This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through AllCEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on the models of treatment. So what we're really going to talk about is some different theoretical approaches because not all of us necessarily ascribed to the same theoretical approach. So when we're working in multidisciplinary teams, sometimes we have to think about the different influences from each person in that team in order to make a compelling argument for what we want to have happen in order to create that win-win situation. So that's kind of what we're going to look at today. We're going to define the principles of effective treatment, which, hey, good to know, explore current trends and practices in treatment programs. And those are rapidly changing. Some of the things that we used to do, we don't do anymore. And some of the things that we haven't been doing, we may start doing in the not so distant future. So I'm going to interject a little bit of new stuff as it relates to the president's commission on opioid use or whatever it was called, that report that just came out. We'll identify some common approaches to treatment, the main components of each approach. We're not going to go in depth. We're just going to kind of hit the highlights, like I said, so you can figure out if you're working with somebody who uses that theoretical framework, how to create a win-win, how to work together harmoniously. And we're going to compare and contrast each approach a little bit in terms of which clients you might use it with and how it might work in different settings, such as mental health, standalone private practice versus community behavioral health, et cetera. And maybe different ways that you might be able to implement it. So principles of effective treatment, addiction and mental health issues are complex, but treatable conditions that affect the brain, the body, and behavior. So this is one of the new changes, and we'll talk about that later. But we're really focusing on the whole person now. We recognize that it's not just the way somebody thinks. It's not just their neurotransmitters. It is a whole brain-body behavior thing. And any change in any one of these areas can affect the other areas. So if you start making better behavioral choices than potentially, like we talked about yesterday with people with alcohol-related brain damage, if they make better behavioral choices, chances are their brain health is going to improve and their body health will improve and their mood, theoretically, will improve too. No single treatment is going to be appropriate for everyone. So when people come into our clinic or facility or whatever you call the place that you work, we can't necessarily assume that group 12-step treatment or individual humanistic counseling is going to work for them. We need to look and say, what does this person need? Now, individual humanistic may work in terms of addressing the cognitions and the mental health stuff, but they also may need some brain-body stuff with either a psychiatrist or a physician. And maybe some social skills or something else. So we need to look at the comprehensive picture. Treatment needs to be available to be effective. And you're thinking, well, duh. But in the big scheme of things, when we look at how many people actually are able to access treatment, only about 10% of people with addictions are able to access specialized treatment each year. And the number is a little bit higher from mental health, but it's not wonderful. Less than 50% of people who have treatable mental health conditions receive treatment. So we want to look at why is that. And one of the reasons, so box warning, is because treatment is too expensive for a lot of people. They have deductibles that are $1,300 and up. So the average deductible for a person, a single person, is $1,300, which means insurance doesn't cover anything until they pay the first $1,300 out of pocket. Now, if a clinician charges $100 a session, that's 13 sessions, which could be virtually the entire course of treatment before insurance even kicks in. And a lot of people don't have that kind of money just kind of laying around. So we want to look at the affordability and availability of treatment, which is one of the reasons I push groups a lot, because groups are a way that we can provide a lot of services for affordable amounts for the clients and still, you know, put food on our own tables. So looking at how can we as clinicians make treatment more available to those in our community? Virtual services, that's something that we can look at. Tele-mental health, so people don't have to get babysitters, don't have to travel. Group therapy, having services on the weekends or during the evenings. Those are always great. Now you're thinking, well, that's what I want to be with my family. True. So it's always a trade-off. You've got to figure out, you know, could you do evenings two days a week or something in order to be available? And that's something that, you know, is a choice that you've got to make on your own. I know when we were setting up new programs, we would always look at where the demand was. Where did we have the waiting list? Was it the morning programs or was it the evening programs? And, you know, what kinds of services were in highest demand? So effective treatment attends to the multiple needs of the individual. So we're not just doing that mental health assessment and going, okay, you've got, you meet the criteria for major depressive disorder. So we're going to treat that. And we're going to talk about all the reasons that you're depressed. Well, effective treatment is also going to look at their nutrition, their social, their living environment, is their stress there, their work environment. And, you know, attending to any medical needs that may need to be addressed to also deal with the depression. Current trends and practices, focus on the client competencies and strengths. Instead of saying we're going to get rid of your depression, we're going to say we're going to help you feel better. Yeah, it's the same thing. But instead of getting rid of something, we're adding something. We're putting something awesome in its place. And one of the principles of behavior modification is that you don't want to just punish a