I have no financial interest in anything I’m presenting!

1. I have no financial interest in anything I’m presenting!

4. Is the Cart before the Horse: Failure to Launch and Substance Abuse Issues

5. Is the Cart before the Horse • The Paradigm • Client • Concept • Theoretical ‘lenses’ • Implementation • Verification • Continuous feedback/improvement

6. Is the Cart before the Horse • Client Characteristics • Raised with conflicting parenting styles • Peer relationships that are characterized by using and being used • Selfish, non-empathetic life orientation • Little functional, internal sense of identity or control • Rigid thinking with little consideration of future consequences flowing from present actions • Selfish, simplistic moral/ethical reasoning • Some degree of severity of substance use disorder

7. Is the Cart before the Horse • There are no objective measures for quality of sobriety • There are, however, characteristics of addicts that contribute to the continuation of their addiction • Changing these characteristics can be objectively measured

8. Is the Cart before the Horse CONCEPT

9. Is the Cart before the Horse • Develop : To go through a process of natural growth, differentiation, or evolution by successive changes • Therapist : A trusted counselor or guide • Treatment : A contrived developmental crisis

10. Is the Cart before the Horse • Individual Development • Establish functional relationships • Move toward self-mentored development • Develop an internal locus of control • Create and adhere to an internal value system • Trace the past to free the future • Develop character traits conducive to positive life functioning

11. Is the Cart before the Horse • Family Development • Restoration of balance • Clarity of roles • Partnership parenting • Demarcation and forgiveness • Agreements for the future

12. Is the Cart before the Horse • Character Development • An internal framework of moral principles • Character traits • Defined in terms of one’s actions and choices • Consistent with a set of moral values

13. Is the Cart before the Horse THEORETICAL ‘LENSES’

14. Is the Cart before the Horse • Erik Erikson’s Stages of Development • Trust vs. Mistrust • Autonomy vs. Shame & Doubt • Initiative vs. Guilt • Industry vs. Inferiority • Ego-identity vs. Role Confusion

15. Is the Cart before the Horse • Erik Erikson’s Stages of Development • Trust vs. Mistrust • First reliable, caring relationship • Success leads to development of trust

16. Is the Cart before the Horse • Erik Erikson’s Stages of Development • Autonomy vs. Shame & Doubt • Develop sense of personal control • Energy directed toward skill development • Learns control • Success leads to feelings of control and autonomy

17. Is the Cart before the Horse • Erik Erikson’s Stages of Development • Initiative vs. Guilt • Assertion of control and power over the environment • Too forceful or experiencing disapproval results in sense of guilt • Success leads to a sense of purpose

18. Is the Cart before the Horse • Erik Erikson’s Stages of Development • Industry vs. Inferiority • Coping with new social and academic demands • Lack of mastery leads to inferiority feelings • Success leads to a sense of competence

19. Is the Cart before the Horse • Erik Erikson’s Stages of Development • Ego-identity vs. Role Confusion • Developing a sense of self • Developing personal identity • Developing internal system of values • Marcia’s work on ego-identity status

20. Is the Cart before the Horse • James E. Marcia’s work on Ego-Identity • Diffused – no exploration, no commitment • Foreclosed – no exploration, commitment • Moratorium – exploration, no commitment • Achieved – exploration, commitment

21. Is the Cart before the Horse • James E. Marcia’s work on Ego-Identity • Central are exploration and commitment • Empirical studies of the identity statuses • Greater individuation after crisis/exploration • Ego development • Locus of control – external LOC associated with depression; internal LOC associated with developed identity and higher level moral reasoning • Field independence • Greater personality differentiation in terms of relationships with others after crisis/exploration

22. Is the Cart before the Horse • The Substance user “Achieved Identity” • Under-functioning • Manipulative • Internal locus of control is the ability to use • External locus of control is dictated by the approval of other addicts • Continuously reinforces the negative cognitions of self he wishes to avoid by using • Relationships characterized by using and being used

