Addiction Counselor Exam Review

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Vulnerabilities Dr. Dawn-Elise Snipes Objectives • Define vulnerabilities • Identify some of the most common vulnerabilities • Their effects • Ways to prevent them

Note: Each of the vulnerabilities has its own presentation. This section is designed to give you an overview and get you thinking about possible small changes that might have a big impact. Why I Care
Vulnerabilities are situations or things that
Make it more difficult to deal with life on life’s terms leading to depression, anxiety or “stress”
Make it easier for you to over-react or get stuck
Depression occurs if you feel helpless or hopeless
Anxiety occurs if you feel powerless or out of control
Addictive behaviors increase when you feel a need to escape because of stress, anxiety, depression or pain Individual Vulnerabilities: Physical
Pain
Effects
Sleep problems
Difficulty concentrating
Irritable mood
Medications are depressants and can worsen all of the above
Interventions
Talk with your doctor
Explore nonpharmacological interventions Individual Vulnerabilities: Physical
Poor nutrition
Your body needs the building blocks to
Recover from injury
Keep you from getting sick
Make happy chemicals
Interventions
Water…. 60 ounces per day
Have three colors on your plate at each meal (condiments don’t count)
Try to eat smaller meals every few hours Individual Vulnerabilities: Physical
Lack of sufficient, quality sleep
Drug/alcohol induced sleep is rarely good quality
Lack of Sleep Effects
Fogginess
Difficulty concentrating
Irritability
Overeating
Interventions
Develop a sleep routine
Cut back on caffeine and other stimulants 6-12 hours before bed Individual Vulnerabilities: Physical
Illness
Effects
Sleep disruption
Exhaustion
Foggy head/difficulty concentrating
Irritability
Interventions
Compassion
Good nutrition

Individual Vulnerabilities: Physical - Brain changes - Brain changes can be - Hereditary - From an accident - As a result of addictive behaviors - Effects - Changes in the structure of the brain have all kinds of effects including memory, concentration, and mood. - Intervention - Eat a good diet to give the body the necessary building blocks - Get adequate quality rest - Medication

Individual Vunerabilities: Emotional - Anger - Anxiety - Depression - Grief - Guilt - Jealousy - Resentment - Inability to self-soothe

Individual Vunerabilities: Emotional - When you are feeling negative emotions - Effects - It causes the brain to keep the fight-or-flight reaction going (which takes energy) - It lacks or prevents the happy, calming neurotransmitters from being excreted - Interventions - Develop coping skills to deal with them - Insert positive/rewarding experiences - Get plenty of rest - Eat a healthy diet - Exercise

Individual Vulnerabilities: Mental/Cognitive - Global, internal, stable attributional style - Effects - When everything is always it adds extra stress - When anything that happens reflects on you as a person, it adds extra stress - Interventions - Focus on things being specific and alterable - Identify what is good about you as a person - Explore the difference between what makes you a good person vs your skills Individual Vulnerabilities: Mental/Cognitive - Extremely external or internal locus of control - Both situations add stress - Effects - External locus of control means you feel you have no control over anything - Internal locus of control means you feel like you should be able to control everything. - Interventions - Identify what things you can control and use your energy for them - Figure out how you are going to cope with things you cannot control Individual Vulnerabilities: Mental/Cognitive - Low Self-esteem - Self esteem is how you feel about who you are compared with who you think you should be - Effects - Low self-esteem can cause people to feel helpless or not deserving of love or success - Interventions - Explore what characteristics you think you should have but do not - Decide if they are important. - Decide what to do about it.

