Therapeutic Approaches | Addiction Counselor Exam Review Podcast

Welcome to the addiction counselor exam review. This presentation is part of the addiction counselor certification training. Go to. Learn more about our specialty certificates. Strength starting at $149. Hey there, everybody. And welcome to this episode of addiction counselor exam review. Today we're going to be talking about therapeutic approaches. Among some other things, we're going to review different therapeutic approaches, including cognitive behavioral, motivational enhancement, contingency management, and trauma informed care. We'll talk about types of treatment, including individual, group, and family. And we'll look at benefits and drawbacks of each. And then we'll also look at culturally appropriate strategies, methods for family engagement, how to do crisis intervention, and some techniques for relapse prevention. So we're going to cover a lot in this hour. Therapeutic approaches refer to basically how you approach solving a problem. Behavioral and cognitive behavioral approaches are grounded in social learning theories and principles of identity. Operant conditioning. Now, when you think operant conditioning, I want you to think back to Pavlov's dog. He heard a bell ring. He would start to salivate. So a lot of what we talk about with triggers revolves around operant conditioning because something in the environment a lot of times will trigger cravings for a substance or a behavior. Emphasis is on functional analysis of behaviors to understand within the context of their antecedents and consequences, why they happen. And antecedents are what happens before. So what types of things happen leading up to this use, and what are the consequences of this use that are supporting or rewarding continued use? Because when people are using, yes, there are some drawbacks, but there are some benefits, too. So we want to look at what are some of those benefits in addition to what triggered it in order to understand what is maintaining this addiction. Cognitive behavioral approaches. And behavioral also provides skills training through which people recognize the situations or states in which they're most vulnerable. So situations could be a bar or your relative's house or whatever. And states could be if you're depressed or if you're anxious or if you're overtired, different conditions that basically make you more vulnerable to using. And then you learn how to avoid those situations or deal with them if they're unavoidable. And finally, behavioral and cognitive behavioral approaches use a range of behavioral and cognitive strategies to help people cope effectively with situations that can't be avoided. So if you can't avoid going to your families for the holidays, but you know that's a huge trigger, you would talk with your therapist or you would identify ahead of time cognitive strategies and things you could do. Behavioral strategies in order to reduce the likelihood that you would relapse. So, for example, avoiding the liquor cabinet, you know, stay away from that part of the house. You may want to stay away from certain people that happen to trigger you. They may trigger anger or anxiety or shame that makes you want to. To use, that causes those cravings. So you would look at identifying some of those triggers and ways to cope with them. You would look at developing an emergency plan. So if those cravings got too strong, what do you need to do? Cognitive behavior therapy is based on the idea that feelings and behaviors are caused by thoughts. And, you know, kind of vice versa. All three of these impact one another. When we have negative thoughts, we tend to see the negative in things, and we tend to feel bad, which can make us physically hurt, feel bad, feel depressed, feel energyless, fatigued. And when we're fatigued, we tend to not see as much happy stuff, and we tend to be a little bit more negative. So all of these can impact each other. It's important in that cognitive triad, is what they call it, to recognize that all three of these things impact it. Cognitive behavior therapy says that people may not be able to change their circumstances, but they can change how they think about them and therefore change how they feel and behave. So take a job you hate. You know, we've all had one of them. You may hate that job, but if you keep thinking, this is the worst job ever, I hate my life, I can't do this anymore, then your feelings are going to center around hopelessness, helplessness, anger, resentment, all that unpleasant, negative stuff stuff. And your behaviors may seek to help you eliminate those feelings through engaging in addictive behaviors. Or your behaviors may not be good at work. You know, there are a lot of different things, but if you change your way of thinking about it and say, okay, this job really sucks, I don't like it, but it's paying the bills for right now. And there are a few people at the job that I like. That's a bonus. And I can get through this, you know, until I can find another job. And I do have options for looking for another job. So that gives you hope and empowerment, and you recognize that, yes, this is not an ideal situation, but it is not as oppressive as when you were stuck in your anger and resentment, just going grumbling under your breath about how miserable you were. So that's one of the approaches that cognitive behavioral uses. The goal of cognitive behavioral therapies is to teach the person to recognize situations in which they're most likely to use. Now, we can't possibly create a relapse strategy for every single situation you'll ever encounter. So you need to generalize and recognize situations in which the person is more likely to use. So under stressful situations, I had one client that I worked with who was a pretty heavy user of marijuana and alcohol, but he would not use in front of his children. So that's kind of taking it to the other side. When would you not use? But we integrated that into his treatment plan. So during those times of day, like right after work, when he really had some cravings to use because it was a long, stressful day, he would go home and go out and play ball with his son. So those cravings went away because he wasn't going to use them. So cbt, or cognitive behavioral therapy, encourages people to avoid circumstances in which they're most likely to use and identify alternate behaviors and alternate things to do. Contingency management therapy uses motivational incentives to facilitate behavior change and has improved treatment retention and abstinence rates. Contingency management can be anything from drug courts where if you go through and you stay clean, you stay out of jail and you won't have X and so charge on your record or you get to keep your kids or will close your case, that's a contingency. Then there are also shorter contingency management things. When I ran the adolescent clinic, if the youth did what