1 Situational Awareness: A Primer for SUDs Counselors Instructor: Anita McCrary
2 Outline I. II. III. IV. Setting the Mind Shaking off the Disease Mindset Situational Awareness Theories V. Case Study: Cue Exposure Therapy VI. Clinical Trial: Real-Time Assessment of Exposure VII. Exam DESCRIPTION: The course describes the foundational principles of situational awareness in the context of substance abuse intervention and recovery. Referencing current literature, case studies, and clinical trials, the course teaches the primary principles of mindset and situational awareness theory to educate the substance abuse counselor on emerging brief therapies for intervention and recovery. COURSE GOAL: Upon completion of the module, you will have a broader understanding of the theoretical principles of situational awareness and how they apply to addiction counseling. OBJECTIVES: This module will teach the foundational principles of mindset and situational awareness. The model will introduce Endsley s SA theory and Boyd s OODA Loop concept. The module will provide current research supporting the efficacy of situational awareness and the implications for its therapeutic use in substance abuse counseling. One of the common threads tying all mankind together is the existential challenge of accepting reality. Substance abuse is a vehicle for denial of reality. There is a dynamic kinship between substance abuse and the compulsion to deny reality. Excuses or running away from reality are escape mechanisms from an individual s perception of psychological and/or psychosomatic pain and anxiety. The addict will alter, deny, and escape reality because he or she lacks the coping mechanisms necessary to psychologically manage it. One may as well hand the addict a scalpel and expect them to perform precision surgery. This module will teach the foundational principles of mindset and situational awareness. The module will provide current research supporting the efficacy of situational awareness and the implications for its therapeutic use in substance abuse counseling. The most empirically supported intervention for substance abuse disorders (SUDs) is Cognitive Behavioral Therapy (CBT) (Perron, 2013). CBT uses conditional learning theory to understand the development and maintenance of maladaptive thought processes, emotional reactions, and behavioral responses, (2013, p. 101). CBT treatment manuals provide structure to treatment, but as Perron admits, clinicians readily tailor therapy according to the individual client s needs. Setting the Mind Classical conditioning (i.e. Pavlov) creates the ultimate escape artist (i.e. the addict), but it also leads to recovery through habituation. Through conditioning a recovering addict can increase his or her awareness of behavioral cues, avoid drug use, and enhance his or her decisionmaking ability to make more prudent choices. Theorists (DellaVignaa, 2001 & Gollwitzer, 1990) label this psychic process mindset ; replacing habitual destructive responses for proactive healthy alternatives. It is psychological state management in a nutshell. Mental rehearsal is crucial to forming competent, proactive responses to cue exposure. Sobriety is impossible unless we become masters of our own subconscious. Repetition is the mother of mastery in recovery. By practicing control over conscious and unconscious thought patterns (selftalk), and their physiological and behavioral associations,
3 the addict fine-tunes his or her ability to control, operate, and function proactively. He or she creates mindsets and they have the potential to create psychic and physiological anxiety; or, we can put anxiety on cruise control through mindset. Shaking Off the Disease Mindset Substance abuse is as much a sickness of the individual soul as it is a genetic predisposition from a biological parent. Sobriety and recovery cannot succeed unless an addict takes the fundamental first step in accepting reality and personal responsibility. By seeking treatment the client admits his or her inability to say no to a substance and recognizing the choice to say yes to sobriety. Readiness for change is enhanced when therapy provides a conceptual, coherent method of rehabilitation, one that explains how change is possible in spite of the disease model of addiction (Barry, 1999)(Park, 2012). An addict will frequently use the disease model as an excuse to justify his or her powerlessness over drugs ( I drink/use because my daddy/momma did. ). The addict with the mindset of blaming the disease model for drug use must first acknowledge learned-helplessness is a choice; and he or she should accept personal responsibility as an alternative. The SOCRATES is highly reliable and valid for predicting a patient s likelihood of success (2012). Personal responsibility leads to situational awareness; situational awareness is self-awareness. Mindset begins with a deliberate inventory of selfawareness. Self-awareness requires knowing your strengths, admitting weaknesses, and proactively acting on both in response to cues in the environment. A cue can be any high-risk situation that has previously caused anxiety and fall into four major categories: (1) frustration and anger (e.g. interpersonal conflict), (2) interpersonal temptation (e.g., an offer to use), (3) negative emotional states (e.g., depression, boredom, and loneliness), and (4) intra-personal temptation (e.g., cravings) (Marlatt, 1985). Learning theory and current addiction research teach us cues in the present environment that prompt drug seeking and drug wanting behavior (Vollstädt-Klein, 2011). Deliberate use of mindset conditions the brain to override the physio-psychological effects of high-risk cues (Gollwitzer, 1990). Subject matter experts (SME) in situational awareness (SA) build upon mindset fundamentals (i.e. 360 mindset, warrior mindset, survival mindset, combat mindset, battlespace awareness, etc.); seeing it as the crucial first step in conquering fear and controlling adrenaline s effect on cognitive and physiological functioning. Recent incorporation of SA s global concepts are proving to be a vital therapeutic element in substance abuse disorder (SUD) counseling (Breslin, 2002).