Individual Vulnerabilities: Mental/Cognitive - Negative perceptions/cognitive style - Effects - Seeing the world as negative, depressing, out of control or scary makes life more stressful - If you see everything as negative (not rewarding) you will not want to do anything - Interventions - Look for the silver lining: When you start to think about something as negative, find the positive - Look for exceptions Individual Vulnerabilities: Mental/Cognitive - Poor organization/time management - Poor time management effects - It can lead to being over committed - It cause people to feel rushed/harried - It can cause people to forget to do things leading to conflict - Interventions - Make a list of must-dos at the beginning of every week - Stop saying yes right away - Identify and address time sucks

Individual Vulnerabilities: Social - Poor communication skills - Effects - Impedes you from stating your needs - May cause misunderstandings - Can hurt your relationships - Interventions - Learn about effective verbal and nonverbal communication - Don’t assume you understand what the other person is talking about

Individual Vulnerabilities: Social - Weak emotional boundaries - Effects - You may have difficulty feeling happy unless those around you are happy - You may take everyone else’s bad mood personally - Interventions - Examine why it is not safe to feel how you feel - Start paying attention to your wants, needs and feelings

Individual Vulnerabilities: Social - Need for external validation - Effects - Not feeling okay unless you are constantly surrounded by people who tell you you are okay - Interventions - Identify why you are okay - Look at why you need other people to validate you and work on that. Summary - Addressing vulnerabilities frees up energy so you can deal with other “stuff” that comes your way - Eliminating vulnerabilities can help you feel less stressed, exhausted and overwhelmed all the time - Persistent vulnerabilities are the first relapse warning sign (HALT) - Being mindful of when you are vulnerable and taking positive steps to address it are crucial to recovery success.

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Addiction Counselor Exam Review Case Management and Service Coordination Instructor: Dr. Dawn-Elise Snipes Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery & The Addiction Counselor Exam Review

Objectives ~ Define referral and service coordination within the context of case management ~ Explore why CM is necessary ~ Identify the different approaches to case management ~ Identify the CM role in service coordination ~ Define service planning ~ Identify challenges and solutions to collaboration Service Coordination: Case Management ~ A client-level collaborative process designed to: ~ Help individuals access needed services ~ Select the most appropriate services ~ Facilitate linkage with those services ~ Promote continued retention in services by monitoring participation ~ Coordination of multiple services when necessary ~ Advocate for continued participation Service Coordination: Case Management ~ Objectives of case management ~ Continuity of care ~ Accessibility: ~ Establish relationships with “gatekeepers” ~ Develop contracts or MOUs which specify ~ Available “slots” ~ Consequences for failure to implement specified activities/procedures ~ Accountability ~ Following up on the referral with client and referral resource ~ Measuring outcomes with ~ Client satisfaction ~ Client outcomes ~ Service system outcomes (i.e. reduction in cost to treat) ~ Efficiency “Know the system and make it work”

Service Coordination: Case Management ~ Necessary because of poor service coordination, lack of service continuity and difficulty of clients negotiating the gap between services ~ Structure ~ Case manager who acts as the human link between the client and service providers ~ Core agency ~ Develops contracts with providers for identified services ~ Controls case management funds ~ Acts as a single point of entry for clients ~ Develops missing service elements Service Coordination: Case Management ~ Approaches ~ Intensive/Assertive Community Treatment ~ Comprehensive, multidisciplinary, community based ~ Growth ~ Paternalism ~ Clinical ~ Case manager provides many services including counseling ~ Stabilization ~ Strengths based ~ Focus on strengths and empowerment ~ Growth ~ Empowerment Service Coordination: Case Management ~ Approaches ~ Brokerage ~ Coordinates services and provides few, if any services ~ Stabilization ~ Empowerment ~ Integrated ~ Family-focused, strength-based program that uses an independent facilitator to coordinate all relevant people, including providers, family and natural supports. ~ This team then works in partnership with the family to create a safety-based comprehensive plan addressing the needs of all family members. ~ Growth Service Coordination: Case Management Principles ~ Offers a single point of contact for clients ~ Client-driven and strengths based ~ Involves advocacy ~ Between services with seemingly contradictory requirements to serve the best interests of the client ~ With agencies, families, legal systems and legislative bodies ~ May involve the recommendation of sanctions to encourage client compliance and motivation ~ Community based ~ Pragmatic “Where the client is” ~ Anticipatory based on the natural course of the client’s presenting issues ~ Flexible to individual needs ~ Culturally sensitive Service Coordination: Case Manager’s Role ~ To coordinate, manage, link, advocate and support clients in their quest to maximize their quality of life and achieve as much independence as possible ~ Basic Prerequisites and Competencies ~ Ability to establish rapport ~ Awareness of how to maintain boundaries ~ Willingness to be nonjudgmental ~ Recognize the importance of family, social networks and community in the process ~ Understand the variety of insurance and payment options available ~ Understand culture and respond in a culturally sensitive manner ~ Understand the value of an interdisciplinary approach to treatment ~ Serve as both facilitator of referrals and advocate