behavior. You don't want to just get rid of things because if you get rid of it, you have to have something to put in its place. So too often parents and caregivers and clinicians even sometimes will get in the habit of taking away things, you know, or let's take people. They make New Year's resolutions. I'm going to stop smoking. I am going to stop eating sugar. I am going to stop doing this and stop doing that. Well, that's just grand, but all those things serve a purpose. So what are you going to do instead? And that's one thing that we want to ask, what are we working towards? What's our goal? And what strengths does the person have? Maybe their social skills are weak. Okay. You know, maybe they've got a lot of social anxiety that contributes to their other mood issues. Okay. Well, we'll deal with that, but let's look at what strengths they have. Maybe they're really articulate. Maybe they're really smart. Maybe they are introverts and they just don't really realize that people who are introverted tend to get more stressed out in large groups. So we can help educate them about their strengths as an individual. So we want to focus on strengths and build clients up. We want to focus on what's worked in the past instead of saying, okay, you're in my treatment program. Let's start at square one. We're saying, okay, you're in my treatment program. What's worked for you before? So let's build this foundation and figure out what kinds of tools you already have in your toolbox before we start trying to put more stuff in there. That'll also help us figure out, like I said, what's worked before.  We might ask what about it didn't work for them so we can, you know, make sure that we're going down the right path. But we're going to figure out for that person what helps the most. CBT works well for people who have unhelpful thoughts and cognitions sometimes. But sometimes if they've got emotional dysregulation, they may feel like the clinician just doesn't get how intense this is when the clinician says, well, you just need to change the way you're thinking about things. They're like, it ain't that easy doc. So we want to make sure that we provide individualized client-centered treatment and shift away from labeling. You notice I try really hard not to say addicts, alcoholics, I say people with addictions or addictive issues. I try not to say a person with depression. I try to say a person who has depressive symptoms because I want to look at the person. I want to emphasize that the person is in there. And for me, when I say a person with depressive symptoms, that reminds me that depression doesn't look the same for most people. You know, there's a huge variation in what depression looks like. So I want to look at that person and what symptoms they're presenting with. Acceptance of new treatment goals other than, for example, with substance abuse or addictive behaviors, abstinence. There are some addictions, especially the behavioral ones, but even eating disorders that you cannot completely abstain from. You can't not eat. You could argue the point about sex addiction. Some people say, well, you don't have to ever have sex. You know, when we're talking about the totality of the human organism, that's a choice that each person has to make. But those are the things that we want to look at in terms of what is the person willing to do and what is going to help them lead the healthiest and happiest life. What does happiness look like for them? For some people, you know, their definition of recovery from depression may be very different from mine. But I want to look at what are their treatment goals? Adoption of a recovery paradigm away from problem focused acute care model, which means we want to help them figure out how to achieve a rich and meaningful life, not just eliminate depression. But we also want to look at a recovery paradigm, a recovery network, if you will. It's not just your symptomatic right now, we're going to treat it right now. It'll go away when it comes back. You come back for more treatment. You know, because we know that people who have major depressive disorder, for example, will have recurrences, most likely. What we're looking at is, okay, let's treat what you've got going on right now. Let's help you start feeling better and help you continue to feel better, i.e. not relapse and have another episode. So we want to make sure that we're looking not just at eliminating the present symptoms, but keeping them away. Integration of addiction treatment in multiple disciplines, especially primary care, mental health and addiction. So we want to make sure that addiction counselors know the basics about working with clients that have mental health issues. We want to make sure that primary care physicians have an understanding of how to screen for substance use issues. Evidently, less than 20% of primary care physicians ever received training in that. That was from the report that came out, anyhow. And we want to make sure that each area is aware of the impact of the other areas. So mental health practitioners are aware of the impact of even behavioral addictions, like we're talking about internet addiction, which is in the DSM-5, and other sorts of behaviors. We also want to make sure they're aware of the impact of physiological problems like polycystic ovarian syndrome and hypothyroid. Okay, another trend is the use of evidence-based practices. And if you are in a clinic, you've probably heard about this. If you are in individual practice, you may not have, but I do want to show you this really cool little tool. And I will preface it by saying evidence-based practices are awesome. However, in many circumstances, about 85% of them require you to go through a certain training curriculum or whatever that can be quite expensive, which is why a lot of agencies have difficulty adopting new EVTs because it requires that every staff member be trained on it. And that training is often several thousand dollars. So the new mandate that we start using that came out that treatment facilities start using evidence-based practices. Well, that's wonderful. We've been saying that for a long time. But how can we make it effective and affordable for agencies to switch over? So that being said, little soapbox, maybe a big one. The National Registry of Evidence-Based