they were supposed to do throughout the day, they earned points every time they got a positive hash mark and they could cash in those points for video game time or sleep time or other things that they wouldn't necessarily have. We also had a rewards closet so they could save up their points. And we had like junk food and a variety of different things that teenage boys would find rewarding in that rewards closet that they could purchase with the tokens that they earned from being, you know, doing the next right thing. Motivational enhancement approaches are client centered and they initiate behavior change by helping people look at all of the reasons that they use and all of the drawbacks to both staying the same and to changing. It helps people really understand how they think and how they feel about that situation and harness and internal motivation. It says, you know, I can't make you change, so if you want to change, I'm going to help you figure out reasons that you want to change and deal with all those apprehensions you have about changing. That's my job. But first you have to want to change. And we want to help people identify discrepancies, for example, between their goals and their current behaviors. So if they want to be a lawyer. One client I worked with was in college and he wanted to be a lawyer, but he was actively using some pretty hardcore drugs. And you know, you can't have a felony criminal record and become a lawyer in most states. So we started looking that at that and I said, okay, you're telling me you want to be a lawyer. So, you know, that may mean that you need to give up using these particular types of drugs. You know, there are certain legal drugs and I'm not going to tell him what he can and can't do, but it was important for him to give up the LSD and the GHB and those things that he was using. So that's another avenue that you can pursue with motivational enhancement. For many clients that I've worked with who are involuntary, their whole goal is to get off papers, get off probation, get off parole, be done with me, be done with the system, so to speak. Okay, so that's your motivation. You cannot do that. Get off papers and continue to use at the same time. So during this period while you're under state monitoring, you know, let me help you figure out how you can meet the court's requirements so you can meet your goals and then you can do whatever the heck you want. You know, am I telling them to go back to using? No. But I'm also not telling them that, you know, once you do this, then you won't ever use again. Because for a lot of them, the idea of never being able to use again was way too overwhelming. So we just started with, let's do it for this short period. And I felt in my heart that for a lot of them, if they stopped using for three months or so and got through that post acute withdrawal phase, a lot of them would find that they had developed other behaviors and other skills and other support systems and they didn't have the desire to, to go back to use. That's what I felt in my heart. So, you know, I felt good about helping them work towards a mutually agreeable goal because they're motivated to do that. And trauma specific approaches. Now this can kind of overlap with cognitive, behavioral and everything else. Trauma specific models are take into account the fact that many people have been traumatized and many people's symptoms and, and behaviors are a result or a reaction from that trauma. They may be trying to self medicate ptsd, they may be trying to help themselves deal with anxiety that surrounds being in strange places or whatever it is. But there may be certain things in their present that remind them of the trauma that can trigger the urge to use. There also may be things about the program and about recovery that can trigger their urge to use. One of the biggest triggers for a lot of people, if they go into a 12 step program, is talking about surrender. And surrender is terribly frightening to people who have been traumatized or victimized, because that means relinquishing all control. And yes, theoretically you're relinquishing all control to your higher power. But in their mind, they're like, well, when I didn't have control before and I was victimized, where was my higher power? So they may not trust their higher power. So it's really important to use a trauma informed approach when working with people who are in recovery from anything, because the statistics indicate that the majority of people have experienced some traumas in their life. Trauma specific models are an essential part of treatment because misidentified or misdiagnosed trauma symptoms interfere with help seeking and hamper engagement and treatment, leading to early drop out and make relapse more likely. If you're putting people, for example, in coeducational therapy groups and they have been raped or molested by somebody of the opposite gender, that could be a trigger. They may not be willing to feel vulnerable in front of somebody who reminds them of their abuser. So we need to take all these things into consideration. The primary goal of trauma specific services as are focused on directly addressing the impact of trauma on people's lives and facilitating recovery from that trauma. So we want to look and we want to say this thing happened. Whatever it was, you know, you were in hurricane Katrina, you were raped, you were a victim of a home invasion robbery, Whatever it was that happened, and that was awful. How is that impacting you in the present? In what ways are you still reminded of it? In what ways does it trigger your anxiety or ptsd? And how can we help you deal with that so you're not struggling with that on a daily basis? And how can we prevent re traumatizing you? What types of things in our program might trigger those stress reactions as well? And again, if somebody's been raped, if they are being examined by your physician who happens to be someone of the opposite gender, and they may feel vulnerable, that could be another triggering event. Now, you may only have a male physician to examine females or females to examine males or whatever, and you can't avoid it. So the question is, what do you do? And having a nurse in the room or a female in the room can be helpful. There are a Lot of other things. A lot of it revolves around the doctor's bedside manner. You can overcome a lot with an understanding physician. The addictions and trauma recovery integration model or atrium is one approach, a trauma specific approach that can be used. Seeking safety is another one. And you can buy the seeking safety manual on Amazon. I highly recommend it. I had a couple of clinicians who used that as the backbone of their intensive outpatient programs. And we had just absolutely fabulous results with the women reporting improvements in a lot of different symptoms. Not only drug use, but also anxiety, depression, anger. You know, across the board there