Service Coordination: Case Manager’s Role ~ Facilitator Duties ~ Composing the team ~ Notifying participants of meetings ~ Chairing the meeting ~ Maintaining team focus on the client ~ Ensuring clients’ desires and needs are adequately represented and considered

Service Coordination: Referral ~ Referral is the process of facilitating the client’s use of available services and support systems to meet the needs identified in assessment or treatment planning ~ Involves identifying needs of the clients which cannot be met by the agency (regardless of whether client is receiving case management services) ~ Inappropriate referrals may lead to dropout if clients hopes get up then they are denied access to services ~ Inadequate follow up also often leads to premature drop-out Service Coordination: Referral ~ Counselors must know resources in their community ~ Processes ~ Limitations ~ Requirements ~ Confidentiality ~ Counselors should visit the referral agencies ~ Initially ~ Semi-annually ~ Potential problems in referrals ~ Differences in agency functioning ~ Differences in eligibility ~ Inadequate data sharing ~ Conflicting treatment plans ~ Moving between agencies may interrupt continuity of care Service Coordination: Referral ~ Potential referral resources ~ Marriage and family & mental health counselors ~ Abuse and trauma counseling resources ~ Health: ~ Primary care ~ Women’s health ~ Nutrition ~ Holistic practitioners ~ Pain management ~ Legal ~ Financial counseling ~ Housing ~ Career counseling/educational planning ~ Religious/spiritual/faith support Service Coordination: Referral ~ Potential referral resources ~ Career counseling/educational planning ~ Religious/spiritual/faith support ~ LGBTQ Support ~ 12-step meetings—variety and locations ~ Veterans Administration ~ Childcare ~ Transportation

Service Coordination: Referral ~ Potential reasons ~ Counselor’s agency does not provide that service ~ Counselor may not be the best person to provide the service (i.e. sexual identity issues) ~ Counselor believes there might be a conflict of interest ~ Counselor recognizes the need for a different level of care Service Coordination: Referrals ~ Counselor should ~ Explain the rationale for any referrals to facilitate participation ~ Familiarize the client with the agency to quell anxieties ~ Contact the referral source in the client’s presence ~ Have client schedule the actual appointment ~ Give the client ~ Contact name and number ~ Agency address ~ Document the referral and follow (with client AND provider) up in the client record Service Coordination: Referral ~ Dual-diagnosis or co-occurring disorders indicates the presence of both mental health and addiction issues. ~ People with co-occurring issues often experience more severe emotional, social and physical problems than someone with only one issue ~ Medical, Mental health and Addictive disorders all influence each other ~ Use and withdrawal can both cause mood, social and physical conditions ~ Continuum: Disorders vary in terms of… ~ Severity ~ Chronicity ~ Disability/degree of impairment in functioning

Service Coordination: Service Planning ~ Treatment plans are designed with the provider to identify treatment objectives necessary to achieve goals ~ Service plans is an umbrella document which ties together all of the ~ Treatment plans from the various providers ~ Short term goals and objectives ~ Structure of the Comprehensive Service Plan ~ Long Term Goals ~ Current status narrative ~ Required services, supports and resources

