1 Treatment of Substance Abuse and Co-occurring Disorders in JRA s Integrated Treatment Model Henry Schmidt III, Ph.D. Cory Redman John Bolla, MA, CDP Washington State Juvenile Rehabilitation Administration CODIAC Co-occurring Disorders Conference Yakima, Washington October 1-2, 2007
2 Substance Abuse Treatment and JRA s Integrated Treatment Model (ITM) All youth receive treatment throughout JRA supervision Targets are identified based on treatment model DBT for residential FFPS for parole Substance abuse treatment fits within the broader ITM context Skill-building across multiple domains Improve family functioning
3 Treatment in a Nutshell Clear behavioral targeting Engage and motivate, elicit commitment Assess controlling variables for client s use Reinforcers Cues/contexts of use Behavioral sequences (urges lead to plans ) Statistical risk factors (e.g., mental illness, family use) Modeling, Coaching and Reinforcing of skills Contingency Management Troubleshooting, Relapse Prevention
4 Treatment for Co-Occurring Disorders Mental health diagnosis less important than symptoms Psychiatric care as required Increase client understanding of MH issues and recognition as possible risk factors for target behaviors MH behavior may be a risk factor for a target behavior Solutions for MH risk factors are selected, learned and practiced Solutions are tailored to match client interests, current skills, broad ability
5 Program Development Assessment of client needs EBPs for adolescents, juv justice population Reviewed treatment expert recommendations Fit with EBP treatment modalities currently in use (DBT; FFP; FIT) Identification of treatment assumptions, modes Adaptation and creation of treatment materials
6 JRA Substance Abuse Treatment: Program Elements Screening and Assessment Prevention Pre-Treatment Treatment Aftercare
7 Substance Abuse Screen/Assessment Screens Global Appraisal of Individual Needs (GAIN SS) Substance Abuse Screen (SAS) Client History Review (structured interview) Assessments Biopsychosocial Diagnostic ASAM Assessment Acute Intoxication and/or Withdrawal Potential Biomedical Conditions and Complications Emotional/Behavioral Conditions and Complications Treatment Acceptance/Resistance Relapse/Continued Use Potential Recovery Environment Behavior Analysis
8 Intervention Decision Process Screen Assessment Assignment to Treatment Level Assignment to Aftercare Transition to Parole Services
10 Goals of Prevention A comprehensive prevention curriculum for all youth not needing substance abuse treatment. Practice strategies for rejecting drugs and alcohol. To emphasize that use of tobacco, alcohol, and drugs are not the norm among teenagers. Help youth to develop greater self-worth, self-efficacy, and self-confidence. Enable youth to effectively cope with anxiety, depression, anger, shame, guilt, fear, etc. Link prevention activities within the home, schools, and community.
11 Elements of Prevention Pschoeducation re: Harmful effects of drugs and alcohol (including nicotine) Peer norms for use Risk factors for use Skill Building Refusal skills Reasons to not use strengthen commitment and abstinence/moderation beliefs and expectancies
13 Goals of Pre-Treatment Prepare youth for substance abuse treatment. Introduce preliminary education and information about substance abuse. Identify individual s risk and protective factors, triggers and cues, patterns of use, and functions and drivers. Increase desire to engage in treatment.
14 Elements of Pre-Treatment Orientation to treatment Assess stage of change Increase motivation and engagement toward participation in pre-treatment and treatment Obtain commitment to explore and understand personal substance abuse
16 Decrease: Goals of Treatment substance abuse. physical discomfort from abstaining. urges and cravings to use drugs. apparently irrelevant behaviors. keeping options to use drugs open. capitulating to use drugs. Increase community reinforcement of clear mind behaviors.
17 Dialectical Behavior Therapy (DBT) Developed by Marsha Linehan and colleagues, for Chronically suicidal women meeting criteria for Borderline Personality Disorder Manualized, one-year outpatient treatment model Successful in working with difficult-to-engage, difficult-to-treat populations
18 Substance Abuse DBT Adaptations Linehan et al. (1999) Adolescents Outpatient, Rathus & Miller (2002) Inpatient, Katz et al. (2004) Residential settings Inpatient psychiatric, Swenson et al. (2001) Forensic inpatient - McAnn, Ball, Ivanoff (2000) Washington State JRA Trupin et al. (2002) Other Disorders: Batterers, couples
19 Why DBT and Adolescent Substance Use? Behavioral Dyscontrol Truancy, criminality, substance use, self-injury Emotional Dyscontrol Low-skilled in identifying and regulating emotions Cognitive Rigidity (developmental) b/w thinking, oppositional, rule-governed morals Interpersonal Issues Socially isolated or shifting groups, deviant peers, etc. Issues of Self (developmental) Unstable sense of self, low self-esteem
20 Basics of DBT JRA s Residential Treatment
21 DBT Modes of Treatment Individual Therapy Group Skills Training Telephone Contact Therapist Consultation Group Pharmacotherapy (as needed)
22 Functions of Comprehensive CBT Enhance Client Motivation Acquire Skills Generalize Skills Structure Environment for Treatment Enhance Therapist Motivation and Skills
23 Important Elements DIALECTICS - Balance of Acceptance v. Change BEHAVIORAL ASSUMPTIONS Clients are doing the best that they can Maladaptive behavior occurs because Lack of skills to do otherwise History of it being reinforced Strong contextual risk factors Thus, the behavior makes sense in context
24 DBT Treatment Hierarchy DECREASE Suicidal, Self-Injurious Behavior Treatment-Interfering Behavior Quality-of-Life Interfering Behavior DBT-S Behaviors are targeted sequentially Only one or two targets at a time Substance use is top quality-of-life interfering target