Programs and Practices by SAMHSA is great because you can find an intervention, search by keywords. I love databases if you can't tell. Let's look for major depression. There we go. We're just running a little slow. So there are two programs that came up in the search results. Depression prevention, managing your mood and partners in care. Now this shows whether it's promising outcomes or effective outcomes. The Depression Prevention Program has evidence of effective outcomes in research for depression and depressive symptoms. So you're thinking to yourself, well, that might be something we want to implement. So then you can click on that. And learn more about it, how to access that evidence-based practice. Now let me go back here one more time because I think this is a useful tool. Seeking safety, which we're going to talk about later, is an evidence-based practice and that's one you can get relatively inexpensively. But you can search by program type. So let's say mental health treatment by age. Let's say we're working with adolescents. Sure, why not? Outcome categories, mental health, race, ethnicity. So we're getting to more detail about what's going to work with this population. Let's say Hispanic or Latino and LGBTQ, ITS. Let's just throw that one in there. I don't know if we're going to get anything that matches all of those criteria. But yeah, that pushed it over a little bit once I added the special population. But you can do based on the population you serve, you know them best. How old are they? What they're presenting issues are, what their gender is, what kind of setting you have, whether it's inpatient, outpatient, court, school or classroom. So there's a lot of stuff you can look at here and find the different evidence-based practices. So EBPs are not going away. They are really cool. They are awesome. Motivational interviewing is an EBP that a lot of us have gotten trained in over the years. But you see how many years it took for that to actually get completely integrated into practice where most people had had some training in it. Okay. Use of medications is a new current trend in practice. When you read a lot of the insurance guidelines for reimbursement, the level of care guidelines. One of the statements in every single provider that I've ever worked for in the level of care guidelines is medication is used unless contraindicated.  And that's cool. But all of the insurance companies that I've ever worked with actually have a line item in there that says you need to consider the use of medications for treatment. And telehealth technologies are becoming huge partly because it makes services more accessible and to a little extent, a little more affordable. You're still paying for the clinician's time and the technology. But there are a lot of other ways we can use telehealth, such as support groups in the rooms is an online chat room for people with substance abuse issues. People can log into daily virtual support groups or you can even host one on your own website. If it's a support group, you have less HIPAA issues, especially if you host it on a website other than your own. You create a secondary arm that's your aftercare support thing. Talk to your attorney about HIPAA and high tech confidentiality issues there. But there are a lot of different things you can do. You can provide chat support to your clients so they can get more immediate in the moment support for something that's going on. Maybe they're in the first month of recovery. You can have forums available. The forums have kind of gone by the wayside over the past 15 years or whatever. But they still get used to some and it allows people to communicate asynchronously and provide each other feedback. One that I participate in spark people. It has an app. It's a nutrition and health and wellness app. But there's a lot of really good interpersonal support that goes on on that in that chat room. So that's a good place. And oh, there was another one. I met the man the other day that created pocket rehab is the name of the app. And it's only available on Apple devices right now, but pocket rehab. And he has a really great program that allows people to both do private journals as well as to receive lifeline support from other people who are in recovery. And he incorporates all addictions, not just substances, but also shopping and internet addiction and all those sorts of things. So and online video psycho education. If you have certain topics that you teach every single group that comes through like when I when I was at the clinic in South in Florida, there were certain groups I did every single 30 days. So you can record those and it doesn't have to be super fancy. It can be like this or it can be super fancy, whatever you want and have those available online. They can be password protected so only your clients can get to them if you want to. So they can watch them at their leisure and and or you know they can participate in the group and then they can go back and review the video later if they need sort of a tune up. So how else can we make treatment more available. And that's one of the things that's going to kind of plague us because there's the balance between or struggle, if you will, between making services available, but we can make them available but we've making them affordable is almost more challenging than making them available. A lot of people kind of shy away from groups, especially face to face groups because you know they don't necessarily want to see their neighbor when they walk into a room. Online groups have the benefit of people can't see each other. Or you don't have to do video so people can see each other most of the time they can't. So people feel like they maintain a little bit more anonymity online services. That's another thing. So I would encourage you to continue to think about that. Principles of effective treatment duration and treatment for at least three months is generally critical for substances definitely critical for mental health. You know really 12 weeks is not a long time for somebody who's struggling with major depressive disorder, you know to really get some traction in their recovery. Now if you're dealing with some acute adjustment issues obviously three months isn't what we're talking about but you know major issues that