Evergreen Conference 2018

1. Evergreen Conference 2018 Evidenced Based Practices for Youth with Co-Occurring Disorders Tim Walsh, MA, LP; DPAVice President Minnesota Adult and Teen Challenge

2. Who We Are… • Short-Term Treatment • Long-Term Recovery Program • Inpatient & Outpatient • Programs for Teens & Adults • Personal Approach • Relate, Engage & Inform • Reinforce School Curriculum • Correct Misconceptions • Interactive

4. Diagnostics….

5. 50 to 75% of all clients who are receiving treatment for a substance use disorder also have another diagnosable mental health disorder Further, of all psychiatric clients with a mental health disorder, 25 to 50% of them also currently have or had a substance use disorder at some point in their lives Source: “Integrated Treatment for Co-Occurring Disorders”. Web conference. Hazelden, NAADAC, et. al

6. Psychiatric Disorders in Addiction Treatment Source: Cacciola et al, 2001; Ross, Glaser and Germanson 1988

7. Addiction Treatment Provider Estimates by Psychiatric Disorder (ibid)

8. The Mental Health and Addiction Interaction Make a distinction between mental health symptoms you have while you are actively addicted, and those you experience while you are abstinent /clean /sober

9. Addiction & Mental Health Your drug and alcohol use can mask an underlying mental health disorder. You don’t notice the mental health problem because you are intoxicated You may be medicating yourself. That means you are acting like your own psychiatrist and pharmacist and taking substances that you think will help your mental health symptoms (depression, anxiety, agitation, etc. Your drug and alcohol abuse can lead to mental health symptoms (underlying pre-disposition)

10. “Integrated Treatment for Co-Occurring Disorders”. Web conference. Hazelden, NAADAC, et. al

11. Sanity vs. Insanity The insanity of addictive behaviors vs. co-occurring disorder Abuse and Addiction to substances can cause symptoms of mental health disorders called “Substance Induced” The affects of the drug can carry on even after stopping use. “Persisting Perception disorder” Hallucinations False Perceptions

12. Self Awareness 1. Encourage the clients to step back and sort their thoughts and feelings in the moment 2. Consider the history, experiences, beliefs, values, actions and interactions and how these are interacting with the client 3. Assess yourself - what is going on (Interpret what is going on- What does it mean? Where is it coming from? 4. Ask, How will I intentionally reflect in this moment for the benefit of the client?

13. Are you “Electric” or do you just do what you want to do in the way that you want to do it?

14. PRIMARY THEORY OF CHANGE…

15. Vs. Fidelity

16. MNTC Model Of Treatment MNTC believes addiction is a complex disorder that is reinforced by medical, social, cultural, spiritual and emotional factors. We integrate a variety of evidence-based practices provided by a multi-disciplinary professional team to give clients with education, tools, experiences and support to live a life of abstinence free from all mood altering chemicalsWe utilize the 12 Steps as a framework and model for ongoing recovery. When appropriate, we utilize medications to treat addiction, medical and mental health issues as long as they support the client in achieving long-term abstinence from addictive substances

17. MNTC Model Of Treatment Recovery and healing happens in the community. Foundational to our therapeutic approach is our “Culture of Honor” whereby staff members treat all clients with acceptance, compassion, honor and respect. This environment has a profound effect on clients and allows them to experience life and interpersonal relationships in a positive and self-affirming way which makes change possible. MNTC intentionally partners with individuals, recovery support groups, and churches who exhibit these same values to provide ongoing support to clients once they leave our programs

18. An important lens: What works for this client within this situation with these issues? EBP • http://www.apa.org/practice/resources/evidence/index.aspx • https://www.samhsa.gov/nrepp • http://static.nicic.gov/Library/023358.pdf • http://www.wsipp.wa.gov/BenefitCost?topicId=1 • http://www.wsipp.wa.gov/BenefitCost?topicId=5 Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences (APA, 2005)

19. Finding the Sweet Spot…

20. What Can be Changed? Motivational DirectionThoughtsEmotionsBehaviorsRelationships

21. Focus on Family/Child Engagement

22. Motivation! Their dreams, goals, wants, needs….

23. Your organizational/therapeutic culture matters! LATROGENIC Perhaps…and I am Just saying…but maybe …your therapeutic Milieu sucks…or not… I don’t know  Again…I am just saying

24. Interventions are thus targeted and delivered directly in the home, school, peer, and neighborhood settings in which problems arise, and the interventions are designed in full collaboration with family members and key figures in each setting (e.g. teachers, counselors, principals, etc.). The point is to get the system to orient itself towards new sequences of behavior that support the success of the client. The ecology is the client. Ecological Validity (Henggler, et.al.)

25. “Mental health and juvenile justice systems provide services that have little to do with the functioning of the youth in the real world. Delinquents and their families usually have very real problems at home, in school, and in their neighborhoods. Yet, mental health services typically attempt to “fix” these problems by talking with the youth in an office for 50 minutes per week. More restrictive services such as incarceration and residential treatment attempt to address these same problems by removing youth from their home, school and neighborhood, and providing services in some distant location. Then the youth is returned to the exact same home, school and neighborhood where little has been done to prepare for his or her return. Even if the out-of-home placement did provide useful interventions, it is unreasonable to expect changes to be maintained if the youth’s environment has not been altered to support such change.” ( Henggeler, Focal Point, Vol. 11, no.1).