were improvements in symptoms. And trauma recovery and empowerment model is another approach that you can use. Couples and family approaches, again, they can be used with cognitive, behavioral. Behavioral, which are the identified best practices for working with addictions. But there is some. There's a lot of emotional stuff and there's a lot of social stuff that goes on. So we need to look at how do we apply these things. You know, if you're going to use cognitive, behavioral, for example, do you use it in group, do you use it in couples and families? Do you use it in individual or all of the above? How do you do that? You want to make sure that the approach you're using is trauma informed. So you're looking out for those triggers. No matter what the setting, Whether it's individual, group or family. The defining feature of couples and families treatment is that they're treating substance abuse in the context of the family and the social system recognizing that when we talk about addictions, for the most part, it's very rare to have a single identified patient. And nobody else contributes and nobody else is affected. You know, I've never seen it. It could happen, but I've never seen it. So we want to recognize the fact that this individual, something triggered their use. You know, it could have been lack of social support. It could have been some genetic vulnerabilities. It could have been a lot of things. We don't exactly know what causes addiction, but it also could have come in part from social factors. So we want to look at that. And as that person began to use, how did their behavior impact the family? A lot of times when people come to treatment, they've alienated the majority of their family. The majority of their family has already thrown their hands up and gone. I don't know what to do anymore. I've tried everything. I don't know how to help you anymore. And they've had to institute tough love, so to speak. So families, if we want this person to have A good, strong, sober, saying social support system. We need to integrate the family in treatment. And the family can be anybody that the client defines as family. It doesn't have to be mom, dad, brother, etc. Anybody the person considers family can be part of this treatment. So the prevailing models, and we're not going to go through them right now. I do have some videos on our YouTube channel@allce.com YouTube that goes over some of the family approaches, but brief strategic family therapy, structural or strategic family therapy, multidimensional family therapy, multi systemic family therapy, behavioral and cognitive behavioral family therapy, and solution focused brief therapy. So I will do another review on the different types of family therapy. And like I said, I do have some videos on the YouTube channel. But it's important to understand that there are six prevailing models of couples and family therapy that you may need to be aware of for your exam and, you know, know how to integrate it when you're working with clients to bring them into treatment. Not every approach is culturally appropriate for every person, which brings us to culturally appropriate strategies. Two areas of concern with regard to cultural competence and addiction counseling are the competence of the individual practitioner. How much do we know about the culture that our clients come from? And I do want to put this big red flashing warning thing here. Don't assume that if your client is of a particular ethnicity, we'll say Asian, that they adhere or ascribe to all or any Asian values. We want to know what Asian values are. And that gives us a launchpad so we can start asking. We want to understand the difference between Asian culture and American culture so we can ask the person, you know, does this fit for you? If you've got somebody who's Asian American and they've been here for, you know, six generations, they're probably going to be a lot more acculturated to American culture. But again, you don't want to assume. So we want to look at that because culture impacts what people feel comfortable talking about, what they feel caused the problem, how involved they want their family to be, whether they feel that this issue, mental health, substance abuse, has brought irrevocable shame to their family. There's a lot of issues that come up in culture. It also impacts the type of treatment, whether they're wanting to see an MD type physician or maybe a spiritual healer or a cultural leader in order to address some of their issues. So we do need to be aware of that. It doesn't mean they're going to want it, but we need to know what's culturally sensitive and ask, like when I have somebody come over. Switching gears a little bit. When I have somebody come over who's diabetic, you know, I don't know what they can eat, I don't know a lot about diabetes. So if I'm preparing a meal, I ask them ahead of time, what works for you? What can you eat? What do you like to eat? In order to make sure that I'm being sensitive to their individualized needs. Culture. And the second thing is the cultural appropriateness of the specific intervention strategies. Some cultures, you know, my grandmother, for example, you know, white Catholic, elderly woman. But the elderly part is the part of the culture that was really crucial in addressing treatment issues. Because when she was raised back in the 1920s, you didn't talk about your stuff in a group full of people. You didn't air your dirty laundry. You put on a happy face and you just dealt with it, and you dealt with it behind closed doors. So putting her in group therapy would have been highly inappropriate and she wouldn't have gotten much out of it, most likely. So we do want to consider the appropriateness of the intervention. If you've got someone who is atheist and they are adamantly opposed to any reference to a higher power, well, let's not put them in a 12 step program because that's just going to, you know, they're going to smack into a wall there and their personal values and their approach to life may conflict. So we need to look at what might work better for them, such as smart recovery, rational recovery, something like that. So we do want to make sure that the interventions we're using are culturally appropriate and that we are aware of what is culturally, potentially culturally appropriate. And then we talk to the client and identify what's appropriate for them. Culturally appropriate treatment can include the language used, the format of the program, the goals set for events, and specific program activities. So some cultures, complete abstinence is not a goal, you know, because alcohol or whatever is integral into their culture. For some cultures, medication assisted therapy is not okay. So we want to be aware of that. For some cultures, having someone in residential treatment may not be acceptable or because they believe the whole family should be involved in the treatment process the