are going on. That's really what we want to look at treatment plans must be assessed continually and modified to assure that it meets the person's changing needs. So you're going along for three weeks and all of a sudden the person loses their job or separates from their spouse or something else happens or maybe even they get a promotion at work. That's a good score. That's awesome. But you may still need to adjust the treatment plan based on what the expectations were for that person to do how much time they have to devote to treatment and the current pressures in their life. If they get a promotion, then they also might have new added stressors, if you will, of this new job. So you might have to kind of segue over and add that as an additional treatment plan issue. They need to be voluntary to be effective. What needs to happen is for us to effectively engage the person and develop mutually agreeable goals. Whether you know if they're seeing you for anger management issues their boss said they've got to come to counseling for anger management. Okay, well they're probably going to be pretty ticked off that they're having to go to these groups. I don't blame them. Let's talk about what is it that you can get out of these groups? How might this help you? Your goal is to keep your job. My goal is to help you with your anger management. How can we make these two goals kind of work together harmoniously? I used to ask my involuntary clients, my probation and parole clients, what is it that you always wanted to learn or what skill or tool might be useful in your life? As long as probation and parole is paying for it and you're stuck with me for the next 16 weeks, what is it that I can help you work on? Might as well take advantage of it because you're stuck with me. So that helps a little bit also putting the power back in their court and empowering them to identify their treatment goals and let you know again what they're going to do instead. Hopefully you have the flexibility. So if they say I'm not going to 12 step meetings, for example, you can say, okay. Well, you need a support group or you need some sort of pro-social activity so many hours a week. What are you going to do instead? The medical model of treatment looks at these issues, mental health and substance abuse, more as a chronic disease issue. With mental health, we're looking at neurotransmitter and balances with addiction. These treatments are often hospital or doctor's office based. So you may be working with somebody. It's likely that you're working with somebody who is also seeing their primary care physician or a psychiatrist for psychotropic. Okay, so if you are, that's fine, but we need to look at it and say, okay, that person is addressing this aspect of the depression or the anxiety or the addiction. I'm going to address this aspect over here. We're not really going to overlap, but as the clinician, we probably are the single point of contact. So we need to make sure everything is merging together well. The medical model does use a biopsychosocial approach with an emphasis placed on physical causes and pharmacotherapy. But they do look at the psychological and social aspects a little bit, and the doctor may make some recommendations, but he's not going to do counseling and he's not going to do life skills training. You may see people get detoxification, medication for symptom reduction, medication for aversion like antibuse, which is what they used to give alcoholics and they do still some. And medical maintenance or medication assisted therapy. The spiritual model views mood issues and addiction as being caused by spiritual emptiness, which leads to character defects such as pride, resentment and anger. Now the 12 step models are largely based in the spiritual model, but you also might be working with somebody who's been working with their spiritual guide or their spiritual leader. So we want to be able to understand where that person has been telling the client. This is probably what's causing your your issues right now. Less weight in the spiritual model is given to causation and more of an emphasis is put on a spiritual path to recovery development of values and a sense of meaning and purpose. So we're looking at developing hope, faith, courage, discipline, those sorts of things which really won't hurt anybody. The 12 step models which are mutual help and many people aren't real familiar with 12 steps they've heard about them they know well if somebody has a substance use issue they go to AA or NA. Well there's a lot of a programs out there, a lot of anonymous is they emphasize that one cannot help oneself and recovery requires surrender of one's will to a higher power. Now for some people as soon as they hear that their skin starts to crawl and they're like oh heck to the know. And for other people, they embrace that and go you know what you're right. I've been trying and trying and trying and I can't do it on my own. So one of the challenges we have if we're working with somebody who either doesn't believe in a higher power, or who is angry at their higher power. How do we help them embrace that and one tool, and I'm going to ask you to think about other ways we can help people integrate into 12 step communities if they don't believe in a higher power. But one tool that I've always been taught is to view God as good orderly direction. That is to get to your goals to get a reaching meaningful life.  