Download Overview of Dual Diagnosis Treatment

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!