Clinical Applications in Extended Care of Substance Use ...
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Clinical Applications in Extended Care of Substance Use Disorders Brian Coon, MA, LCAS, CCS, MAC
Transcript of Clinical Applications in Extended Care of Substance Use ...
Clinical Applications in Extended Care of
Substance Use Disorders
Brian Coon, MA, LCAS, CCS, MAC
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Objectives By the end of this training, participants will be able to:
• Identify the clinical characteristics of SUD patients that
would benefit from adding an Extended Care phase of
treatment
– following their first primary treatment, or
– as the major emphasis of a later episode of care.
• Define the clinical goal of the Extended Care focused
treatment model.
• Name and describe the major clinical targets of
Extended Care.
• Name and describe the major clinical methods of
Extended Care.
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Therapeutic Model
1. Education A. Clinician-provided psychoeducational content
B. Bibliotherapy materials
C. Patient education handouts (nursing, counseling, spiritual care, clinical psychology, wellness, etc.)
2. Therapy A. 12 step facilitation and other evidence based
practices
B. Group work, individual sessions, workbooks, medication, etc.
3. Fellowship
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Relapse Prevention Counseling in primary treatment
• Educate: Understanding SUD, recovery and relapse (process, dynamics, etc.)
• Develop: personal recovery plan
• Personal skills for identification and management of SUD-related – thinking (e.g. thinking errors)
– feelings (e.g. cravings, mood management)
– behaviors (e.g. impulse control)
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cont. • Basic SUD and recovery education (Bio-
psycho-social-spiritual)
• Development of life goals and objectives
• Clinical techniques function as the person’s means to the end, to help them overcome barriers, etc.: – Skills training
– Symptom Prescriptions
– Drug Refusal
– Managing cravings (e.g. Urge Surfing, distraction, redirection)
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cont.
– Relaxation skills
– Decision making
– Problem solving
– Planning for emergencies
– Social skills/relationship skills
– Sobriety Sampling
– CBT and on-going 10th Step process
– Development of Early Intervention Plan
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Extended Care for:
• The chronic relapser
• Clinical complexity
(vs. just re-treat)
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Case Example 1 Middle-aged person had good-quality 4 week long
primary treatment, then one year of outpatient
aftercare group. They are now in year four of
continuous sobriety. Have been working a recovery
program of 3-4 meetings per week, and also with a
sponsor. Has had over 2 years of world-class CBT and
psychpharm for their major depression, but that has
not helped. They have been slowly spiraling
downward for the last 2.5 years, in some dynamic,
and will be returning to use eventually. Never had
clinical work on family system, core issue, or a
look at their personality issues relative to recovery.
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Case Example 1
“Can they come to your extended care for the work
they didn’t get?”
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Case Example 2
Older ACOA married to an alcoholic. Works as a private practice LCSW specializing in family systems therapy for people with substance use disorders. Referred by their psychiatrist after revealing they “Can’t go on drinking like this, stay alive, and keep doing therapy with families.” Both parents died drinking. Has two children – one in long term recovery and one in long term active SUD. Pattern of recovery attending AA and Al-Anon for years, and drops off for years, and back into recovery. Stable on SSRI’s for about 10 years, after two suicide attempts with hospitalizations. Remote history of eating disorder. No history of receiving SUD treatment.
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Case Example 2
“Clinical complexity”
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Case Example 3
Person had treatment in IOP and returned to use for a long time. Then had treatment in residential and returned to use again for a long time. Next had a year of abstinence without working a program of any kind, and returned to use for two years. Eventually treated in a good short term residential program, completed step down IOP, and worked a recovery program for 3 years. Then, Step 4 work and new family stressors have the person calling and asking for help, after one night of drinking. They are willing to do anything that is clinically recommended.
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Case Example 3
“More severe disease needs more intensive treatment”
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Do the math: • Don’t use, go to meetings, and work the
steps with a sponsor +
• Go without the therapy that primary
treatment doesn’t do +
• How do their disease management and
their recovery management look? +
• Untreated 4th step material and the
nitty gritty of daily life = ?