23. Is the Cart before the Horse • The Substance user “Achieved Identity” • The less developed the self, the greater the impact of others, the more vulnerable to addiction • “Other esteem” • External Locus of Control • Response to relationship pressure, not thoughtful choice

24. Is the Cart before the Horse • Differentiation of Self “Families and other social groups tremendously affect how people think, feel, and act, but individuals vary in their susceptibility to a "group think" and groups vary in the amount of pressure they exert for conformity. These differences between individuals and between groups reflect differences in people's levels of differentiation of self. The less developed a person's "self," the more impact others have on his functioning and the more he tries to control, actively or passively, the functioning of others. The basic building blocks of a "self" are inborn, but an individual's family relationships during childhood and adolescence primarily determine how much "self" he develops. Once established, the level of "self" rarely changes unless a person makes a structured and long-term effort to change it.” • - www.thebowencenter.org

25. Is the Cart before the Horse Treatment is a “contrived” developmental crisis!

26. Is the Cart before the Horse • Relationships • Parents • Cross-generational alliances • Conflicting parenting styles • Partner • Feeling “incomplete” within the self • Either anxious or avoidant • Friends • Association with negative peer group • Seeking those who will like and want to be liked

27. Is the Cart before the Horse Please get in groups of three!

28. Is the Cart before the Horse • Relationships • Parents • Strong parental dyad • Structurally consistent parenting styles • Partner • Knowing the self before partnering with another • Relationship based on wanting, not needing - Neither anxious or avoidant • Friends • Association with like-minded in terms of positive values • Seeking those who will be honest rather than be liked

29. Is the Cart before the Horse • Parenting Styles • Authoritarian • Absolutes • Overt power • Permissive • Indulgent • Manipulation • Authoritative • Values self-will and conformity • Mentors when to use which

30. Is the Cart before the Horse • Parenting Styles “Preliminary results indicated that parental autonomy support was positively correlated with internal self-regulation, identity development, and emotional outcomes. Parental conditional regard was positively correlated with external self-regulation and negatively correlated with emotional outcomes. Regression analyses confirmed that parenting style predicts identity and emotional outcomes during emerging adulthood, suggesting that these outcomes are a function of parenting behavior.“ (Grundman)

31. Is the Cart before the Horse • Parenting Styles “Parenting styles influence the achievement of identity in adolescence. A parenting style emphasizing high standards and high communication encourages adolescents' exploration in a supportive environment. A parenting style that emphasizes high standards but low communication may interfere with the healthy exploration of identity potential. Permissive parents who do not establish standards for adolescents are encouraging a diffused identity with no clear commitments (Santrock, 2004).”

32. Is the Cart before the Horse • Moral Reasoning • Very simple – “I do or do not do so I won’t be punished” • Self-centered and self-directed • Is the avoidance of life instead of the experience of life • “What I don’t want since I do not understand what I do want”

33. Is the Cart before the Horse • Moral Reasoning “Twenty-six subjects (20 males and 6 females) were administered measures assessing ego identity status, level of moral reasoning, and stage of cognitive development. Expectations that formal operations would be a necessary but not a sufficient condition for the development of post-conventional moral thought and for Identity Achievement status were supported. Level of moral thought was also found to be positively related to achievement of identity.” Ego Identity Status, Formal Operations, and Moral Development, (Rowe and Marcia, 1979)

34. Is the Cart before the Horse • Moral Reasoning “Subjects who achieved an ego identity were generally characterized by the most mature level of moral judgment, while those with a relative lack of ego identity were generally characterized by either the least mature level of moral judgment or a transitional period between moderate and highly mature moral judgment. People undergoing an identity crisis were found to be unstable and inconsistent in their moral reasoning.” Ego Identity Status and Morality: The Relationship between two Developmental Constructs, (Podd, 1972)