whole way through. So there are lot of different things that we need to consider and risk and protective factors may not be relevant for all cultural groups. Most of the risk and protective factors that we know about, we've looked at either white American or black American individuals. We really haven't gotten a really good sample of multicultural risk and protective factors. And for example, you know, going back to those some cultures that really value interdependence instead of independence, they are going to feel it's going to be a greater risk factor if there is disharmony in the family than it is for people who are more independent, potentially. So the impact of these various risk factors we've identified can be different based on cultural values. Programs and practices that have been tested and found effective with one cultural group can be modified to fit other cultural groups most of the time. But you need to actually step back and look at it before you start implementing it. You don't want to implement on the fly and go, oh, let's just tweak this here and tweak that there. That doesn't work. You need to look at it and go, what parts of this do not work for this particular cultural group? And what can we do differently to get them from point A to point B? Modifications can take two forms. Cultural accommodation, which modifies the way the practices are delivered so that can be utilized with a particular culture or community. So cultures that don't feel comfortable sharing their stuff in front of strangers may prefer more individualized activities or may prefer online activities where they're able to maintain more anonymity. Cultural adaptation involves reviewing and changing the structure of the program or practice to more appropriately fit the needs and preferences of the particular cultural group or community. So is, you know, in some treatment programs, maybe a goal is to integrate the nuclear family. And in some cultures, the nuclear family is not necessarily that important. So we want to look and see what goals does this program have and what goals does this individual have? And family counseling. You know, I talked earlier about the fact that there are multiple types of family counseling, and it's important to incorporate this because the effects of substance use disorders go beyond the nuclear family. Feelings of abandonment, fear, anger, embarrassment, or guilt happen for everybody in the family. The person with the addiction, as well as their loved ones. These issues are going to have to be dealt with. Family counseling requires knowledge about the effects of family interactions on the substance use disorder, the impact of the substance use disorder on family interactions. So I remind you of the family roles in the addicted family. The hero, the scapegoat, the mascot, the enabler, the lost child. Those are common in an addicted family. And there's a reason that that pattern exists, because those are often reactions to substance use. So we do want to look at that. And the family therapist needs to understand, be able to identify those roles, why people have chosen those roles, and help people shed that particular skin. In order to become, you know, feel empowered and happy. Family counseling assists members in identifying and interrupting harmful interaction patterns such as passive aggressive behavior, scapegoating, name calling, and presents opportunities for members to focus on their own goals and issues and create a healthier system where everybody can support each other in growth Instead of being afraid of abandonment and holding on for dear life and keeping secrets. The first step, though, is to engage the family. A change in any part of the system will bring about changes to other parts of the system, and that's important to recognize. So when you have a person in residential treatment, that's great, that's lovely because they can focus on that. I love residential treatment for the first 90 days when possible. Gets them through post acute withdrawal, Allows them to start learning about their own thoughts and patterns and developing some skills. But if they're in with you for 90 days and they're making these transformations from caterpillar to butterfly, Their family may not recognize them when they get out. You know, the family's not involved. So we need to get the family involved in this metamorphosis process. So everybody is on. On the same footing. So when John's having a bad day after he gets out of treatment, his wife doesn't automatically assume that he's going to relapse because now he's got these new skills. So she's not making assumptions on the Based on the john she knew three months ago. She's making assumptions based on the john that exists now. Family counseling and addiction treatment has two main purposes. To use family strengths and resources to help find or develop ways to live without substances of abuse. So what are these strengths and resources? Compassion, Caring, willingness, financial. There are a lot of resources that we can look at. You can throw all of those resources at people, and they can fall flat. Because we need to know first, why is the person with the addiction using? Once we identify that, then we can identify what strengths and resources they need to bolster their recovery. And we can figure out which ones the family has. And that's the great place to start. And we can say, okay, you've got a really supportive family member over here, and you've got a good place that you can go live with your uncle Tom over in Jersey and get away from your dealer and other people. That may trigger you for a while. And we can look at the strengths that exist and build on those. Family counseling also ameliorates the impact of addiction on both the client and family, because family counseling helps families understand why the person with the addiction developed it. Much as possible and see their recovery process and be able to be proud and inspired by that recovery process. They're able to deal with all those issues of anger and resentment and abandonment and all that stuff. They're able to deal with it in counseling. So it's not this negative undercurrent that's out there. They're able to get it out, deal with it. So they're starting fresh, so to speak. And I always go back to that analogy of the caterpillar turning into a butterfly. Caterpillars eat far different things than butterflies do. Caterpillars look far different than butterflies do. Caterpillars move different than butterflies do. Same thing with clients that, you know, they come in and they have an addiction. They come out and they are in recovery. It's a whole different ball game. The person using substances is regarded as a subsystem within the family. Every person is their own subsystem. So we need to look at how does this subsystem interact? And I want you to think of a big factory, you know, if a big factory or the electric. Electric grid for the United