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Overview of Dual Diagnosis Treatment John Rodolico, Ph.D. McLean Hospital Harvard Medical School Training Objectives Introduction and Spirit of Motivational Interviewing Understand the Foundation of MI Know the guiding principles of eliciting change Eliciting and responding to change talk Responding to resistance Gaining client commitment to change Developmental Mismatch Most adolescent treatment is based on an adult model Operates on a passive vs assertive approach Assumption: Reality: Build it and they will come…. NO THEY WON’T Why use MI The perception of harm is low and getting lower One of the hardest addictions to treat because of this MI is nonjudgmental so you can avoid the political/its natural discussion Few adolescents volunteer for treatment they are usually bumped into treatment Thomas Gordon’s 12 Roadblocks 1. Ordering, directing, or commanding 2. Warning or threatening 3. Giving advice, making suggestions, providing solutions 4. Persuading with logic, arguing, lecturing 5. Moralizing, preaching, telling them their duty 6. Judging criticizing, disagreeing 7. Agreeing, approving, praising 8. Shaming, ridiculing, labeling, name-calling 9. Interpreting, analyzing 10. Reassuring, sympathizing, consoling 11. Questioning, probing 12. Withdrawing, distracting, humoring, changing the subject Negative Practice Think of something you want to change in your life but have not been able to Your partner will try their hardest to convince you to do this Switch roles after 5 minutes Demonstration Conversation About Change Beginning Definition of Motivational Interviewing: MI is a collaborative conversation style for strengthening a person’s own motivation and commitment to change- Communication Model from Thomas Gordon Communication can go wrong because: (1) The speaker does not say exactly what is meant (2) The listener does not hear the words correctly (3) The listener gives a different interpretation to what the words mean The process of reflective listening is meant to connect the bottom two boxes (4), to check whether “what the listener thinks the speaker means” is the same as “what the speaker means.” Communication Model from Thomas Gordon The Words the Speaker Says 2 The Words the Listener Hears 3 1 What the Speaker Really Means 4 What the Listener Thinks the Speaker Means Communication Styles All three styles are used by all clinicians No “right” way to talk to patients A matter of “fit” Communication Styles Following The “good’ listener Avoid bringing your own “stuff”, while showing interest and giving full attention to what is being said e.g. “I won’t change or push you. I trust your wisdom about yourself, and I’ll let you work this out in your own time.” Communication Styles Following Suited well for: Giving bad news Beginning of an interview When you want to elicit more details Communication Styles Directing Take charge Assumes: expertise, authority, power Expects adherence or compliance from the other party Communication Styles Directing Very important style of communication in many clinical setting: Emergency situations Medical decisions that require expert knowledge Some patients prefer that the clinician “tell them what to do”. Communication Styles Guiding A guide is directing the patient, but allows the patient to decide where to go A guiding style communicates “I can help you to solve this for yourself” MI is a guiding STYLE Communication Styles All three styles can be used within the same interaction The skillful clinician will weave these styles depending on the nature of the particular topic or situation Flexibility in style is important: also in supervising, teaching, or parenting Decisional Balance Ambivalence is a normal part of the process of change Using this “conflict” to promote positive change Weighing the Pros and Cons of behavior Increasing Discrepancy Good/Bad things about the status quo Good/Bad about change Myths about Motivation Motivation If not motivated, they can’t be helped One It is a prerequisite for change is either “motivated” or “unmotivated” is a personality characteristic Facts About Motivation Motivation is a state of readiness to change, which may fluctuate from one time or situation to another. This state can be influenced Motivation for change does not reside solely within the patient The provider’s style is a powerful determinant of patient resistance and change An empathic style is more likely to bring out self-motivational responses and less resistance from the patient Facts About Motivation People struggling with behavioral problems often have fluctuating and conflicting motivations for change, also known as ambivalence. Ambivalence is a normal part of considering and making change, and is not pathological. Each person has powerful potential for change. The task of the provider is to release that potential and facilitate the natural change process already inherent in the individual. What is MI and When is it Used? A collaborative, person centered, form of guiding to elicit and strengthen motivation for change MI is used when a person expresses low motivation, hesitancy to engage in treatment, or