35. Is the Cart before the Horse • Family/Systems Perspective • Multigenerationalism • Structural views and interventions • Patterns of communication

36. Is the Cart before the Horse Family/Systems Erikson’s Stages/ Moral Reasoning Marcia’s EIS Relationships Locus of Control Parenting Style

37. Is the Cart before the Horse • Substance Use Disorders – DSM - 5 • Taking the substance in larger amounts or for longer than the you meant to • Wanting to cut down or stop using the substance but not managing to • Spending a lot of time getting, using, or recovering from use of the substance • Cravings and urges to use the substance • Not managing to do what you should at work, home or school, because of substance use • Continuing to use, even when it causes problems in relationships • Giving up important social, occupational or recreational activities because of substance use • Using substances again and again, even when it puts the you in danger • Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance • Needing more of the substance to get the effect you want (tolerance) • Development of withdrawal symptoms, which can be relieved by taking more of the substance.

38. Is the Cart before the Horse • Substance Use Disorders – DSM – 5 The DSM 5 allows clinicians to specify how severe the substance use disorder is, depending on how many symptoms are identified: Two or three symptoms indicate a mild substance use disorder Four or five symptoms indicate a moderate substance use disorder Six or more symptoms indicate a severe substance use disorder

39. Is the Cart before the Horse IMPLEMENTATION

40. Is the Cart before the Horse Seven Guiding Principles Provide age-appropriate tracks and gender-specific programming Say no to the status quo Measure twice, cut once Empower, never punish Go further than Twelve Step Build a launch pad Include family and friends

41. Is the Cart before the Horse Assessment Assessment at full medical detox and admission to same if criteria for detox is met

42. Is the Cart before the Horse • Assessment Psychiatric Evaluation Psychological/Educational Beck’s Depression Inventory Beck’s Anxiety Inventory Rotter Incomplete Sentence Blank WRAT-4

43. Is the Cart before the Horse • Assessment Psychological Well-being Ryff Scales of Psychological Well-Being Trauma PTSD Symptom Scale Executive Functioning BRIEF

44. Is the Cart before the Horse • Assessment • Fifteen days of assessment as to ability to function in a mature and positive manner • Establish where the client is on the continuum of Substance Use Disorder • Acclimation into the treatment environment • Client makes decision if they need to stay or not

45. Is the Cart before the Horse • CORE programming • Gender- and age-appropriate programming • Thirty day commitment • Character education • Principles of recovery • Initial trauma work (if needed) • Exposure to AA, NA, Smart Recovery, Celebrate recovery

46. Is the Cart before the Horse • Expand, not limit, peer support groups for clients • AA, NA, Smart Recovery, Celebrate Recovery, etc. • There does not have to be an ‘either/or’ between a Clinical approach and the inclusion of support groups in recovery • Support groups are about: • Development/Identity • “Growing up in public” • Healing relationships/Treating self and others better • Spiritual connection/Higher moral reasoning • Accountability/Responsibility/Internal LOC • Doing “the next right thing”

47. Is the Cart before the Horse • Extended programming • Forty-five day commitment • Continued gender- and age-appropriate programming • Continued implementation of Character education • Alternatives to substance use defined, experienced and integrated into daily living • Completion of trauma work (if needed) • Further integration into the support group of the clients’ choice,

48. Is the Cart before the Horse • The treatment team • Information • Coordination • Representation from all areas • Feedback, ideas, and implementation from all areas • Emphasis on appropriate and logical consequences for behavior

49. Is the Cart before the Horse • Residential • Primary goal is the safety of the clients • Staff qualified, trained and boundaried • Authoritative approach to giving instructions • Staff model a culture of mutual respect • Staff model a culture of firm boundaries

50. Is the Cart before the Horse • Staff support and setting expectations • Disrespect to staff is not tolerated • Disrespect to clients is not tolerated • Clients are told from the beginning they are capable and the expectations will be high