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TIME is their friend – how so?
• Neurocognitive impairment
• Serious addiction disease
progression
• Serious medical comorbidity or
risks with use
• Behavioral rehearsal
• Protective setting
PERSONALITY in the way?
• vs behavioral adherence to daily
plan
• vs bonding to the milieu and
fellowship
• vs accommodating and applying
primary tx
Address SOCIAL system(s)?
• Workplace colleagues and friend
group
• Current family system
• Current primary partner
• Parents
• Recovery-safe living environment
RECOVERY/RELAPSE pattern?
• Recovery and relapse patterns
• Relapse process dynamics
• The old status quo
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Let’s define terms
• “Recovery”
• “Relapse”
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What is “recovery”?
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What is Recovery? (Gorski)
• Understands their disease
• Understands its management
• Understands what recovery is
Works a program of recovery based on the above, while sober, for a minimum of 90 days.
If using occurs within the 90 day time frame, Gorski defines that as “continuous disease”.
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Developmental Model of Recovery (Gorski)
What are the
stages of recovery
and
what do they look like?
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Developmental Stages
of Recovery: Gorski
1. Transition
2. Stabilization
3. Early Recovery
4. Middle Recovery
5. Late Recovery
6. Maintenance
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Developmental Stages
of Recovery: Gorski
1. Transition
– Develop motivating problems
– Failure of normal problem solving
– Failure of controlled use strategies
– Acceptance of need for abstinence
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Developmental Stages
of Recovery: Gorski
2. Stabilization
– Recognition of the need for help
– Recovery from immediate effects
– Interrupting pathological preoccupation
– Learning non-chemical stress management
methods
– Developing hope and motivation
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Developmental Stages
of Recovery: Gorski
3. Early Recovery: First 2 years
– Full recognition of SUD disease
– Full acceptance and integration of SUD
– Learning non-chemical coping skills
– Short term social stabilization
– Developing a sobriety-centered value system
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Developmental Stages
of Recovery: Gorski
4. Middle Recovery
– Resolving demoralization
– Repairing SUD-caused social damage
– Establishing a self-regulated recovery
program
– Establishing lifestyle balance
– Management of change
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Developmental Stages
of Recovery: Gorski
5. Late Recovery
– Recognizing effects of childhood problems
on sobriety
– Learning about family of origin issues
– Examination of childhood
– Application to adult living
– Change in lifestyle
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Developmental Stages
of Recovery: Gorski
6. Maintenance
– Maintain a recovery program
– Effective day-to-day coping
– Continued growth and development
– Effective coping with life transitions
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What is “relapse”?
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What is “Relapse”? Terry Gorski
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What is “Relapse”? Terry Gorski
• “Relapse” is the process of becoming
dysfunctional in recovery that ends with the
renewed symptoms of SUD or related
mental or personality disorders.”
• Relapse is a return of symptoms, and
progression to a problematic pattern or
dynamic, but does not necessarily include a return to use.
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Stages of Recovery, Change, and Treatment
Recovery (Gorski)
• Transition
• Stabilization
• Early Recovery
• Middle Recovery
• Late Recovery
• Maintenance
Change (Prochaska)
• Pre-contemplation
• Contemplation; Determination/ Preparation
• Preparation, Action
• Action/Maintenance
Treatment (Osher)
• Persuasion/ Engagement
• Persuasion/ Engagement; Stabilization
• Active Treatment
• Relapse Prevention
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What Is Extended Care?
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Extended Care Where primary treatment focuses on the
“Transitional” stage (moving from active illness, through detox, and stabilization, and begins the
initial shift to early recovery)…
Extended Care is specialized care:
1. It focuses on those with patterns or cycles of
active SUD illness, recovery, and relapse. (The
major difference in the modality is the need of
Relapse Prevention Therapy).
2. It is also used to address the level of clinical
complexity that serves as a major barrier to
recovery.