So if we're thinking about good orderly direction in terms of a higher power, or a higher direction. Sometimes that can help people deal with 12 step meetings if they were a bit resistant, because sometimes the court just requires 12 step meetings, and you can't you have no way to get around it. You can advocate till you're blue in the face and it ain't gonna help. So one thing that I do want to point out with that is emotions anonymous. I said there's a lot of a's out there. Emotions anonymous is designed for people basically who have emotional dysregulation issues where their emotions they go from zero to 240 and 1.2 seconds. And they feel like they're not able to control their anger, their depression, their anxiety, any of those dysphoric feelings. If they're willing to explore a 12 step sort of approach, EA is a good activity for them. They have their own literature, they have their own books. The meetings are not nearly as plentiful as there are AA and a meetings around, but they're always open to people starting new meetings. So if you're interested in learning more about it maybe starting a meeting at your facility. That could be an avenue that you go down. Okay, so how can you use a spiritual model with clients who don't believe in a higher power. And for me, it comes down to working with them to define what spirituality means to them. And in what way they think spirituality or lack there of or spiritual roadblocks are contributing to their unhappiness right now. And so we get into a much more abstract conversation about what's going on and talking about what does recovery look like and if you're recovering spiritually. If you were recovered spirit spiritually, what would be different? What do you need to enhance? Are we talking virtues or what behaviors? And we kind of picked that apart for a little while to develop their ultimate goal plan. Okay, the psychological and self medication model says that addiction and mental health issues result from deficits in learning, thinking or emotion regulation. So this is the stuff we were all taught in grad school. Treatments can be ranged from behavioral self control to individual and group counseling to pharmacotherapy. I mean, we're not opposed to helping people figure out what may need to be addressed and advocate for them or encourage them to advocate for themselves with their physicians in order to access pharmacotherapy that might help them. So the goals will start with behavioral self control training.  So increase self awareness of what's going on, what you need, what your triggers are or your stimuli and establish external controls so you can implement coping skills. Help people start learning how to set goals so they have something out there that they see I need to accomplish this this week or this month or whatever it is. And they have this external plan that's helping them monitor and shape their behavior. You can use behavioral contracting. So for example, what would you contract for with somebody who has major depression, who has difficulty getting out of bed, we may contract for having the person get up by a certain time each day and put in rewards for achieving that. And if they don't achieve it, then we want to look at, you know, what's going on, what happened there. But each day, just like with standard behavioral interventions, if they do what they're supposed to do or trying to do, we need to make sure that it's rewarding. So if they do get out of bed at whatever time you identify, we need to make sure they have access to some sort of rewards. Trigger management. So encouraging people to be aware of what their triggers are.  And I was at the gym the other day and I looked up and they had this poor little shivering dog in the video and it just broke my heart. I was like, okay, no, not even watching that. But what are people's triggers for their mental health stuff? It could be a meeting that they have to go to at work. It could be a person. It could be a place. But helping them identify what those triggers are and figuring out how to work with and or through them. Functional analysis of the behaviors, not the diagnosis. So if somebody has symptoms of depression, they meet the criteria for major depression, whatever you want to say. All right, we're not going to look at what is the function of depression. Well, depression looks different for different people. What is the function of not being able to get out of bed, not feeling, you know, they just don't want to get out of bed in the morning. That's the behavior. So what's motivating that? Well, they may not be sleeping well. They may feel fatigued and exhausted. Okay, let's look at what's causing that. Because then we can figure out something to address the underlying issue that's causing the targeted behavior, the behavior you want to eliminate. So conducting those functional analyses, if somebody stress eats, okay, so that's a specific behavior. So what purpose does it serve? And what else could you put in its place to satisfy the need instead of stress eating? Relapse prevention. So we want to look at relapse prevention strategies for both mental health and addiction. And they're basically going to be the same. Good sleep, good nutrition, good social support, mindfulness, relaxation and recreation regularly. I won't say every day because some people just, they work two jobs, have six kids, can't do it. Okay, that's fine. But we want to make sure that these people are living or trying to live a happy, healthy life. So that's what relapse prevention is, is helping the person prevent those conditions, prevent stuff that caused the neurochemical imbalances that led to their depression, which may have led to their... Unhelpful thinking. So, you know, wherever the unhelpful thinking came in the process, you know, it doesn't really matter. We end up needing to treat or address everything. But realizing that relapse prevention means preventing those conditions from occurring again, just like when there's a hurricane, there's a certain set of conditions that have to happen for a hurricane to form. Well, there's a certain set of conditions for each person that need to kind of occur for them to have a recurrence of their major depressive episode in most cases, like 99% of the cases. So we want to know what those are so we can try to prevent them. And we want to know what those are and what the symptoms are of the beginning of an episode so people can intervene early. If they notice, you know what, I'm starting to feel kind of wonky. Then they can start saying, I need to back off. Maybe I need to take this weekend off and rest and relax because I'm starting to get burned out and I'm starting to feel blue and I really don't want to go into a whole depressive episode. That's relapse prevention. So preventing an early intervention. Dialectical behavior therapy came as a response to people who weren't doing well with traditional cognitive behavioral. Clients in traditional cognitive behavioral often and traditional therapy often unintentionally reward ineffective treatment while punishing therapists for effective therapy with a lot of clients. When we start digging when we start pushing buttons when we start