States. You know, there are lots of grids here and there, and each substation has its own grids and its own backups. So each person is sort of a substation. Now what happens if they go offline or what happens if they're producing too much electricity or whatever? So we want to recognize that each person in the family is a subsystem that impacts the entire system. The familial relationships within each subsystem are the point of therapeutic interest and intervention. So you have John here, and, you know, he's his own subsystem, and you want to see how he interacts with mom. That's one interaction. And how he interacts with dad and sister and brother. Okay, you're understanding how he interfaces with these other subsystems out there. But then you also want to look at how does mom interface with brother? You know, you're going to start looking at the family dynamics, because if mom shows favoritism towards brother and disparages John, then we see where there might be a disconnect in this, the energy of this system. Goals of family counseling include helping families become more aware of their own needs. You know, what do you need in order to be happy and healthy and functional? What are your stressors? What is triggering substance use behavior? What is triggering, you know, difficulties in this family system? You know, it can be things like poverty, sickness. If sickness is one of those things, then maybe we need to help them access medical care. If their living environment is not a safe one, maybe we need to help them do that, but we need to help them identify. What needs do you have that are preventing you from being happy and healthy. If any one of those subsystems in the system is unhealthy, mentally or physically, then it's going to impact the rest of the system. So we need to help everybody achieve health and wellness. Family counseling provides genuine, enduring healing for family members. It works to shift power to the parental figures in a family, if that's appropriate. You know, if you're dealing with all adults, then that may not be as appropriate. But I've worked with a lot of families where the eight year old is tucking in mom who's passed out on the couch and, and there's, and making sure that his little sister gets on the bus in the morning. That's a lot for an eight year old to handle. So family counseling redistributes power, as it should be. It improves communication among family members, helping them learn how to assertively communicate. And the other people. It enables them to learn how to hear without being defensive. It helps the family make interpersonal, intrapersonal and environmental changes. And it keeps substance abuse and mental health issues from moving from one generation to the other. So if we can break these patterns and make the system healthier, then it's probably going to produce healthier products. Codependency refers to people who are in a close relationship with the addicted individual and are overly involved with the other person. The other person's problematic behavior, such as using, sometimes to their own detriment. So a lot of times people who are enablers or codependent are really invested in covering up for the behaviors of the person with the addiction. Enabling is when the codependent person unintentionally or intentionally helps an addict to continue in their addiction by repeatedly putting out little fires for the addicted person. You know, they just want to make sure that nobody sees the problem and paint a happy picture. So they're going to cover up and they're following around, cleaning up this person's messes. Well, what does that communicate to the person with the addiction? It communicates there are no consequences for their behavior, so they might as well go ahead and do what they want. Addiction treatment programs that involve family generally use family interventions that differ from those used by family counselors or therapists. Because we generally in a lot of treatment programs, we don't have a licensed marriage and family therapist. So we use certain techniques, but we're not Implementing, you know, agency wide strategic brief, family therapy or something. An intervention refers to confrontations that a group of family and friends have with the person in order to convey the impact of the substance use, urge them to enter treatment. So what kind of treatment do we have? I said we talk about, you know, different types and levels. Individual counseling. And some of the benefits of individual counseling is a lot of the privacy and you're able to elicit really strong emotions because you're focused on that person for the whole hour. You've got more flexible pacing with individual counseling. With groups, you tend to want to stay on a certain pace, make sure everybody's making progress. But with individual counseling, you know, you can drop back two or three steps if it seems like you've gone too far and go, okay, let's slow our roll a little bit and see, you know, what we need to do differently or what did we miss? It's individualized to the client and often involves brief interventions. Now you can have individual counseling that goes on for months or, you know, even years. If you're going into years. I'm sensing a dependency, really. Clients often are ready to take a break after about six months, usually. Brief interventions often use cognitive, behavioral or motivational approaches. They're typically three to six sessions and they're generally effective. Their approach provides feedback to clients about what we see in the assessment. We just were kind of tactfully blunt. You know, this is the information that I've got and this is where you tell me you want to be. These are your goals. I'm wondering how I can help you deal with the discrepancies. It places the responsibility for change on the client's shoulders. We can't make them change. It says, if you're ready, I'll be here. We can provide advice about what they may want to do and a menu of options. So if I say, you know, my advice is that you enter treatment now, there are these, all these different kinds of treatments that you can enter into and we can talk about what you might be willing to do. We provide empathy because change is hard and this is scary. You hear about people who, you know, are in recovery and they relapse and relapse repeatedly and it seems like it's, you know, a no win situation. So we want to provide empathy to how scary this process is and we want to encourage self efficacy, encourage that can do attitude. They don't have to relapse, they don't have to do anything. What is it that they want to do and how can I help you do that, how can I be a support to you? So this is remember what we call the frames process. Group counseling is one of the most effective approaches to treating substance use disorders though. Because clients learn about themselves by interacting with others, they get peer support from one another. You can