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Therapeutic Model examples for Extended Care
1. Education – Reading: Gorski “Staying Sober” – Learning labs
2. Therapy – Relapse Prevention Therapy
– Problem Solving Group Therapy
– Specific clinical tools
3. Fellowship – Nightly 10th step process
– On campus and off campus activities
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Relapse Prevention Therapy
in Extended Care
What is it?
How is it different?
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Sorting out Relapse Prevention Work
Primary Treatment Relapse Prevention
Counseling (RPC)
• Psycho-educational focus
• Skills-based
Extended Care Relapse Prevention Therapy (RPT)
• Insight-oriented
• Aimed at the core issue level
After a minimum 90 day period of abstinence and recovery,
a relapse occurs. There is limited awareness of what
happened. RPT may be indicated.
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Targets of Relapse Prevention Therapy
Clinical goal: “Identify and manage the triggered state.”
• Kindling and the neurological cascade.
• Consequences of the triggered state (PAWS, cravings,
emotionally triggered, thinking errors, general and progressive loss of self-efficacy)
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Targets of Relapse Prevention Therapy
Is the clinical goal: “Know your core issue, and be able to state it as a single phrase?”
NO. The goal is to identify and manage the triggered state.
PS: “Core Issue” is defined as the central, false, self-defeating thing you tell yourself about your self.
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RPT 1. The RPT assignments
2. Problem Solving Therapy process
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RPT 1. The RPT assignments
2. Problem Solving Therapy process
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RPT assignments at EC IDENTIFICATION AND MANAGEMENT OF:
Post-Acute Withdrawal Syndrome
• Understand PAWS & stress interact and spiral
• List personal signs and symptoms of PAWS
• Principles for early recovery: balance, proactive strategies for self-soothing, be kind to your brain
Triggers (list unplanned encounters)
• Internal and external
• Write management plans specific for each
High Risk Situations (list scheduled events)
• Eliminate the event; second-safest is manage the event
• Write a management plan for each situation that shuts the door on the situation
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RPT assignments at EC
RELAPSE JUSTIFICATION EXERCISE
List what would lead you to relapse in the future. Process it.
Rationale:
• Provides imagined exposure to the negative events
• Emotionally links events to the consequences and fears of using
• Helps wall off the midbrain to promote self efficacy later in real life if/when real relapse justifications are encountered.
The Relapse Justification exercise
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RPT assignments at EC
EARLY INTERVENTION PLAN
• Build the list of personal identifiers from completed work on Triggers and High Risk Situations assigments.
• Team of people listed with phone numbers: must be people who are often close by, understand the patient’s SUD, understand recovery support, and have willingness to support the plan
• Phase 1: self-identify, self-correct
• Phase 2: team member notices, calls other team members, arranges a team meeting with the patient
• Phase 3: “Save My Life” including advance directives written from position of recovery, for care with leverage, of future self.
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RPT 1. The RPT assignments
2. Problem Solving Therapy process
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Emphasis on two major aspects:
1. Problem Solving Therapy
– “Problem” is defined as the “Core Issue”, not the surface situation troubling the person
– “Core Issue” is the central, self-defeating erroneous belief about yourself
2. Relapse Warning Signs – Identification
– Management
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Problem Solving
Groups and Sessions Clinician: Informed and active listening, and active note taking (not relying on memory)
• Pull out the symptoms of the triggered state from the work - write them down while you listen
• Read back the symptoms to the patient for their own note taking; this is patient education
• Interpret the work based on stage of recovery and their relapse process patterns - feedback
• Tie the symptoms back into their RPT assignments for them to add (the assignments are never “done”) – say the small assignment
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Output of Problem Solving
Groups and Sessions
• No “solutions” at the surface level.
• Link the cascade/triggered state to
– personality traits
– core issues
– developmental life history (imprint)
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Interpret the Work
1. Imprint: life events birth to age 18
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Interpret the Work
2. When was the earliest time in life you felt
that way?
