Download Develop - Office of Substance Misuse and Mental Health Recovery

I have no financial interest in
anything I’m presenting!
Is the Cart before the
Horse: Failure to Launch
and Substance Abuse
Issues
Is the Cart before the Horse
• The Paradigm
– Client
– Concept
– Theoretical ‘lenses’
– Implementation
– Verification
• Continuous feedback/improvement
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
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
Is the Cart before the Horse
CONCEPT
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
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
Is the Cart before the Horse
• Family Development
– Restoration of balance
– Clarity of roles
– Partnership parenting
– Demarcation and forgiveness
– Agreements for the future
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
Is the Cart before the Horse
THEORETICAL ‘LENSES’
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
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
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
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
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
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
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
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
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
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
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
Is the Cart before the Horse
Treatment is a “contrived”
developmental crisis!
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
Is the Cart before the Horse
Please get in groups of three!
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
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
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)
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).”
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”
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)
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)
Is the Cart before the Horse
• Family/Systems Perspective
– Multigenerationalism
– Structural views and interventions
– Patterns of communication
Is the Cart before the Horse
Family/Systems
Erikson’s Stages/
Marcia’s EIS
Moral Reasoning
Relationships
Locus of Control
Parenting Style
•
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.
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
Is the Cart before the Horse
IMPLEMENTATION
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
Is the Cart before the Horse
Assessment
Assessment at full medical detox and admission to same if
criteria for detox is met
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
Is the Cart before the Horse
• Assessment
Psychological Well-being
Ryff Scales of Psychological Well-Being
Trauma
PTSD Symptom Scale
Executive Functioning
BRIEF
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
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
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”
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,
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
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
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
Is the Cart before the Horse
• Residential
– Real-world practice
• Field trips and community support group meetings
• Outdoor therapy activities
• Service to community via Treatment and support
group
• Opportunities to leave the milieu to explore new
ways to socially interact
– Service and empathy as an expectation
Is the Cart before the Horse
• Therapy
– The plan
•
•
•
•
•
•
Understanding developmental deficits
Developing identity based on moral values
Developing increased internal Locus of Control
Unbalancing and restructuring the family system
Family experiential education in a workshop setting
Rotating the theoretical lenses
Is the Cart before the Horse
• Therapy
– The goals of treatment
• Clients
–
–
–
–
–
Identifying negative cognitions and origins of same
Developing interdependent relationships
Identification and correction of developmental deficits
Developing an internalized system of values
Developing an internal locus of control
• Parents and siblings
–
–
–
–
Strengthening the parental dyad
Establishing consistent, authoritative parenting
Teaching purposeful communication
Enhancing empathy between family members
Is the Cart before the Horse
VERIFICATION
Is the Cart before the Horse
• Verification
– Clinical – Julian Rotter – Incomplete Sentence
Blank
• Twenty-nine paired statements
• Chose a or b
• Easy and quick to score
Is the Cart before the Horse
• Verification
– Clinical – Mental Health
• Beck’s Depression Inventory
• Beck’s Anxiety Inventory
Is the Cart before the Horse
• Verification
– Clinical - Protocol
• Three instruments administered during Assessment period
• Three instruments administered again after completion of
CORE programming
• Three instruments administered two weeks prior to program
completion of Extended program
– Comparisons examined on changes from administration to
administration
– Built-in time to address unresolved issues
• Correlations examined between instruments
Is the Cart before the Horse
• Summary
– Client
– Concept
– Theoretical ‘lenses’
– Implementation
– Verification
• Continuous feedback/improvement
Is the Cart before the Horse
• References
– Baumrind, D. (1966) Effects of Authoritative Parental Control on Child Behavior,
Child Development, 37(4), 887-907.
– Baumrind, D. (1967). Child care practices anteceding three patterns of
preschool behavior. Genetic Psychology Monographs, 75(1), 43-88.
– Neal, J. and Frick-Horbury, D. (2001) The Effects of Parenting Styles and
Childhood Attachment Patterns on Intimate Relationships, Journal of
Instructional Psychology, Sept.
– Robinson, C., Mandleco, B., Olsen, S., Hart, C. (1995) Authoritative,
authoritarian, and permissive parenting practices: Development of a new
measure. Psychological Reports, 77, 819-830.
– Ainsworth, M.D.S. (1985) Attachment across the life span. Bulletin of the New
York Academy of Medicine, 61,792-812.
– Diehl, M., Elnick, A., Bourbeau, L., Labouvie-Vief, G. (1998). Adult attachment
Styles: Their Relations to Family Context and Personality. Journal of Personality
and Social Psychology, V.74, 6, 1656-1669.
Is the Cart before the Horse
• References – cont’d
– Franz, C. and White, K. (1985) Individuation and attachment in personality
development: Extending Erikson’s theory. Journal of Personality, 53,2, 224-256
– Erikson, E. (1950). Childhood and Society. New York: W.W. Norton.
– Erikson, E. (1959). Identity and the Life Cycle. New York: W.W. Norton.
– Woolfolk, A. (2001). Educational Psychology. Boston: Allyn and Bacon.
– Marcia, J.E. (1966). Development and validation of ego identity status. Journal
of Personality and Social Psychology, 3, 551-558.
– Adams, G.R. and Bennion, L.D. (1986). Extended Objective Measure of Ego
Identity Status – Revised (EOM-EIS). Journal of Adolescent Research, 07435584, v1, 183-198.
– Shakva, H., Christakis, N., Fowler, J. (2012) Parental Influence on Substance
Use in Adolescent Social Networks. www.archpediatrics.com.
– Rotter, J.B. (1954) Social learning and clinical psychology. New York: PrenticeHall.
– Hall, E. (2001) Feelings About Drug Use Drug-Related Locus of Control.
www.uclaisap.org.
Is the Cart before the Horse
• References – cont’d
– Fraley, C., Heffernan, M., Vicary, A. (2011) The Experiences in Close
Relationships – Relationship Structures Questionnaire: A Method for Assessing
Attachment Orientations Across Relationships. Psychological Assessment, 23,
3, 615-625.
– Podd, M. (1972) Ego Identity Status and Morality: The Relationship between
Two Developmental Constructs. Developmental Psychology, 6, 3, 497-507.
– Benson, M., Harris, P., Rogers, C. (1992). Identity Consequences of Attachment
to Mothers and Fathers Among Late Adolescents. Journal of Research on
Adolescence, 2, 3, 187-204.
Is the Cart before the Horse
• Gary D. Hees MA, LPC
VP – Professional Relations
Decision Point Center
Prescott, Az
– [email protected]
– 928-778-4600 x114