help a lot of clients at once. It reinforces self discipline and inspires hope because they're seeing those same people come back time after time and they're all staying clean and it's like, okay, we're doing good here. And they can communicate quite honestly. Having done individual and group counseling, I can tell you group counseling in many ways is a little bit easier because you've got eight other pairs of eyes watching each person. So things that you as a clinician may miss, which we do miss things other people may pick up on those nuances and call them out. So that's the beauty of group therapy is it's everybody's trying to help one another and themselves. There are different types of groups that you can use. Psycho educational groups provide information about psychological issues and coping and all that stuff. Skills development groups help people develop skills so they can have a happier, healthier life. Employment skills, job skills, life skills Cognitive behavioral groups help people change the way they think about a situation. Support groups provide support. Interpersonal process groups help people work with each other to enhance their interpersonal skills and to learn more about themselves. Because generally we develop a microcosm of our outside life in the group. So in this interpersonal group, people start learning more about themselves and how they treat other people. Relapse prevention groups self explanatory cultural focus groups involve bringing people that are of a particular culture and are embracing that culture together so we can provide culturally sensitive treatment. And art therapy is another great group that can be used as well as specific issue groups such as groups for depression, self esteem and trauma recovery. In addition, you know, we're getting all these layers here. In addition to the approach you choose, whether it's cognitive, behavioral or solution focused or motivational, and then the setting you choose, whether it's individual, group or family, and making sure that any interventions you choose are trauma informed and cultural, culturally appropriate. We also need to look at medication. Not everybody wants meds. Some people do. And medication can be beneficial for some clients. So who is often benefits from medications? Clients who face health risks as part of withdrawal. So thinking about especially your alcohol and your benzos, you know, this can be life threatening. So medication can help clients who will not quit using because of withdrawal. This is where methadone, buprenorphine and Suboxone can be helpful. And some of your nicotine replacement drugs. Clients who have tried everything else but keep returning to treatment and continue to relapse, that tells me there's probably a co occurring issue somewhere that we're missing. So clients may benefit from either drugs that will prevent them from getting the benefit from the drugs, like ant abuse or naloxone, or looking at something that may help address their mental health issues which are a trigger for their use, such as depression or anxiety. Clients who believe they're unable to quit using on their own may benefit from medication. And this is one of the reasons that nicotine replacement drugs are so effective. Clients who feel overwhelmed by cravings, clients who believe that medication will help them engage or benefit from psychosocial treatment. And this one's really true. If you've got a client in there who is just miserable from cravings and they feel like they've got the worst flu ever, they're not getting a daggone thing, you're saying. So if they're able to take the edge off that, then they're going to be able to function and focus a little bit better. If they're clinically depressed, they're not going to give a rat's patootie about anything you've got to say, most likely, and they're going to have a hard time concentrating. So if they start taking some psychotropic medications to deal with their mental health issue, that may help them benefit more from psychosocial treatment. And clients without medical addiction or family history risks associated with medication may benefit. So basically this is a laundry list of pretty much every client can benefit if there's a way that the medication can help them. Even if they start on a mental health medication, it doesn't mean they have to take it forever. It can be one of those where they take it for six months or a year while they're getting clean, helping their body get healthier and developing the new skills and tools they need to deal with life on life's terms. Crisis is a situation in which there's a risk of harm to the client unless intervention occurs. And it's important to remember that a relapse can be a crisis. So we want to look at what can we do and how can we identify crises. Crises can be emotional or physical. You know, a heart attack is a physical crisis, depression is an emotional crisis. And crisis has five components and probably need to know these for your test. A stressful traumatic event, a vulnerable or unbalanced situation, a precipitating Factor, you know, what caused this? The active crisis state, based on the person's perception. Now, some people may perceive this one situation as not a big deal, whereas other people, it may feel like the end of the world. So we need to look at what's causing that crisis state and what's the person's perception of it and a resolution of the crisis. Remember that a stressful event alone does not constitute a crisis. Crisis is determined by the individual's view of the event, their personality and temperament, their life experiences, their current physical state. If their intoxicated or withdrawing or in pain, it's going to impact them differently than if they are physically well rested, nourished and healthy, and varying degrees of stress and coping skills and their response to the situation. So, I mean, even think about yourself. On any given day, you may respond better or poorly to a situation based on how rested you are, whether you feel healthy or sick, and how much social support you have. So we need to really recognize that crises can differ. A crisis represents a time of danger and opportunity. It's another thing you probably need to remember. The danger is the person could go further into crisis and become suicidal or homicidal. The opportunity is the fact that people, when they're in crisis, need that crisis to stop. You know, that it's an untenable thing to maintain. So it's an opportunity for them to get motivated to make certain changes in their life that maybe they weren't motivated to make before. All models of crisis intervention involve making sure the person is safe, stabilized, helps them process the crisis event and encourages them to draw conclusions from the process that they can integrate into their life as a learning experience. So what triggered it? You know, what triggered the event? What was the event? How did I respond to the