4 Ongoing research (Clinical trial no. NCT ) by the National Institute on Drug Abuse (NIDA) assesses environmental influence, or cues triggering psychological stress and drug use (Epstein, 2009). The NIDA study taps into the fundamentals of SA by holding the addict accountable for their substance abuse (National Institute of Health, 2008) (Epstein, 2009). Situational Awareness Theories Situational Awareness (SA) is the cognitive ability to quickly and accurately assess a situation and environment. It is proficiency in detecting subtle environmental and human behavioral changes that may create tension. It is the competency to act as an agent of control during tension (mindset), and effectively demonstrating control after. The Department of Defense Architecture Framework (DoDAF) relies on Ensley s theory to measure national security protocols and training (Chase, 2009; Endsley, 1998 & 2000). The OODA Loop is a theory of decision-making; a cycle of observe-orient-decide-act (1995). The OODA Loop is used in business (i.e. Honda, Wal-Mart), healthcare, and emergency first response training (Hogan, 2006). Boyd concluded that people relate to the world and others in moral, mental, and physical ways (Boyd, 1987). With practice, the OODA loop supplies proaction instead of reaction. Human factor science and SA research relies heavily upon the military as a control technique test bed. The majority of human factor assessment instruments (i.e. SHERPA, NASA-TLX, etc.) use Mica R. Ensley s three-level model. Also, her situation awareness global assessment technique (SAGAT) boasts the most validation evidence in military and trauma environments (Hogan, 2006). Endsley s SA theory (1995 & 2000) uses the information processing cognitive psychological approach. It is a person s ability to evaluate a situation, know what to do, when to do it, and awareness of the probable outcome. During a complex cognitive task, a person s behavior and performance reflect on his or her ability to form mindsets and apply goal-oriented action. Revisiting the Marshmallow Self-Control Test in 2011, a report in Time magazine shows those people who possess the personality characteristic of self-control are wiser and richer (Szalavitz, 2011). Only training can build self-control and confidence. According to Ensley, three hierarchical levels comprise SA: Level 1: perceiving the elemental cues in the environment; Level 2: comprehending how they distract the individual rom the goal; and Level 3: projecting motivation toward the future. OBSERVE: the raw, real-time information used to make decisions and act accordingly ORIENT: filters current information through culture, genetics, and previous experience DECIDE: fluid works-in-progress used to determine a course of action ACT: implementation of a decision The Cognitive-Existential Approach to SUDs Previously the point was made how CBT is becoming a fluid rather than a static therapeutic technique. Today s clinicians adapt therapeutic protocols in an effort to more effectively supply the client s needs, desires, and values. SUDs counseling should address these idiosyncratic factors. Existential theory emphasizes the idea that a new
5 therapy is created with each client (Yalom, 2002). Themes include client responsibility and freedom, a confrontation with negative internal forces, and a belief that people have the capacity for self-awareness and choice (sound familiar?) Consequently, interventions are aimed at increasing client self-awareness and self-understanding, (p. 100) (Milton, 2012). Two therapies, coping-skills training (CST) and cueexposure treatment (CET) have been shown to be effective treatments (Monti, 1999; Rohsenow, 2001; Marrissen, 2007; Sugarman, Nich, & Carroll, 2010) for SUDs and assists the addict in seeking healthy alternatives. The implications to integrate situational awareness into a therapeutic setting are clear. By enhancing CBT