Service Coordination: Linking, Monitoring, Advocacy ~ Linkages ~ goes beyond providing a list of resources ~ Involves developing a network of known resources and contacts ~ Foundation for successful implementation is based upon interdisciplinary team planning effort (including the client) ~ Decides goal priorities ~ Assigns responsibilities for each goal ~ Reaches consensus in overall approaches Service Coordination ~ Encompasses administrative, clinical and evaluative activities that bring the client , treatment services, community agencies and other resources together to focus on needs identified in the recovery plan ~ Service coordination includes: ~ Case management ~ Collaboration with client and SOs ~ Coordination of treatment and referral services to address issues contributing to and caused by addictive behaviors ~ Liaison activities with community resources ~ Ongoing evaluation of treatment progress and client needs ~ Client Advocacy

Service Coordination ~ Tasks ~ Initiating and collaborating with referral source “warm referral” ~ Obtain, review and interpret all relevant screening, assessment and treatment planning information ~ Confirm client eligibility for admission and continued readiness for change ~ Completing necessary administrative procedures for admission ~ Coordinating all treatment activities with services provided to the client by other resources

Service Coordination ~ Tasks ~ Establishing realistic recovery expectations including ~ Nature of services (IOP, Residential etc.) ~ Program goals ~ Program procedures (schedule, services offered) ~ Rules regarding client conduct ~ Client rights and responsibilities ~ Schedule of treatment activities ~ Costs of treatment ~ Facts impacting duration of treatment

Service Coordination ~ Types of services ~ Mental health ~ Physical health (liver (including hepatitis), brain, HIV, tuberculosis, STDs etc) ~ Job skills ~ Employment opportunities ~ Interpersonal skills ~ Training/education ~ Legal services ~ Housing services ~ Food ~ Childcare ~ Transportation

Service Coordination: Collaboration ~ Service coordination is essential to ~ Prevent clients from falling through the cracks ~ Foster a more holistic view of the client…not just a person with an addiction ~ Client no-show because cant find sitter. Noncompliance or responsible parent? Service Coordination: Collaboration ~ Challenges ~ Use of different assessment tools at each agency to gather same information ~ Produces a fragmented picture of the client (unless integrated) ~ Creates frustration for the client. (Didn’t I just do this?) ~ Agreeing which agency or clinician is “lead” or primary contact for the client and other agencies ~ Lead agency uses holistic assessment that meets the needs of all associated agencies ~ Funding/eligibility barriers (i.e. services for persons with a felony) ~ Difficult to treat clients ~ Differing staff credentials

Service Coordination ~ Challenges to collaboration/service coordination ~ Can occur at 3 levels ~ Personal: Attitudes and attributes ~ Professional: Differing theoretical beliefs/approaches to treatment of addiction, and “jargon” ~ Organizational ~ Not recognizing the need for partnership ~ Lack of a shared mission ~ Lack of ownership by senior management ~ Lack of trust between agencies ~ Unclear guidelines for collaboration ~ Lack of a process for monitoring and managing collaboration process The End ~ This concludes our series for the Addiction Counselor Exam Review ~ In-depth podcasts and videos of all of the topics we reviewed can be found on our YouTube channel, allceus.com/YouTube or as episodes in the Counselor Toolbox Podcast. ~ If there are areas you would like additional information, please send a support ticket to support@allceus.com and I will create future podcasts for this series based on viewer questions. Summary ~ Case management is necessary because of poor service coordination, lack of service continuity and difficulty of clients negotiating the gap between services ~ There are many CM models ranging from brokerage to clinical ~ Case managers are charged with developing the comprehensive service plan to ensure client needs are met ~ Collaboration challenges can often be addressed through effective communication, creativity and negotiation

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Addiction Counselor Exam Review Podcast Episode 22 Pharmacology Instructor: Dr. Dawn-Elise Snipes, PhD Executive Director: AllCEUs.com, Counselor Education and Training Podcast Host: Counselor Toolbox & Addiction Counselor Exam Review

AllCEUs offers Addiction Counselor Precertification Training for $149 for 400+ hours of multimedia education. We also are there for you when you need CEUs for as low as $59 for unlimited CEUs.