event? How could I prevent something like this in the future? And if something like this in the future happens, what skills and tools have I realized that I have that I can use to deal with it? The best way to handle a crisis is obviously to prevent it. So early assessment of clients for their potential for agitated or assaultive behavior is essential. And, you know, this kind of behavior can happen at any point. And I've had clients before who've been, you know, in treatment for three weeks and doing fine. And then they get a call from their lawyer and they find out that there's a warrant out for their arrest, and all of a sudden they spiral downwards very, very rapidly. So it's important to keep your finger on the pulse of what's going on with your clients. And early Assessment isn't just at the beginning. You are regularly assessing your client for any changes in their status. Clients should be taught strategies aimed at helping them manage their own behavior, such as stress and anger. Prevention of violent and aggressive behavior needs to start at admission. So if you've got somebody who's agitated, we need to get them on a behavior contract and or see the doc. They may need some medication to help them rein it in a little bit. It just depends on the reason for their aggression. We need to make sure that they're safe, the other clients are safe, and the staff is safe. Clients need to be assessed and asked about past violent incidents, whether they've ever been put in seclusion or restraint, and whether they've ever experienced abuse as a child or an adult. And remember, abuse as a child or an adult is a traumatic experience. So if that person has been restrained or abused before and they need to be restrained now, that's probably going to escalate the situation. So that's that trauma informed approach to crisis management. So we need to know these things. When at the clinics I've worked at before, we've asked clients at the beginning if you become, you know, extremely upset, what things help and what things absolutely make it worse. So we have it written down in their chart and we know ahead of time that if you lay hands on them when they're angry, it's going to get ugly. It doesn't mean that we necessarily won't. But most of the time, you know, if you avoid some of their early identified triggers, they feel respected and they don't feel as vulnerable. One of the most recommended intervention strategies is verbal crisis de escalation, which is aimed at meeting the agitated person's immediate needs and calming the situation. So let me hear what you need. A lot of times a person in crisis, one of the first things they need is to be heard because they feel out of control and they need to be heard and validated. Okay, let's do that. Another immediate need is to get rid of the bystanders, because the bystanders just inflame the situation. A third immediate need when people are upset is often to enable them to move. And a lot of times we want people to sit down and calm down, but think about when you are just like really revved up, how hard it is to sit down and be still. So sometimes it's better if you can and if it's safe to take the client to a place where they can walk around and talk, even if it's just pacing in circles in A group room. If it's a safe environment, it may help them diffuse some of that adrenaline and energy. Steps in crisis intervention Assess the severity of the crisis. Form a connection, demonstrating that you're there with the client. Explore the problem, focusing on the client's immediate situation using active listening and paraphrasing in order to restore the person to his or her previous level of functioning. You know, we're not trying to get them to be, you know, cured. We're trying to get them to where they were this morning before they got agitated. Deal with feelings and emotions, including not only the content of the material, but also the underlying feelings. If they're telling you that their attorney just called them and they've got three warrants out for arrest and they're looking at 15 years of prison time and they're telling you all this, okay, that's content. That's, you know, obvious content. How do they feel about that? They're probably devastated, terrified. You know, let's start looking at how are they feeling? You know, what is, what are the words that help describe their level of agitation? Generate alternative solutions and summarize your understanding of the situation. Develop an action plan which is very specific regarding time. People in crisis need some relief and need some hope. If we say, you know, okay, at some point we need to do this and that, the person's not going to feel really reassured. If we say, okay, in 30 minutes we will call your attorney and then we will figure out when your court date is and, you know, blah, blah, blah. But you get immediate goals, you develop some sort of sense of immediate relief. So, you know, maybe calling the attorney is not going to do a whole lot of good, but we can call him and look at what are our options and maybe identify some things that might mitigate the sentencing process and start working on what they can do and what the client can do in order to improve their chances they'll stay out of jail and then develop a specific follow up plan. With a lot of clients who were in crisis, they may start to feel better and then they get upset again. So generally when I've worked in a residential situation or even outpatient, we have clients check in periodically and it could be every hour, it could be every four hours. That way we know they're still doing okay. And as the time between the crisis incident and now gets longer, we can expand the window for when they're checking in. So initially have them check in every hour and then every four hours. And then after a couple of days, maybe they only need to check in once a day. But that gives you a chance to provide early intervention. If they should start decompensating again, remember that relapse is certainly a type of crisis. You know, this is when people see all of their hard work going down the toilet in many of their eyes. What I want them to remember is it's not going down the toilet. You know, yes, you made a choice and it was an unfortunate choice, but all those skills and tools you had, they didn't just disappear, you just chose not to use them. So we need to figure out why. Why was using more rewarding than the stuff you've been learning in treatment? What triggered this situation and what did we miss? Because clearly life got the better of you right now. So we need to figure out how to prevent that from happening again. A lapse or recurrence of use is thought to have a different cognitive and behavioral process different from relapses. So if somebody just uses once, has a lapse, generally that's different than if they go on a one or two week bender. Interventions designed to stop a lapse may prevent a full blown