26. Ecology: The real life and relationships of the client

27. Thinking Systemically about the Problem and Solution

28. Brofen Brenner Nested Socio-ecological

29. Responsivity Considerations: What is it about the client that affects the outcome? • Level of psychological development • Sensation seeking • Motivation • Anxiety/Psychopathy • Social Support for service/change • Case management strategies • Mental disorders • Gender • Age • Ethnicity/Race (Gendreau, P., Andrews, D.)

30. Culturally Competent Approach:Overarching Principles Culturally matched/competent therapists Model and enhance families’ advocacy skills with systems Address historic distrust, passivity, anger and other volatile emotions and use as levers for change Respect culture through strength-based, family centered and unconditional approach (Mason, 1998)

31. Counselor’s style, approach, and traits make a difference Empathetic | Genuine | Honest | Supportive | Trustworthy • EXAMPLES • Directive/Intentional • Motivational • Strategic • Solution-Focused • Structured • Positive Psychology • Contingency-based • Pro-Social/Healthy

32. What is it about my style that affects outcome? Confrontational Blaming Hostile Demanding Commanding Wishy-Washy - Unclear - Non-Specific - Non-Direct Touchy-Feely • Sympathetic • Parenting • Friend

33. Another Important Lens: Strengths-Based Strengths are anything--assets, supports, skills-- that will help the client to live successfully and responsibly. The strengths-based approach is to discover, focus on and build upon the positive aspects of the client and the family. Strengths must be an integral part of assessment, treatment planning and service delivery. You need to find out what strengths the client possesses, how you can build on these strengths in the program and use these strengths as the levers or motivators to work with the client to do the hard work of change.

34. POSITIVE PSYCHOLOGY: VS. DEFICITS, DISORDERS, PATHOLOGY, SICKNESS…

36. Change the WHAT & WHO

37. Utilizes Social Learning….“Learning”=How People Change A role model the individual can relate to Direct instruction on the skill by R.M. Demonstration of the skill by R.M. Role play by client Positive reinforcement of client by R.M. Feedback to client by R.M. Skill practice to mastery Transfer of skill to real world situations Use of sanctions and rewards in real world to support learning Relapse planning & modify ecology/support system

38. The Social Learning Model: what works for co-occurring ATTENTION: the client is conscious, aware and focused. MOTIVATION: the client is motivated because they are able to learn the behavior, is in control of learning, can learn in this situation, values people who value this behavior, feels their plan of action will be effective, feels learning will be valuable and will get them they really want. REHEARSAL: the client practices the behavior until she has achieved mastery.

39. The Social Learning Model: what works for co-occurring RETENTION: the client uses effective strategies to remember the skill learned (e.g. cues, prompts, reinforcers, cliché, mnemonics) APPLICATION: the client applies the behavioral skill in the real world. REINFORCEMENT: the client receives reward for doing the behavior; the behavior allows the client to avoid undesirable consequences or the failure to do the behavior results in undesirable consequences.

40. Is Transferable/Generalizable (Bandura) The treatment environment is similar to the community environment, Thus, the more treatment is a world unto itself, artificial, and self-contained, the less likely it is to be effective The client has ample opportunity to practice the learned behavior in the new environment (i.e. home/community)There are consistent incentives/reinforcers to maintain new thinking and behavior within the community environment

41. Is Transferable/Generalizable (Bandura) Treatment environment approximates some of the same challenges as the real world (without being counter therapeutic) Learning is slowly phased from the treatment environment to the community environment. The client is likely to kick into old thinking and behavior if he or she is introduced to the community environment cold from the treatment environment. Likewise, with a dramatic phase shift, the client is likely to revert to what is comfortable for him or her i.e. automatic thinking and reflexive behavior—the same old, same old. The behavior has some real world application.

42. NEUROSPIRITUALITY: The Role of Faith Camchong, et. al, Alcohol Clin Exp Res. 2013 May ; 37(5): 794–803. doi:10.1111/acer.12037Davidson, R.J., Kabat-Zin, J., Schumacher, J., Rosenkranz, M., Muller, D., Santorelli, S., et.al. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65(4) 564-570. Emmons, H., M.D. (2006). The Chemistry of Joy. New York: Fireside Ibid (2010). The Chemistry of Calm. New York: Touchstone. Glynn, P. (1997). God The Evidence: The Reconciliation of Faith and Reason in a Postsecular World. Jennings, T. (2013). The God-Shaped Brain. IVP Books Koenig, H.G. (1999). The Healing Power of Faith Lazar, S., et. al, NeuroReport, 16(17), 1893-1897. Ibid. Newberg Lipton (2005). The Biology of Belief Newberg, A.; Waldman M. (2009). How God Changes Your Brain: Breakthrough Findings from a Leading Neuroscientist. New York: Ballantine Books Nowinski (2015). If You Work it It Works!: the Science Behind 12 Step Recovery. Hazelden Publishing Pew Forum (2008). http://www.pewforum.org/2008/05/05/how-our-brains-are-wired-for-belief/ Ramachandrian (20ll). The Tell Tale Brain Siegel, R.D. (2010). the mindfulness solution: Everyday Practices for Everyday Problems. New York: The Guilford Press.

43. QUESTIONS?