difficulty in changing behavior What MI is Not Theory laden A trick to get people to do what you want Decisional balance CBT Client-centered therapy Easy to learn What you already do The answer to everything The Spirit of MI Practitioner’s Definition Motivational Interviewing is a client centered counseling style for addressing the common problem of ambivalence Spirit of Motivational Interviewing THE SPIRIT OF MOTIVATIONAL INTERVIEWING PARTNERSHIP—Counseling involves a partnership that honors the client’s expertise and perspectives. The counselor provides an atmosphere that is conducive rather than coercive to change EVOCATION—The resources and motivation for change are presumed to reside within the client. Intrinsic motivation for change is enhanced by drawing on the client’s own perceptions, goals, and values ACCEPTANCE —The counselor affirms the client’s right and capacity for self-direction and facilitates informed choice COMPASSION – This form of interview shows a good deal of compassion for the difficulty the client is facing along with the long road ahead Spirit of MI Focus is on patient concerns, yet the provider maintains a strong sense of purpose and direction, actively choosing the right moment to intervene in incisive ways. It combines elements of directive and non-directive approaches. The goal is to help patients clarify their values and amplify the discrepancy between their values and their behavior. Spirit of MI Motivational Interviewing contrasts with an authoritarian, confrontational style. It specifically avoids argumentative persuasion. It involves listening, acknowledging, and practicing acceptance of a broad range of patient concerns, beliefs, emotions, and motivations, even when the provider does not necessarily agree with the patient’s views. Demonstration 4 Fundamental Processes in MI Engaging Focusing Evoking Planning Change Talk Technical Definition of MI Motivational Interviewing is a collaborative, goal oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the persons own reasons for change within an atmosphere of acceptance and compassion Basic Skills OARS Strategies - OARS OPEN-ENDED QUESTIONS AFFIRM REFLECTIVE LISTENING SUMMARIZE Strategies - OARS OPEN-ENDED QUESTIONS Ask questions that cannot easily be answered with a brief “yes” or “no” or short response. With ambivalent clients ask for both positive and negative aspects of the problem. This helps establish trust and lets the client know you are interested in their situation. Allows you to get a lot of information and insight into the client’s issues. Strategies - OARS AFFIRM Affirm and support the client with compliments and statements of appreciation and understanding. “I think it’s great that you want to do something about this.” “That’s a good suggestion.” “I appreciate how hard it must have been for you to decide to come here.” Strategies - OARS REFLECTIVE LISTENING Foundation of MI We think we listen well Most challenging to maintain throughout a session Fundamental, but not “easy” Strategies - OARS REFLECTIVE LISTENING Reflective listening involves forming a reasonable guess as to what the meaning of the clients' statements are and giving voice to this guess in the form of a statement. Realize that what you believe or assume people to mean is not necessarily what they really mean, and reflect words as well as feelings. In particular, any statements that indicate the client is motivated to change should be reflected back. Strategies - OARS REFLECTIVE LISTENING A “wrong” reflection is just as valuable as a “right” one. You reflect back in the form of a statement rather than a question. ”It sounds like you ...” ”You are feeling ...” ”You mean that …” Your inflection goes DOWN, not up. Strategies - OARS REFLECTIVE LISTENING Simple: Acknowledgement of disagreement, emotion or perception Double-Sided: Acknowledge both sides - What is said - Their ambivalence Amplified: Reflect in an exaggerated form Strategies - OARS SUMMARIZE A form of reflective listening. Use periodically and as a transition. You choose which points to summarize--making it directive. This helps both you and the client to stay focused. At the end of a session, it is useful to offer a major summary, pulling together what has transpired. Strategies - OARS SUMMARIZE Capture both sides of ambivalence Can include information from other sources (lab results, information from medical providers, etc). End with an invitation for client to respond: -How did I do? -What have I missed? -What else would you like to add? A Little Taste of MI Why would you want to make this change If you decide to make this change how would you do it What are the three best reasons for you to do it How important is it for you to make this change (on a scale of 0-10 how would you rate the importance) why not a lower number Non-directional Use of OARS One person will play the client One person will play the counselor One person will be the observer The speaker will talk about something they feel two ways about Counselor should do the following: - Use OARS strategies, especially reflective listening - Offer no opinion or advice - Make no attempt to “fix” it, solely understand the dilemma