Objectives ~ Review symptoms of intoxication and withdrawal of drugs of abuse ~ Learn about Post Acute Withdrawal Syndrome (PAWS) ~ Identify factors that impact symptomatology General ~ Purity of the drug, hydration levels, route of administration and usage patterns all can impact ~ Speed of the effect ~ Intensity of the effect ~ Range and intensity of negative consequences/side effects ~ Injecting can result in blood infections, collapsed veins, kidney and heart problems (Fastest) ~ Inhaling can result in ulcerated nasal passages ~ Oral ingestion must be filtered through the liver and kidneys and often also irritates the GI tract (Slowest) Drugs of Abuse ~ Alcohol ~ Classified as a sedative-hypnotic, CNS depressant ~ Ethanol/Ethyl alcohol 8 stages of effect as BAC increases ~ Subclinical ~ Euphoria ~ Excitement ~ Excitement/confusion ~ Confusion stupor ~ Coma ~ Death Drugs of Abuse ~ Alcohol ~ Men drink more ~ Women more likely to ~ Develop drinking problems ~ Experience alcohol related organ damage at lower levels ~ Women’s BAC reaches higher levels with same amounts of alcohol as men ~ Alcohol mixes with water and men tend to have more body water

Drugs of Abuse ~ Alcohol related medical conditions ~ Loss of control of eye muscles ~ Hypoglycemia ~ Gastritis / Pancreatitis ~ Reduced immunity ~ Cardiac arrhythmia ~ Anemia ~ Constant flushing ~ Peripheral neuritis ~ Fatty liver ~ Cirrhosis ~ Blood pressure increases ~ Wernicke/Korsakoff’s syndrome / Alcohol related dementia Drugs of Abuse ~ Cannabis ~ As of 2016, still considered a schedule 1 by the DEA ~ Schedule 1 substances have no medicinal use and high risk of abuse ~ Legal in 29 states for medical use and in 8 of those states for recreational use ~ 9-17% of occasional users become addicted ~ 25-50% of daily users become addicted ~ Methods of administration ~ Smoked (pipes, bongs, blunts, Dabs) – rapid action ~ Consumed (tea, brownies) –slower action ~ Acts on cannabinoid receptors which influence memory, pleasure, concentration, sensory perception Drugs of Abuse ~ Cannabis ~ Dabs ~ Concentrated doses of cannabis that are made by extracting THC and other cannabinoids using a solvent like butane or carbon dioxide, resulting in sticky oils ~ Even when home extraction goes well, there’s no way to know the quality or purity of your finished product. “Dirty” oil may contain chemical contaminants or excessive amounts of residual solvents that could present health hazards ~ Cannabis extracts often test between 60-90% THC, which means it doesn’t take much to become profoundly high ~ Can be inhaled using a dab-pen or a e-cig with attachments ~ Besides coughing like a maniac, the second most common side-effect associated with dabbing is sweating like you ran a marathon Drugs of Abuse ~ Cannabis ~ Effects ~ Respiratory illness ~ Heightened heart attack risk ~ Neurobehavioral effects on fetus ~ Increased depression, anxiety and suicidal thoughts, esp. in adolescents ~ Loss of motivation ~ Exacerbation of schizophrenia ~ Impaired judgement ~ Impaired motor coordination ~ Reduced life satisfaction ~ Lower academic/career success

Drugs of Abuse ~ Synthetic Marijuana (Spice/K2) ~ Synthetic cannabinoids refer to a growing number of man-made mind-altering chemicals sprayed on dried, shredded plant material or vaporized to get high. ~ Synthetic cannabinoids are sometimes misleadingly called "synthetic marijuana" (or "fake weed") because they act on the same brain cell receptors as THC ~ The effects of synthetic cannabinoids can be unpredictable and severe or even life-threatening. Drugs of Abuse ~ Synthetic Marijuana (Spice/K2) ~ Synthetic cannabinoid users report some effects similar to those produced by marijuana: ~ elevated mood ~ relaxation ~ altered perception ~ symptoms of psychosis ~ Synthetic cannabinoids can also cause serious mental and physical health problems including: ~ rapid heart rate ~ vomiting ~ violent behavior ~ suicidal thoughts ~ Susceptible to hydration levels Cocaine, Meth and Other Stimulants ~ Signs of Stimulant Intoxication ~ Dilated pupils ~ Restlessness ~ Hyperactivity ~ Loss of appetite ~ Weight loss ~ Sweating