helping them move through those stuck points, it hurts and they don't like it. In certain circumstances among certain groups of people, their symptoms escalate so much that the therapist has to back off every time they start to get to a point. The client either discharges or rapidly escalates or decompensates. So cognitive behavioral wasn't helping to deal with the distress that was caused by pushing on those buttons and dealing with those old wounds. The sheer volume and severity of problems presented by clients makes it impossible to use the standard cognitive behavioral format in many cases because they would be doing ABC worksheets until doomsday. So we need to help them figure out how to moderate some of this distress and how to figure out what the root causes are. Clients found the focus on change inherent to CBT invalidating. Because cognitive behavioral was often saying, again, this is your problem is caused by unhelpful cognitions and behaviors. That's what you need to change. It's very practical, very pragmatic, but clients who are struggling and who are extremely emotionally raw often felt very invalidated. So the overriding themes in DBT are mindfulness using that wise mind getting out of the emotional reactive mind distress tolerance. Sometimes life is going to be unpleasant and you can't necessarily make it stop. So what do you do? How can you address it? Emotion regulation and interpersonal effectiveness and problem solving. A lot of people who have emotional dysregulation have difficulty managing those emotions and not going from zero to 240 in 1.2 seconds. They've had struggles with interpersonal relationships. A lot of people with borderline personality disorder characteristics also struggle with relationships because of their lack of internal sense of self, their need for external validation. So more interpersonal effectiveness skills need to be taught, but they also need to be able to regulate their emotions and tolerate their distress. Another model that you might not be familiar with but has a lot of really awesome units for straight up mental health is the matrix model for stimulant use. Now if you're going to use it as an evidence-based practice, obviously you're using it with stimulant abusers. But this manual for the matrix model provides you with worksheets. I mean, it's a clinician's manual for identifying triggers, body chemistry and recovery, thinking, feeling and doing, work and recovery, guilt and shame, sex and recovery, truthfulness, trust. Being smart, not strong, talking about asking for help. So there are a lot of really awesome things that you can get some ideas off of to do group if nothing else. The goals of the matrix model are to learn about issues critical to addiction and relapse. Receive direction and support from a trained therapist and become familiar with self-help programs, not just 12 step, but that can include celebrate recovery and some of those others. The therapist functions simultaneously as teacher and coach, fostering a positive, encouraging relationship. So a lot of this is psycho-educational. But like I said, a lot of the groups are applicable to people who don't have any addiction issues at all. Motivational enhancement therapy is unique because it usually only consists of three to five sessions, period, and a story. It's used to help resolve ambivalence about treatment and abstinence or change, whatever the change may be, and that can be relationship issues or whatever. The therapy consists of an initial and assessment battery because you want to get an understanding of what's going on in this person's life so you can provide them feedback. Followed by two to four individual sessions with a therapist and they're not usually weekly. They're spaced out where you develop goals and you empower the person to make changes on their own. The first treatment, you want to provide feedback about the initial assessment. Place the responsibility for change directly on the shoulders of that person saying, you know what? You got this, but I can't do it for you.  So we want to elicit self-motivational statements, identifying the reasons they want to do it, and examples of how they've succeeded in the past, so self-motivation and self-efficacy. We want to strengthen motivation and build a plan for change, so this is still the first session. It's a long one. We provide advice, such as coping strategies for high-risk situations. Then we provide a menu of options. So here's some advice about, you know, different directions you could go. Here's a menu of options for different types of treatment, different books you could read. You know, these are things I think would help you. Here's a laundry list. Now let's figure out what looks good to you. We want to provide empathy and enhance self-efficacy. So feedback, responsibility, advice, menu of options, empathy, and self-efficacy. In the subsequent sessions, the therapist monitors change, reviews the change strategies being used, and encourages change. You're the cheerleader at that point. So this is very behavioral in nature and motivational in nature, and puts a whole lot of responsibility on the person, which means it's really good for some people who are really high-functioning and really motivated. Family behavior therapy I really like. It demonstrates positive results in both adults and adolescents. It addresses not only substance use and mental health problems, but other co-occurring issues because it's family behavior therapy, not identified patient behavior therapy. So we're looking at the whole family going, all right, what's going on here? It can start addressing conduct disorders, child mistreatment, family conflict, unemployment, you know, the range of things goes on. So if you want to figure out what are the weak links, if you will, or the trigger points in this family that are causing the identified behaviors, what they want to get rid of, and how can we help them meet those goals? It involves the patient along with at least one significant other such as a cohabitating partner or a parent. So it doesn't have to be the whole family. Ideally, it is. Everybody living in that household, but it requires at least one other person. FBT combines behavioral contracting with contingency management. So you set up a contract. You agree to do these things. If