with the principles of mindset and situational awareness, clients learn self-awareness and can more readily accept reality and recovery. By becoming masters of subconscious thought patterns and proactive responses, drugs no longer operate as the psychosomatic puppeteer of the soul. RESULTS: Both groups responded with a decrease in self-reported cue reactivity (craving, mood). The CET treatment group showed a significant decrease in physiological reactivity (skin conductance) compared to the group not receiving CET. However, dropout and relapse rates were significantly higher in the CET group. CONCLUSIONS: This is the first randomized controlled trial showing that CET, compared to a non-specific psychotherapy, might increase dropout and relapse rates among abstinent heroin-dependent clients in a drug-free setting. Implementation of coping skills training may help to prevent relapse. Copyright 2007 S. Karger AG, Basel. PMID: [PubMed - indexed for MEDLINE] CLINICAL TRIAL: ClinicalTrials.gov Identifier: NCT Developing Field Tools for Real-Time Assessment of Exposure to Psychosocial Stress and Drug Use in an Outpatient Treatment Population (ClinicalTrials.gov). Background: Researchers are interested in developing more accurate methods to assess environmental influences on psychological stress and drug use. One key to a more accurate assessment of environmental influences is minimizing the delay between exposure and reporting. Portable devices such as personal digital assistants (PDAs) and global positioning system (GPS) units may be able to provide a more real-time image of these factors. CASE STUDY: Cue Exposure Therapy for the Treatment of Opiate Addiction: Results of a Randomized Controlled Clinical Trial. Psychotherapy and Psychosomatics 2007, Vol. 76, No. 2. BACKGROUND: Persistent cue reactivity to drug-related stimuli is a well-known phenomenon among abstinent drug users and has been found to be a predictor of relapse. Cue exposure therapy (CET) aims to reduce this cue reactivity by exposing abstinent drug users to conditioned drug-related stimuli while preventing their habitual response, i.e. drug use. The objective of the study is to assess the use of PDAs to measure stress and drug use, and GPS units to assess the effects of neighborhood environment in an outpatient treatment population. Researchers ask current heroin users in Baltimore to carry a PDA and a GPS unit for 18 weeks. The participants make entries (1) each time that they use a drug, and (2) each time they feel overwhelmed, anxious, or stressed more than usual. Also, the researchers prompt participants to make three random-signal-triggered recordings per day and one brief (end of day) recording. While carrying the PDA/GPS units, participants also undergo daily methadone maintenance. After 18 weeks, participants discontinue use of the PDA and GPS units and are given the choice of transferring to a community clinic or undergoing a 10-week taper from methadone at the research clinic.
6 Exam 1. Classical conditioning leads to SUDs recovery through: a. Intervention b. Coping skills c. Mindset d. Sobriety 2. Which is the proper order of Endsley s SA theory? a. Projection, Comprehension, Perception b. Perception, Comprehension, Projection c. Comprehension, Projection, Perception 3. Active attention enhances goal-directed behavior. True or False 4. Taking personal responsibility is the foundation to situational awareness. True or False 5. Psychological state management describes: a. Situational awareness b. The OODA Loop c. Mindset d. Goal-oriented behavior 6. The OODA Loop is a a. Behavioral theory b. Human Factor Theory c. SA Theory d. Military Protocol 7. Situational awareness therapy is useful in substance abuse recovery because it: a. acts as an agent of control during tension. b. gives meaning to a person s life. c. creates individual therapy. d. conditions a person for goal-oriented behavior.