Cocaine, Meth and Other Stimulants ~ Signs of Stimulant Withdrawal ~ Initial ~ Dysphoria ~ Anxiety, and agitation ~ Intense drug craving ~ Rapid eye movements ~ Concise but quivery speech ~ Brisk, somewhat jerky movements ~ Thinking is scattered and subject to paranoid delusions

Cocaine, Meth and Other Stimulants ~ Signs of Stimulant Withdrawal ~ Middle ~ Anxiety and agitation are followed by a period of fatigue, increasing depression, and anhedonia with decreased mental and physical energy. ~ An intense desire for sleep, often accompanied by insomnia, usually replaces the drug craving. ~ During this part of the crash, users may use alcohol, benzodiazepines, or opiates to induce and prolong sleep. ~ The middle crash phase lasts 24 to 36 hours during which time any attempt at therapy or other intervention is inappropriate.

Cocaine, Meth and Other Stimulants ~ Signs of Stimulant Withdrawal ~ Late/Protracted ~ The user experiences symptoms that are opposite to those of stimulant intoxication: fatigue, loss of physical and mental energy, depression, anhedonia, and a limited interest in his surroundings. ~ Symptoms may increase in intensity over the 12 to 96 hours immediately following the crash, and may wax and wane over several weeks. ~ A severe and persisting depression in this phase can result in suicidal ideation or suicide attempts ~ Anhedonia and dysphoria usually dissipate over a 6- to 18-week period. ~ Periods of drug craving may reemerge, triggered environmental cues and emotional states.

Cocaine, Meth and Other Stimulants ~ Tolerance ~ Tolerance to many of the initial effects, often after only a few weeks of use. ~ Tolerance develops rapidly to the euphorogenic and anorectic effects of stimulants and weight loss stops after several weeks. ~ Tolerance also appears to develop to the cardiotoxic effects of large doses that many users survive. ~ Many of the initial symptoms of stimulant intoxication disappear with chronic use: Blood pressure may be normal, and nausea and vomiting are seldom seen.

Cocaine, Meth and Other Stimulants ~ Sensitization ~ Sensitization is essentially the reverse of tolerance, and is a unique phenomenon of stimulants ~ Users are especially vulnerable to psychosis-inducing effects ~ After one psychotic episode is experienced following use, a lower dose of may induce another psychotic episode

Stimulants Misc… ~ Cocaine users are more likely than MA users to present with serious and potentially lethal physical complications (e.g., cardiac arrhythmia, chest pains, strokes, toxic seizures, hypertension crises, hyperthermia). ~ Cocaine users are also more likely than MA users to use multiple substances, especially alcohol, benzodiazepines, or opiates.

Hallucinogens (PCP) ~ Signs of PCP abuse include: ~ Sedation ~ Immobility ~ Amnesia ~ Numbness ~ Slurred speech and other speech difficulties ~ A sense of invulnerability ~ Blank stare ~ Rapid, involuntary eye movements ~ Hallucinations ~ With the loss of the self, the user may feel intense alienation -- as though the world and the people in it make no sense -- and feelings of depression. ~ Delusions ~ High blood pressure ~ Rapid heartbeat ~ Reduced pain sensitivity ~ Apathy

Hallucinogens (PCP) ~ Low doses are characterized by numbness in the hands and toes as well as general drunken-like behavior. ~ Moderate doses produce partial or full anesthesia, where the person cannot move their limbs or any part of their bodies. ~ High doses have the potential to cause convulsions and even death. ~ Can be added to marijuana or other smoked material