relapse. Remembering that lapses can actually occur behaviorally too. So if people start returning to that stinkin thinkin', we need to intervene. Even if they haven't picked up yet, they may be three months from picking up. But if we see that they're stopping following their recovery plan, if they're not taking good care of themselves, if they've returned to stinking thinkin, that is a relapse just waiting to happen. So we need to provide intervention. Oftentimes lapses occur in response to an acute stressor. So maybe they got fired and that was just too overwhelming, so they went and had a few drinks, then they felt really guilty afterwards. That's different than a relapse that builds over time and generally kicks off a series of future events. Lapsing back into use indicates that treatment needs to be reinstated or adjusted or that another treatment needs to be tried. So you know, let's look at again, what did we miss or what needs were not getting fulfilled. Similar to drug and alcohol treatment, treatment for chronic illnesses are effective but require strict adherence to medical and behavioral regimens. Clients with these diseases often do not comply with their treatment. And a lot of clients we work with have things like hepatitis, cirrhosis, hiv, chronic pain. So we do need to make sure that they're following their treatment plan for all of their conditions. Three key points forming a comprehensive view of relapse. Relapses are common and clients should Understand that they are likely to be vulnerable. We all hit periods where we become vulnerable to relapse. Merely mentioning the R word relapse will not cause the clients to relapse. Relapse is reasonably predictable. When examining general precipitants. You know what things generally trigger people to relapse? Stress, Anxiety, catastrophic, something happened like a hurricane. There are some pretty predictable things that cause most people to hit a crisis point and can trigger a relapse. But we also want to look at people's own personal triggers, including social situations, whether they're taking care of themselves or getting hungry, angry, lonely and tired. Personal emotions and situations that can be danger zones and need to be anticipated. For some people, you know, you think anger, anxiety, depression, those are huge danger zones. Well, they are. But for some people, happiness, if they feel like they're getting too happy, it also could be a trigger for use because they're afraid that, you know, that happiness is going to end and then they're going to screw up, so they self sabotage. We need to be aware of that. Relapses are preventable with the use of self monitoring and abstinence maintenance activities, including AA or other self help groups, counseling, involvement with the recovery community, religious congregation, health club or fitness group, or any lifestyle that is inconsistent with use. Remember this for treatment planning. When people are getting out of treatment or if they're in intensive outpatient, they need something to do the other hours of the day where they're not in treatment. So they need to be involved in things that keep them in a safe situation. Relapse prevention is an umbrella term encompassing most skills based treatments that incorporate cognitive, behavioral skills, building and coping responses. The overall goal of relapse prevention is to help people create more positive habits and positive changes in their lives in order to prevent relapse and sustain their own recovery. So positive habits include getting enough sleep, eating healthfully, being mindful of their mood and their activities, engaging in social activities that they're comfortable with for social support. Relapse prevention therapy, or RPT, is a behavioral self control program that teaches clients to understand that relapse is a process. It's not just out of the blue. You know, you look back and you see that a lot of things led up to it. Identify and cope effectively with high risk situations. Cope with urges and cravings. Implement damage control procedures during a lapse to prevent a full blown relapse. Stay engaged in treatment even after a lapse or a relapse, and identify when and how to create a more balanced lifestyle. So it's about creating a recovery lifestyle. Recovery is not something you do for six months and then you're recovered. You want to embrace a recovery lifestyle. Cognitive techniques provide clients with a way to reframe the habit change process as a learning experience with errors and setbacks expected. You may have lapses, you may have relapses, you may have thought lapses or you know, recurrence of your depression. That's expected during this process. We just need to communicate so we can help clients identify these when they start happening early and provide as intervention as early as possible. Behavioral techniques include the use of lifestyle modifications such as meditation, exercise, and spiritual practices to strengthen the client's overall coping capacity. The cnapps model of relapse prevention therapy is also based on the belief that total abstinence plus personality and lifestyle changes are essential for full recovery and you can learn more about cnapps if you just Google it online. There are five components to the CNAPPS process assessment, Warning sign identification, Warning sign management, Recovery planning, and relapse early intervention training. So they identify their warning signs, they identify how to manage them, they create this great plan for a recovery lifestyle, but then they also have an emergency plan for intervening early if they see that they're starting to head down a bad path. There are many approaches to treatment, including cognitive, behavioral, motivational, trauma, informed relapse prevention, and family approaches. These approaches can be applied in individual, group, or family settings, and counselors must constantly remain aware of the impact of culture on choosing treatments and interventions. Family engagement is crucial in the recovery process, but family is who the client defines it as. It may not be blood relatives Crisis has five components, and what causes a crisis can be different for each person, but as clinicians, we need to be aware of the seven steps in crisis intervention. Most relapse prevention theories address relapse triggers, unpleasant emotions, interpersonal conflict, and social pressure. These triggers account for almost three quarters of the relapses. So these are those general factors that we were talking about unpleasant emotions, interpersonal conflict, and social pressure. Antecedents to relapse can be found within within an individual, such as the person's mood or coping style, or may be triggered by interpersonal events. So we need to really talk to a person about what triggered your prior relapses or what triggers your cravings, and look at individualizing their plan. 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