7 References: Angerman, W. (2004). Coming full circle with Boyd s OODA Loop ideas: An analysis of innovation diffusion and evolution. Wright Patterson AFB, OH: Air Force Institute of Technology, Air University. Barry, K. (1999). Brief interventions and Brief Therapies for Substance Abuse. Rockville, MD: U.S. deptartment of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Boyd, J. (1987). Strategic Game of? and? In C. &. Richards (Ed.)., (p. [Unpublished briefing slides]). Boyd, J. (1995). The Essense of Winning and Losing. Breslin, F. Z. (2002). An Information-Processing Analysis of Mindfulness: Implications for Relapse Prevention in the Treatment of Substance Abuse. Clinical Psychology: Science and Practice, 9 (3), Chase, L. (2009). Integration of Cyber Situational Awareness into System Design and Development. Wright- Patterson Air Force Base, OH: Air Force Institute of Technology, Air University. DellaVignaa, S. &. (2001). Learning to Make Risk Neutral Choices in a Symmetic World. Mathematical Social Sciences, 41 (1), Endsley, M. G. (2000). Modeling and Measuring Situation Awareness in the Infantry Operational Environment. Fairfax, VA: TRW Systems Integration Group. Endsley, M. (1995). Measurement of Situational Awareness in Dynamic Systems. Human Factors, 37 (1), Endsley, M. S. (1998). A comparative analysis of SAGAT and SART for evaluations of situational awareness. Proceedings of the Human Factors and Ergonomics Society, Annual Meeting 1 (p. 82). Santa Monica, CA: Human Factors and Ergonomics Society. Ensley, M. (1995). Toward a Theory of Situation Awareness in Dynamic Systems. Human Factors, 37 (1), Epstein, D. W.-R.-L. (2009, January). Real-time electronicdiary reports of cue exposure and mood in the hours before cocaine and heroin craving and use. Archives of General Psychiatry, 66 (1), pp Garland, D. &. (2000). Situational Awareness Analysis and Measurement. Mahwah, NJ: Lawrence Erlbaum Associates, Inc. Gollwitzer, P. (1990). Mindset theory of action phases. In K. &. Van Lange, Handbook of Motivation and Cognition: Foundation of Social Behavior (pp ). New York: Guilford Press. Hogan, M. P. (2006). Use of human patient simulation and the situation awareness global assessment technique in practical trauma skills assessment. The Journal of Trauma, 61 (5), Klein, G. (1989). Recognition-primed decisions. In W. Rouse, Advances in man-machine systems research (pp ). Greenwich, CT: JAI Press. Marlatt, G. &. (1985). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press. Marrissen, M. F. (2007). Cue Exposure Therapy for the Treatment of Opiate Addiction: Results of a Randomized Controlled Clinical Trial. Psychotherapy and Psychosomatics, 76 (2), Miller, W. &. (1996). Assessing drinkers motviation for change: The Stages of Change Readiness and Treatment Eagerness Scales (SOCRATES). Psychology of Addictive Behaviors, Milton, A. (2012, December). Drink, drugs and disruption: memory manipulation for the treatment of addiction. Current Opinion in Neurobiology, in press. Monti, P. &. (1999). Coping-Skills Training and Cue- Exposure Therapy in the Treatment of Alcoholism. Alcohol Research & Health, 23 (2), National Institute of Health. (2008, October). Developing Field Tools for Real-Time Assessment of Exposure to Psychological Stress and Drug Use in an Outpatient Treatment Population. Bethesda, MD, US. Retrieved from Park, J. P. (2012). Standardization Study of the Korean Version of the Stages of Change Readiness and Treatment Eagerness Scale for Smoking Cessation (K-SOCRATES-S) and It s Predictive Validity. Psychiatry Invetigation, 9 (3),
8 Perron, M. V. (2013). Social Work Practice in the Addictions. New York: Springer Science + News Media. Rohsenow, D. J. (2001). Cue exposure with coping skills training and communication skills training for alcohol dependence. Addiction, 96 (8), Sugarman, D. E., Nich, C., & Carroll, K. M. (2010). Coping strategy use following computerized cognitive-behavioral therapy for substance use disorders. Psychology of Addictive Behaviors, 24 (4), Vollstädt-Klein, S. L. (2011). Effects of cue-exposure treatment on neural cue reactivity in alcohol dependence: a randomized trial. Biological Psychiatry, 69 (11), Yalom, i. (2002). The Gift of Therapy. New York: HarperCollins.
Coping-Skills Training and Cue-Exposure Therapy in the Treatment of Alcoholism Peter M. Monti, Ph.D., and Damaris J. Rohsenow, Ph.D. Coping-skills training (CST) and cue-exposure treatment (CET) are two
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