Observer: Count number of O,A,R,and S Activity: Strategies - OARS Processing the Activity How was it for the counselor? How was it for the client? What did the observer see? Motivational Interviewing with a Twist Should use the same principles of empathy, discrepancy, evocation, and self-efficacy Confrontation with a motivational style, creative empathic reflection Be sure to keep your integrity with the facts Use personal feedback to enhance motivation (DSM V Criteria) What do we do in Treatment? Motivational Interviewing and CBT Cognitive Behavioral Therapy Tremendous amount of evidence showing positive results for adults Dearth of efficacy trials for adolescents, however gaining clinical support Cannabis Youth Treatment Study: Showed significant increase in days of abstinence (combination of MI+CBT) CBT Model Emotions Feelings Sensations Thoughts Images Behaviors Actions What to focus on Triggers Cognitive Emotional Abstinence-Violation Effect (AVE) Biphasic response Loneliness Boredom Numbness Emptiness Skills Situational Peers Family Structure Relaxation / Physical grounding Emotion regulation Cognitive restructuring Mindfulness Problem-focused coping IPE Patterns Warning signs Anticipate high-risk situations Relapse planning – “map” Maintenance Emergency plan 50 Approach Ind’l, group, and milieu-based interventions (+ family) Always focused on functions of thoughts, emotions, and actions CBT / DBT / BA Process-oriented Kids drive the discussion “Dubious” change talk MI-consistent stance Curiosity Setbacks are normal Support persistence Maintenance of change 51 JS 18 yo Psychiatric hx MDD Dysthymia ODD ADHD Marijuana dependence MDMA abuse Family Intact Sister – long-standing psychiatric issues Conflict School grade 12 not complete College acceptances 52 JS Thoughts Self “I’ll always be depressed” “Mj use is not a problem” Others “My parents don’t get it” “Friends mean everything” Future “I’m not sure what will happen” Emotions Anger Sadness Actions Increased conflict with parents and teachers Asked to leave IOP Walked off psychiatric unit 53 Building Motivation for Change “What do you think will happen if you don’t change anything?” “What would be the advantages of making this change?” “What personal strengths/skills do you have that will help you change?” “What would you be willing to try?” 54 Building Motivation to Change Recognize disadvantages of status quo “I never really thought about it as harmful” Recognizing advantages of change “I’d probably feel better” Expressing optimism about change “I think I could do it if I decided to” Expressing intention to change “I’ve got to do something” 55 Step One Adolescents frequently increase their understanding of at least some of the following items: How and why their substance use evolved Connections between substance abuse and psychiatric conditions Previous patterns of risky behavior Losses and consequences due to substance use Necessary steps for relapse prevention planning 56 Step One – 10 components Progression: change in substance use over time, e.g. circumstances, frequency, quantity, type. Feelings: specific emotions and general moods. Behaviors: notable actions related to substance use , e.g. stealing money, lying to parents, skipping school. Losses: concrete or abstract consequences related to substance use. Family Interactions: relationships with different family members. Denial/Minimization: times when patient downplayed his or her use or its severity. Relapse: explanation of any periods of sobriety or reduction in substance use; why patient changed substance use and what contributed to the eventual relapse. Obsession: significant time and energy spent obtaining, using, and recovering from substances. Insanity: continued use despite knowledge of negative consequences. Aftercare: changes patient will make and how patient will enact those changes. 57 STEP ONE HISTORY (Combination of MI +CBT+TSF) Obsession Progression Losses Relapse Family Interaction Insanity Behaviors Relapse Written history of substance use Increases change talk Moves patients from one stage of change to another Emotion regulation Describing sensations – physiological responses Identifying emotions Adopting simple classification strategy Color, shape, character, voice Rating emotions (0-10; intensity) SUNWAVE Awareness Notice sensations 59 Emotion Regulation Relaxation strategies Diaphragmatic breathing Progressive muscle relaxation Intensive exercise Temperature Orange Washcloth 60 Cognitive distortions Situation Automatic thoughts Assumptions Core beliefs 61 Common unhelpful thoughts Overgeneralization Selective abstraction “I lapsed because I failed - everyone knows” Catastrophizing / Fortune telling “I lapsed because I had no willpower” Self-reference “It’s just weed” Excessive responsibility “I’ve been sober for 6 months but I still got high that one time” Minimization “One slip = Slips inevitable” “I’ll lose all my friends if I stop using” Dichotomous thinking “I’m either sober or I’m a failure” 62 A.V.E. – The ‘**** It’ Effect SLIP “I failed” BINGE 2 components: – Lapse attributed to internal, stable, and global factors that are viewed as uncontrollable – React with