PCN-100 Major Approaches of Treatment Speaker Notes PDF

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Title Page: Major Approaches of Treatment by Emma Kaplan Contents Levels of Care In The ASAM Criteria Treatment exists on a continuum marked by four distinctive and broad categories for the level of care in addiction to an early intervention level. Decimal numbers are used for the gradations in the intensity of service. The ASAM Level of Care is used as a standard when conducting assessments to determine what services are required to meet a client's needs. The Early Intervention Level is marked at 0.5. This level of care calls for treatment appropriate for individuals who are known to be at risk for developing substance abuse related issues or when there has not yet been sufficient data collected for a diagnosable substance-abuse disorder. ASAM Level 1 calls for outpatient services for either adolescents or adults. This service typically consists of 9 hours of treatment per week in the case of adults and 6 for adolescents. Organized services can be administered in a variety of settings for recovery and motivational enhancement therapies and strategies. ASAM Level 2 includes intensive outpatient services and partial hospitalization services. This level of care specifically meets the complicated needs of people recovering from addiction and co-occurring conditions.Level 2.1 is the first gradation and refers to intensive outpatient services. Generally adults receive 9 or more hours of service every week and adolescents receive 6 or more hours. More time in treatment every week and a client’s multidimensional instability have a direct relationship. Organized outpatient services are delivered during the day, in the evening, or on weekends. It can accommodate the usual work or school schedule so addiction treatment does not disturb a person’s life in the extreme. The care setting is adjusted based on a client’s needs. Level 2.5 calls for partial hospitalization services that provide 20 hours of service a week or more in cases where 24 hours care is unnecessary. Clients with similar needs as 2.1 that exhibit more severe instability benefit best. ASAM Level 3 includes residential treatment and inpatient services with 4 gradations. Treatment is a co-occurring capable, co-occurring enhanced, and complexity capable service in a 24 hour living situation. A range of services are provided and the staff and medical personnel provide support and structure for addiction and mental health recovery. At 3.1, clinically-managed low-intensity residential services include at least 5 hours of clinical service a week. Clinically managed population-specific high-intensity residential services at 3.3 stabilize imminent danger along with less-intense individual and group treatment for clients with any impairment unable to participate in full active therapeutic communities. Level 3.5 is called clinically managed medium-intensity services to stabilize imminent danger and acts as preparation and a precursor to outpatient treatment. Patients are able to tolerate a full active therapeutic social environment. At 3.7, clients in medically monitored high-intensity inpatient services or medically monitored intensive withdrawal management services administer nursing care and access to physicians for any significant health problems. Patients at this level can require more medical supervision or

medication and typically have a recent history of inability to complete withdrawal management or move into continuing addiction treatment. This setting is most appropriate for people with emotional, behavioral, or biomedical complications severe enough to require 24 hour care. ASAM Level 4 is at the most extreme end on the continuum of care. Medically managed intensive services provide 24 hour nursing care and daily physician care for adults and adolescents exhibiting extreme instability. Patients can engage in 16 hours of counseling every day. Evidence-based Interventions EBIs are defined by the National Alliance on Mental Illness as treatments that have been proven effective through academic or scientific research and multiple replications in investigations or studies. When treating substance-abuse disorders specifically, pharmacotherapies, motivational interviewing, and several psychotherapies are known to be successful. Solution-Focused Therapy Solution-focused therapy is a radically simple, short term form of psychotherapy often used in combination with other approaches like Motivational Interviewing, Person-centered therapy, Existential therapy, and many Cognitive-behavioral therapies. This theory was conceived and developed in 1985 by De Shazer & colleagues at the Brief Family Therapy Center in Milwaukee, Wisconsin. This intervention places the emphasis on pragmatism and mental health rather than mental illness. Practitioners prioritize the client’s strengths, accomplishments, resources, and capabilities and express absolute confidence in client’s motivation and ability to change with the working assumption that recovery is inevitable. “Exceptions” to problematic patterns are given more importance and attention than any failings or mistakes. These are used to formulate a solution with the client to try to utilize going forward. The focus and goals are adjusted to client needs. Starting with manageable tasks with high success rates builds the patient’s motivation and belief in themself. Positive differences are celebrated no matter how seemingly small. Therapists encourage the client as well as their family and friends to recognize and acknowledge change and improvements. Taking control of their treatment leads to increased cooperation and ultimately more successful outcomes in the therapeutic interaction. Twelve Step Recovery AA founded by Dr. Robert Holbrook Smith and Bill Wilson on June 10, 1935, inspired by their own experiences with an addiction to alcohol. They created meetings to help other alcoholics by sharing what had worked for them which slowly grew in popularity. Alcoholics Anonymous published in 1939, detailing the 12 steps and 12 traditions. The 12 step model inspired more specific meetings like Narcotics Anonymous, Cocaine Anonymous, Al-Anon, Alateen, Women for Sobriety, Rational Recovery, Codependents Anonymous, etc to meet the needs of different populations. The group is united in accomplishing common goals: abstinence, stable employment, positive connections, physical/emotional health, and spiritual strength The stories shared present the reality of addiction through confessions, experiences with addiction, personal struggles with sobriety, and testaments to recovery. Meetings are either open to anybody who wants to participate or closed and can be discussion based, speaker led, Big Book readings, or 12 step focused. Eight  characteristics contribute to group success: members have a shared experience, education is the primary goal, groups are self-governing, the emphasis

