treated one way with EMDR or humanistic or cognitive processing therapy. Who knows, depends on the person. They also may have relationship issues that need to be addressed through social skills training. They may have medical issues that need to be addressed. So the psychotherapeutic interventions need to look at all of the issues and help people develop the coping skills and tools that they need to deal with them. Medication assisted therapy is used for both addictive and mental health issues to get people started on a level playing field. It doesn't mean they have to be on it forever, but a lot of times it's helpful for people in the first six months to two years to have that additional boost to kind of help stabilize them until their brain and body fully recovery. Wraparound services are provided to ensure people have access to necessary resources to achieve their goals. And that includes housing, food, financial advice, legal advice. The list goes on. And family therapy is provided to improve the interpersonal environment of the person. We know it's easier to stay clean, sober and happy when you've got a healthy, supportive social environment that may not be your immediate family, but it's whoever the client defines as their family. We want to help them try to improve those relationships because those people are going to be in their life and if those people are going to be in their life, we want to make sure that those people are at least not harming, ideally they're supporting, but at least not harming this person's recovery. So we've talked about a lot of different theories. Behavioral self control is just what it sounds think Behavior modification Dialectical behavior therapy helps clinicians recognize when they're being played by clients, but it also helps clients develop the skills and tools to understand their emotional reactions to things and develop tools to address those. The Matrix model is remember a 45 session model, but it provides a lot of information about addiction and triggers and coping skills. Motivational Enhancement therapy is your, you know, three to five session therapy that basically focuses on one issue and says how can we help you achieve your goal to address this issue? It doesn't look at a bunch of the other stuff that may be going on and the therapist provides a lot of coaching and encouragement in motivational Enhancement Therapy. In family behavior therapy, the client plus one other person in the family need to be involved and it incorporates behavioral contracting and contingency management so they make agreements and then there are consequences as well as rewards for following the contract or not following the contract. Medication assisted therapy is available in terms of addiction or for alcohol and opiates and nicotine, but there are also a lot of medications out there that will help with the emotional issues, the depression, the anxiety, the bipolar disorder, et cetera that may be undergirding the desire to use. Relapse Prevention therapy helps people identify their triggers and cues, learn to identify what it feels like when they're being triggered and and how to take positive steps when they start feeling that way in order to effectively cope with that high risk situation. And finally, harm reduction doesn't necessarily stop people from using, but it tries to prevent them from having additional problems in multiple areas including liver lover, livelihood and law. Alrighty. Thank you for being with me today on this episode of the Addiction Counselor Exam Review. I'll see you next time. All of us at all ceus wish you great success on your exam. Once you're certified or licensed, please remember to visit all CEUs for all of your continuing education needs. We offer unlimited CEUs for $59 for addiction and mental health counselors, social workers, and marriage and family therapists. If you're still thinking about becoming an addiction counselor, all CEU's offers the training you need in three different formats. You can choose online multimedia self study self study plus live webinars or even face to face weekend intensives which meet one weekend per month for 12 months. We can even present a training series at your facility. Just email supportlce.com to schedule it. To learn more, you can also visit allce.com acer that's allceus.com acer thank you.