guilt, shame, anger, or perceived loss of control Demonstrate that lapse can be caused by external, unstable, changeable factors - skill levels 63 10 Ways to Untwist Your Thinking 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Identify Distortion Examine Evidence – Test of Evidence The Double-Standard Method The Experimental Technique Thinking in Shades of Gray The Survey Method Define Terms The Semantic Method Re-Attribution Cost-Benefit Analysis 64 Biphasic response Consideration of long- and short-term effects of substance use Typically, positive outcome expectancies Neglect long-term distress Work on anticipating biphasic response Consider immediate [+/-] consequences Consider delayed [+/-] consequences 65 Plan + Scales “What’s the plan - partial or full sobriety?” Importance (0-10) Confidence (0-10) Readiness (0-10) “Why not a …?” Try to distinguish between confidence and readiness Discuss previous attempts to slow down or be sober What went well; what didn’t; what would you change 66 Marty McSober 18 yo male Dx of MDD and GAD Not med compliant 2 previous hospitalizations Doesn’t like tx All current friends use Daily mj smoker (5x/day) Binge drinks on weekends Dabbles with molly + coke “Self-medicates” with mj Substance use Irritability and anger Avoidant Lives with mom and stepdad Lost all sober friends Sees father every other WE Relations strained due to use Steals from Mom CHINS for truancy Irregular checks by officer 67 The Cards Practicalities High-risk situations that may potentially trigger urges to use Family / home environment School Friends Romantic Intrapersonal Mood and anxiety sxs 68 Practical questions What are your top 3 triggers for drugs / drug use? Drinking makes you more fun to be with in social situations. Now that you’re not drinking, how will you deal with being social? If you were to relapse, what steps would you take in order to get back on track? What are 3 changes that you are willing to make in order to prevent relapse? Name 3 people that you should no longer hang out with in order to remain clean? 69 Practical questions What are 3 reasons why you want or need to remain clean and sober? After you leave EH, how often will you attend therapy, groups, and/or AA/NA meetings? What are 2 thoughts that you could have that would indicate that your motivation for sobriety is slipping? What do you need to remove from your bedroom / house in order to create a more sober-friendly environment? How can your family be supportive in your recovery? 70 High-risk situations “You’re going through your stuff in your room, and you find a pill…what do you do?” “You get into a huge fight with your parents and storm out of the house. You run into a friend who asks you if you want to go to a party. What do you do?” “You’ve been out of treatment for 3 weeks (still sober), but you start to feel anxious being at school. What do you do?” “At school, you go to the bathroom and you see 2 kids doing lines – what would you do?” 71 High-risk situations “You’re at your friends’ house. You go to the bathroom, open the medicine cabinet, and…BOOM! Benzos and opiates. What do you do?” “Your parents are finally off your case and have stopped drug-testing you. Unfortunately, your depression and anxiety have returned. You have access to drugs/alcohol, and could easily get away with it – what would you do?” “You haven’t smoked marijuana for awhile, and you have a chance to smoke. You’re 90% sure that you won’t get caught. What do you do?” 72 High-risk situations “I’m angry at my family and some friends. I’m at a party and I’m thinking “**** this” Someone offers me some shots. I have little motivation and haven’t had fun or felt happy lately. I’m really stressed about school. I’m at a point where I’m overwhelmed and sick of trying. What do I do?” “You’re more depressed and you’ve started to isolate, avoid responsibilities and human interactions, and feel really alone. All you want to do is use. What do you do to avoid using and getting back on track?” A person who you are attracted to - he/she is hot! – asks you to get high. What do you do or say? 73 Cue Exposure Rationale: Told to avoid cues/triggers, is it possible for adolescents? Urges decrease while in residential treatment giving a false sense of confidence Exposure Planning: Patients develop a list of triggers and create a trigger hierarchy range from high to low Skills Training: The first two exposures pts are encouraged to use skills coaching after that they will start this process on their own Family Therapy Many different types of family based treatments with great success Community Reinforcement and Family Training (CRAFT) (Waldron et al, 2007) Contingency Management Approaches Outcome depends on the treatment setting, number of sessions, and population As with MI, it improves the potency of all interventions with adolescent substance abusers Self-Help Groups Difficult for adolescents to get to Not enough groups for young people Professional involvement has shown to enhance outcome When it works, it works well Extends benefits of treatment (Kelly et al, 2010) Adolescents should be exposed to the principles of self-help groups Questions Thank You!