is on self-governing, there is a single common purpose, membership is voluntary, anonymity and confidentiality are prioritized, and members must make a personal commitment to change. Sponsors, typically having gone through the steps, are tasked with guiding new members through the program and acting as a support whenever needed. Attending 12 step meetings often supplements the treatment plan. Research suggests groups are at least helpful in the recovery process, but success rates are difficult to quantify because of how the meetings work. There are many advantages to 12 step treatment, but it is not suited to everyone. Meetings are from and easily accessible almost everywhere and at any time. The influence of the group is often more effective than positive pressure from one therapist. Recovering addicts can find a community that not only can support their sobriety, but also help them relearn social skills and coping techniques without the use of any substances. It is an opportunity to build meaningful connections. However, meetings do not involve any professional supervision or trained clinicians. The structure is inconsistent and boundaries can be blurred between members. The negative influence of the group can be as powerful as the positive. Members are often pressured to conform to group norms and can develop unhealthy habits in place of addiction. The general message is limited in the scope of who can benefit. There is a stressed reliance on external structure and powerlessness is a common theme, which is the opposite of encouraging self-efficacy and confidence in a client’s capabilities. The Christian foundation and predominantly male perspective dominates much of the text and teaching, which is especially alienating for women. There is no screening for the meetings and people experiencing comorbidities in addition to a substance abuse disorder can not be adequately treated using the 12 step method. Motivational Interviewing Establishing strong internal motivation to change is critical for a sustainable recovery. Motivational Interviewing is a technique designed to foster the client’s initiative to change destructive behaviors. This  transtheoretical approach is a relationship and client centered system to rework a client’s unhealthy mindsets and behavioral patterns. Using collaborative communication in an interview format, the counselor offers unconditional support and empathy and encourages the client to embrace personal autonomy. It is particularly effective when treating an individual with an addiction. Whether they have come to counseling of their own volition or in response to external pressure, Motivational Interviewing is an evidence-based intervention proven to be effective. Lack of motivation to quit no matter the severity of the consequences is one of the most significant obstructions between where an addict is when beginning treatment and an attainable and fulfilling future. Counselors use this approach to guide a client through the stages of change. Clients often come in in the precontemplation stage with minimal awareness of any problems or motivation to fix anything. The contemplation stage starts with acknowledging the existence of the issues and committing to change in the preparation stage, formerly referred to as the determination stage. Unhealthy perceptions and actions are adjusted in the action stage and become habits that continue in the final maintenance stage. Motivational Interviewing observes four pillars of philosophy that act as guiding primary principles. Therapists must express empathy no matter the present stage of change; develop discrepancies by creating an awareness of the disconnect between a person’s beliefs and their behaviors; roll with resistance by changing direction rather than doubling down on an argument;

and support self-efficacy by encouraging a client to make the changes only they can make. The client-counselor relationship resembles a partnership. Even though the counselor is responsible for guiding the client towards change, it is up to them to assume responsibility for the progress of their recovery. Change means deciding  to do something differently, engaging in healthier thinking and practices, & sustaining improved patterns. Resistance is when the client seems to oppose change and tries to maintain the status quo while the counselor makes a case for engaging in recovery. Examples of this include arguing, ignoring, negating, and interrupting. It is the job of the counselor to elicit information and guide the client toward resolving ambivalence and committing to change by eliciting change talk, reducing resistance, asking open ended questions, demonstrating reflective listening, encouraging reflection by making summarizations, and enhancing confidence with affirmations. Pharmacotherapies (medication assisted therapies) Pharmacotherapy refers to the use of medications in treating substance abuse disorders. Each pharmacotherapeutic varies in its specific mechanisms, but a majority of the time they help restore neurological processes disturbed by addiction. Counseling can address mental and emotional challenges, but medication can break physical dependence as well as treat additional medical and mental health issues. Medications assisted therapy is controversial in addiction treatment and “anti-medication” bias is pervasive. The popular adage “you can treat a drug with a drug” maintains pressure to remain “drug free” or the belief that medication is a “crutch.” However, counselors have an ethical obligation to discuss pharmacotherapy in terms of scientific evidence of effectiveness despite any prejudices, either personal or external. Clients should be able to take advantage of the myriad of treatment options. It is a counselor’s job to educate and discuss the use of medications with clients. Keeping a psychopharmacological reference guide on hand is recommended for client education. A discussion on pharmacotherapy should involve asking and listening to the client’s beliefs and attitudes in regards to medication, working to understand the client’s perspective rather than contradict or correct them, withholding any response until client has expressed all major arguments for or against medication, and grounding any discussion of compliance concerns within client’s point of view. Pharmacotherapy: Rational and Application Addiction medication works by addressing the physical processes that perpetuate addiction. Craving plays a crucial role in the transition from substance use to dependence and the mechanisms underlying relapse is key to the logic behind medication assisted therapies. There are three types of cravings: reward cravings, relief (stress-reduction) cravings, and obsessive cravings(disinhibition i.e. lack of control). Easing the power of cravings, especially when exposed to a trigger, helps a client maintain sobriety in early recovery. Pharmacotherapeutics can also manage withdrawal symptoms, another physical influence encouraging continued substance abuse. Medications can work as antagonists that act by blocking off the receptors targeted to induce a high or agonists that activate the receptor to induce a similar high to a lesser extent. Disulfiram is an example of aversion treatment, specifically to manage alcohol abuse. It leads to an unpleasant intoxication that discourages use. It’s success rate is mainly limited to situations with adherent clients, specific high-risk clients, and when administration can be