3. “I hear your core issue”. Or “Who installed that?”
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Interpret the Work
4. “Repetition Compulsion is at work again.”
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Interpret the Work
5. “Here’s what your unconscious is saying and doing…”
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Interpreting the Work
Promotes recovery-oriented autonomy:
• Self-awareness (accurate insight, mindfulness in the moment).
• Differentiating the authentic self from their “disorder as self” and their core issue.
• Awareness of windows of opportunity (e.g. moments of clarity) for making just-in-time shifts, and more timely use of skills.
• Developing one’s growing edge; mitigating the themes (dysthymia, shyness, etc.)
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Other Clinical Tools In Extended Care
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Common Clinical Tools in Extended Care
• Factors of character or personality
• Creativity work (e.g. narrative therapy)
• Action methods
• Conjoint sessions
• Multi-Family Group
• Relationship contracting
• Financial contracting
• Recovery, relationship, family system monitoring
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cont.
• Family enters treatment: – With the patient
– Separate residential care
– Multi-day intensive
– Continuing care planning and personal recovery
• Adjustments in service, setting, dose, intensity, duration (personal plan, or program plan)
• Service or volunteer work – processed in therapy
• Work part time – increments of hours, days, days off
Constructing a Recovery and Relapse Timeline
• List key events tied to functioning:
hospitalizations, residential admissions, etc.
• Note the:
– major symptoms at time of event
– probe for moderate problems prior to the event
– and early shifts before those changes
• Changes in thoughts, behaviors, affect; mood,
withdrawal, sleep, appetite
• Interpret to include relapse process dynamics
Tip: Compare changes to the person’s own
behavioral baseline, not the patterns of others
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RPT
Identification and Management of
Personal Relapse Warning Signs
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Relapse Warning Signs – self identification against the
general list
Comprehensive Retrospective Analysis – review completed
by self and by others
Daily Self-Check was created to help you monitor both your
disease process and your recovery. You can utilize the self-
check to detect patterns of emotions, thoughts, and behaviors
and change your pathway before a return to use occurs.
Check-In Summary serves as a personal analysis of your daily self-checks and can be used as recommended and scheduled
by the treatment team.
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References/Resources • Blatner, A. & Blatner, A. (1988). Foundations of Psychodrama:
History, Theory, & Practice, 3rd Edition. Springer: New York.
• Carroll, D. (2012). The 9 and 12 Workbook: Renewing Your
Recovery, Re-claiming Your Life. Don Carroll.
• Emmerson, G. (2003). Ego State Therapy. Crown House
Publishing: Williston, VT.
• Gorski, T. T. (1989). The Relapse/Recovery Grid. Hazelden.
• Gorski, T.T. (1992). The Staying Sober Workbook: A Serious
Solution for the Problem of Relapse. Herald House/Independence
Press.
• Gorski, T.T. & Miller, M. (1986). Staying Sober: A Guide for
Relapse Prevention. Independence Press.
• Hendrix, H. (2008). Getting The Love You Want: A Guide For
Couples. Henry Holt & Company: NY.
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References/Resources • Hendrix, H. & Hunt, H.L. (1997). Giving the Love That Heals: A
Guide For Parents. Atria Books: NY.
• Hendrix, H. & Hunt, H.L. (2003). Getting the Love You Want
Workbook: The New Couples’ Study Guide. Atria Books: NY.
• Melemis, S. M. Relapse Prevention and the Five Rules of
Recovery. (2015). Yale Journal of Biology and Medicine.
88(3):325–332.
• Osher F.C. & Kofoed, L.L. (1989). Treatment of Patients With
Psychiatric and Psychoactive Substance Abuse
Disorders. Hospital and Community Psychiatry. 40:1025–1030.
• Prochaska, J., Norcross, DiClemente,C. (2007). Changing for
Good: A Revolutionary Six-Stage Program for Overcoming Bad
Habits and Moving Your Life Positively Forward. HarperCollins,
NY.