you do, there are certain rewards that you can get, and they set up the rewards. Therapists seek to engage families in applying the behavioral strategies taught in sessions and acquiring new skills to improve the home environment, such as, you know, how do you deal with the toddler if, you know, there are difficulties with child neglect or child maltreatment? You know, some education about how to do that. And okay, when Sally starts asking, why is this blue or why is this green for the 700th time? And you just want to pull your hair out. What do you do instead of losing your temper? So basically providing these tools, but it's set up in a contract with rewards for successful completion. And it does, in contrast to the other things, it looks at the family system, it looks at the environment, and addresses biopsychosocial spiritually, environmentally, the trigger points that may be prompting the behaviors you want to eliminate. Seeking safety, love this one, is a present focus therapy for trauma, PTSD, and addiction. It is available as a book with guidance for clients and clinicians and you can get it on Amazon. And it can be done in individual or group. I had two clinicians where I used to work that used to run this program, or different instances of this program, and the clients loved it and did super, super well as far as their outcomes. The topics, I'm not going to go into a huge depth, you can look at it on Amazon, but they range from introduction to safety, PTSD and taking it, taking back your power, compassion, creating meaning, detaching from emotional pain and grounding, identifying red and green flags and self nurturing. And again, you can conduct these in any order. So your particular group may need a different order. And maybe you don't work with people who have active substance use issues. So you can take that substance group kind of out of it because this is really looking at PTSD recovery and creating safety. The socio cultural model emphasizes the socialization process, culture, observational learning and reinforcement of behaviors. So somebody using this model is really going to look at the social and family relationships. And in substance abuse recovery, we often say that people need to change people places and things. Well, that's easy to say, but it is almost impossible to do for most people. They're going to go back to that same environment out of which they came, because that's the only place they have to go. They don't, they can't afford to go to a sober living facility that may charge $1500 a month or something. So they're going back home.  That's not so easy, but we can help them develop skills and tools to deal with the stressors in their family and social relationships, in their environment. We can help them develop social competency and interpersonal effectiveness. Playing on the observational learning, if they see John and he's doing, he's, he goes drinking when he's had a bad day and it seems to help him feel better. And your client says, well, maybe I ought to, when I have a bad day go out drinking, we want to encourage him to think what are your ultimate goals and is following what John does, even though it looks like it might help. Is that really going to help you? Is that going to be the solution that you're looking for? And encourage people to work within their own cultural infrastructure to find a safe place. You know, what is it that I can do where, so I'm remaining true to my culture as I define it. But I'm also happy and healthy and all those sorts of things. Relapse prevention is a really basic approach and it adopts strategies designed to help clients become aware of cues or triggers that make them more likely to abuse substances or become symptomatic. Triggers and I've told you before that, you know, it can be holidays, it can be seasons, it can be smells, it can be, there are a variety of things. I know for me there are certain smells that trigger really positive memories and certain smells that trigger trauma. And I've learned how to deal with those triggers through practice and experience. But it's important for clients to be able to reground if they have a smell, for example, that triggers a traumatic memory for them to be able to stay in the present and not, you know, go back there. Wherever back there was. So relapse prevention helps people be a lot more cognizant of their environment and more mindful. One of the things that we don't, we don't usually use the words mindfulness and relapse prevention together, but you can't have one without the other. Mindfulness helps clients identify when they start feeling that queasy little feeling that pit of their stomach that says this is not a good place for me to be. Or this is going to be stressful. So they can address it early, that early intervention. And it helps them look around and eliminate as many triggers as possible. So they can have positive things around if they're say, particular, you know, billboard on their way to work that triggers them, they can go a different route. Maybe they're driving past the neighborhood where they used to live with their ex spouse, and that just devastates them every time they drive by it or it makes them really angry. Well, maybe they can find a different route to work. So monitoring and managing those triggers so they're not intentionally putting themselves in stressful or dangerous high risk situations and helping them develop alternative coping responses to those cues. All right, so you have to drive by your old neighborhood, you get enraged when you drive by there and you're thinking about what happened. Oh, can't stand it. What can you do?  