supervised. Benzodiazepines like valium are popular withdrawal treatments and have a history of effectively easing symptoms. However, certain anticonvulsants are often considered a better alternative due to the lack of addictive potential, interactions with alcohol, and various adverse side effects. Buprenorphine is used to address withdrawal from opioid use. This medication activates rather than blocks the receptors associated with opioids, but to a lesser extent.There is a limit to the effects produced, and it is impossible to achieve any significant feelings of euphoria, almost completely discouraging abuse. Buprenorphine is highly effective in weaning individuals off of an opioid dependence. The most common anti-craving treatment is Naltrexone, which can apply to alcohol or opioid addiction. It works by specifically targeting neurons impacted by opioids. Blocking these receptors prevents the addictive highs elicited by drug use. It is safest when used after medically supervised detox as it can result in severe withdrawal symptoms and extreme discomfort or pain. Naltrexone eliminates the effects of imbibing an opioid, making it an opioid antagonist. Lamictal can be used to address cravings as well as comorbidities like schizophrenia, bipolar disorder, and depression. Like with any other prescription treating a psychological disorder, use of pharmacotherapeutics should be supervised by a medical professional to the extent appropriate to the individual client. In some cases, restricted distribution or regular blood testing is necessary and recommended. Treatment of Co-occurring Disorders The comorbidity of substance abuse disorders and other mental disorders is extensive and extremely correlated. Treating a single substance abuse disorder with no other coexisting disorders is rare. Patients with comorbid psychiatric problems require flexible and integrated treatment methods and services to meet their diverse needs. Abstinence, discharge criteria, confrontational, and self-help methods are stressed in the case of a dual diagnosis. Meeting any cognitive limitations, obvious to the disorder or not, can be achieved by using concrete communications, simpler or repeating concepts, and multiple formats. Comorbid Disorders: Treatment and Care Needs Substance and behavioral use disorders are characterized by compulsive and continued use with no control in spite of any consequences as well as obsessions and cravings related to the drug or behavior. In combination with mental health issues, a very complex clinical picture is created. Comprehensive assessment brings more clarity. There are three questions that should be asked to determine the course of treatment: which one came first, which one is primary, and which one should be treated first? Understanding if mental illness is the product or is exacerbated by substance use or if substance use is a method of coping with the symptoms of a mental disorder is critical to meeting the client’s needs. Generally, detoxification and any other medical interventions are dealt with immediately. Treatment should be holistic because the interactions of compulsive behaviors attributed to one disorder can trigger the other. Recovery must extend to every aspect of the client. There are several best practices essential when working with a dual diagnosis. Screening, assessment, and referral should be conducted thoroughly and effectively in addition to a physical and mental health consultation. A multidisciplinary team, including a psychiatrist to prescribe and oversee medication, is needed to meet all of a clients needs. On-site groups and off-site

self-help groups encourage recovery and give clients a sense of community and understanding. Psychoeducational classes help a client to manage their own recovery. Family treatment and education in relation to the client and substance use and mental disorder is necessary for treatment as well. When working with a client, sensitivity to culture, age, gender, and cognitive limitations is essential for an effective therapeutic interaction. There are several treatment models that can be applied depending on the counselors preferences and personal beliefs. The Disease Concept Model is the most popular and highly compatible with 12 step programs. Abstinence is encouraged which makes treating co-occurring disorders easier. Some meetings will be better suited to an individual client while some can be damaging, so meeting the clients needs takes priority when deciding to include 12 step groups into the treatment plan. It is important that the counselor has a comprehensive understanding of the language, culture, and organization of self-help groups to make sure their sessions are compatible and supplement or correct any shortcomings. The client should be prepared on what to expect from attending and participating, like coping with the social anxiety. The Self-efficacy Model is an alternative the the Disease Concept Model. In this theory, substance use issues occur on a continuum. Varying levels of severity require different approaches. There are five types of “self-efficacies” that are practiced according to what is appropriate for the patient: resistance, harm reduction, action, coping, and recovery. They range from practicing complete abstinence to practicing moderation. The Solution-focused approach works within the client’s frame of reference. Unlike the AA model, there is an emphasis on the positives and confidence in the client’s capabilities and motivation rather than teaching powerless and confessing personal suffering and failures. The solutions presented are clear, simple, and attainable. No model or approach is wrong as long as it facilitates an effective counselor/client relationship and recovery....