For some people, you know, one thing I might suggest for a client who has to do that is to think. All right. If they know ahead of time, they're going to have to drive by that place. What can they do leading up to it positive self talk leading up to it and distraction techniques as they pass it. So maybe having their favorite song really loud on the radio, or the company channel on or something that can help so they get so they get past it, or if they have an unreasonable fear of bridges. What can you do if you know you've got to go over a bridge to get through it so it doesn't throw you for for a loop. Now, obviously those are acute responses, but enough stressors could potentially trigger a full blown relapse of anxiety or or depressive major depressive symptoms. Medication assisted therapy, which allegedly is supposed to be becoming available at all treatment facilities. And I'll wait to see that happen includes methadone, suboxone, Vivitrol, and abuse and some SSRIs your selective serotonin re uptake inhibitors. They've been found to help with certain compulsive behaviors. Certain antidepressants, especially Zoloft has been found to be really helpful with people with bulimia. So there is some evidence out there that SSRIs can help with some compulsive behaviors in addition to mood issues. Vivitrol is helpful for alcohol and opiate abuse. Antibuse is the thing that people take that makes them throw up and really, really sick. Actually, it increases the rate at with which they get alcohol poisoning is technically what happens if they drink. So there's a lot of different types of medication assisted therapy out there. It's not necessarily meant to have somebody on it indefinitely. I helped start a methadone clinic where I came from in Florida and our psychiatrist really looked at it as an 18 month treatment program. Get people on, you know, get them to the point where they're not having cravings to use. Then they had in methadone clinics you are required by the food and drug not food and drug by the DEA. There are all kinds of requirements for counseling that have to take place in a methadone clinic. Not in the patient, not in the doctor's offices where people go and get suboxone. That's generally just getting them suboxone. But in methadone clinics, people have to undergo pretty intensive therapy in addition to it. And a lot of clinics will only maintain people on it unless there is an overriding reason not to discharge them for about 18 months to two years. You have to present to the powers that be at the DEA or wherever compelling reasons to keep somebody on methadone more than two years. Now some of the people that I worked with that were veterans did have chronic pain. They had opiate addiction issues. Methadone was being used to help monitor manage their pain. You know, there were some outstanding outliers or whatever. But understand that methadone really for the most part is not meant to be something that people get on and stay on for the rest of their lives. It's not replacing one addiction with another. It's supposed to help them get through that period until their neurotransmitters can kick back in and they develop the skills they need to deal with life on life's terms. Medication assisted therapy for mental health issues are your SSRIs, your SNRIs, your atypical antipsychotics, your antipsychotics. Some people need those. Obviously, if somebody has a psychotic disorder or a bipolar disorder, they're probably going to have to be on medication. People with generalized anxiety and major depressive disorder and some of your mood disorders may not have to be, but it may help them get through until they start getting some treatment traction. Harm reduction is the acceptance that drug use and mental health issues are just a reality. The goal is to prevent harm caused by severe mental health issues, you know, not being able to get out of bed, losing your job, relationship problems. You can have a lot of problems from mental health, even if you don't have an addiction. When we talk about these, we talk about the four L's just to make it easier to remember, liver, lover, livelihood and law. So we want to prevent health problems. We want to prevent relationship problems. We want to keep people employed and keep them from getting involved with the law. Interventions for harm reduction include low threshold pharmacological interventions, so like what we just talked about. If we're talking about drugs, needle exchange programs, emphasis on non-injection routes of administration, such as oral tablets, and even smoking and inhalation, but injection, inhalation and smoking are the three fastest ways to get high and three most potent. So we want to steer people away from those as much as possible, lead more towards oral as needed.  But we don't want people ideally injecting themselves every single day unless it's inevitable. But with the antipsychotics, a once a month injection of the antipsychotic would keep the person going so they didn't have to remember to take it. So we want to look at harm reduction. What can we do to help this person? And involvement of those with a history of use or distress in program development. So to develop a harm reduction program, we need to ask people who have the problem, what is going to help you out? What can minimize the ancillary problems caused by this behavior condition or addiction? Multi-disciplinary psychotherapeutic interventions for co-occurring issues, medication-assisted therapy for both addictive and mental health issues, wraparound services including legal and childcare and social services to ensure people have access to necessary resources to achieve their goals, and family therapy to improve the interpersonal environment of the person. Now, if you can get all those in the same facility, awesome! But these are all things that we need to consider when we're looking at providing a comprehensive treatment program. There are many approaches to dealing with mental health and addiction issues. Since co-occurring issues are the expectation, not the exception, it makes sense to be aware of strategies to address both or all issues, or at least where to find those evidence-based and promising practices. Current trends and practices are steering clinicians to use more individualized, strength-based, biopsychosocial spiritual approaches. Are there any questions? Alrighty everybody, you have an amazing day. I am going to be doing an extra little recording. It's not a CEU thing, but let's see, it's one o'clock now. In about 30 minutes, I'm going to be doing another recording in the same room on the recommendations that came out from the opiate commission thingy. So if you're interested in learning about it, you can tune in. If you don't want to, that's cool too. It will be on the YouTube channel on Saturday. Have a great weekend everybody! This episode has been brought to you in part by AllCEUs.com, providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists, and nurses since 2006.