Hallucinogens (PCP) ~ There are other symptoms that may show up in a person who has used PCP over a long period of time, such as: ~ Stuttering ~ Impaired memory ~ Inability to think clearly ~ Inability to speak ~ Suicidal thoughts ~ Anxiety ~ Depression ~ Isolation and withdrawal

Hallucinogens (LSD “Acid”) ~ Some common signs of LSD abuse include: ~ Sweating. ~ Dry mouth. ~ Dilated pupils. ~ Numbness. ~ Dizziness. ~ Loss of appetite. ~ Tremors. ~ Increased blood pressure and heart rate. ~ Mood swings. ~ Hallucinations. ~ Distorted thinking and sense of time. ~ Impulsiveness. ~ Impaired judgment. ~ Intensified sense of smell and hearing

~ Flashbacks, lasting long after intoxication has ended.

Hallucinogens (LSD “Acid”) ~ Many individuals may take LSD and be unaware that it takes between 20 and 90 minutes to elicit its effects ~ Does are not standardized ~ LSD overdose symptoms (Serotonin Syndrome) include: ~ Markedly dilated pupils ~ Dangerously elevated blood pressure and temperature ~ Tachycardia (rapid heart rate) or irregular heartbeat ~ Muscle shakes or tremors ~ Extreme drowsiness ~ Nausea/Diarrhea ~ Excessive sweating ~ Flushing ~ Tingling or prickling sensations/Goose bumps ~ Breakdown of muscle tissue, which may lead to kidney failure (Rhabdomyolysis)

Drugs of Abuse ~ Prescription Drugs ~ Opiates ~ Ranks #2 behind marijuana as most abused drug ~ 60% of people who abuse it got it free from friends/relatives ~ Treat ~ Pain ~ Depression

~ Depressants (Benzos / Barbiturates) ~ Anxiety ~ Sleep disorders ~ Stimulants ~ Narcolepsy ~ ADHD ~ Obesity Drugs of Abuse ~ Prescription and OTC (i.e. DXM, pseudoephederine) drugs can be abused by: ~ Taking medication prescribed for someone else ~ Taking drugs in a higher amount or via a different method than intended ~ Taking drugs for a different purpose than intended ~ Combining drugs ~ Same class ~ Different class Withdrawal from Drugs of Abuse ~ Sustained use of addictive substances of behaviors causes reversible adaptations within the body ~ Reduce the effects of the drug (tolerance, dependence) ~ Withdrawal ~ Euphoria producing drugs act on the nucleus accumbens (pleasure center) ~ Alcohol and benzodiazepine withdrawal can be life threatening Post Acute Withdrawal Syndrome ~ Describe the rollercoaster of intermittent withdrawal symptoms, especially mood, sleep, and pain related that can continue after acute withdrawal symptoms have gone away. ~ Each episode of PAWS can last for a few days or weeks followed by symptom-free periods and can continue cyclically for a year ~ It can be just as intense as acute withdrawal and puts a person at risk of relapse in an attempt to stop the discomfort. ~ A good initial relapse prevention plan prepares the person for PAWS PAWS Symptoms ~ Mood Swings ~ Anhedonia ~ Sleep Disturbances ~ Cognitive impairment (memory, learning, concentration) ~ Fatigue ~ Drug Cravings ~ Stress sensitivity ~ Lower pain threshold

Summary ~ Many people are polysubstance users ~ Signs of withdrawal are often opposite those of intoxication ~ Pupil dilation and nystagmus are good indicators of potential intoxication ~ Protracted withdrawal can last for up to a month for many drugs ~ LSD can trigger serotonin syndrome ~ Post Acute Withdrawal Syndrome refers to the mood, cognitive and (sometimes) pain related symptoms that may persist intermittently for up to a year

~ American Society of Addiction Medicine (ASAM) 2017 https://www.asam.org/resources/definition-of-addiction ~ University of Oklahoma Department of Medicine (2017) http://www.drugdetection.net/PDF%20documents/Dubowski%20-%20stages%20of%20alcohol%20effects.pdf ~ Center for Substance Abuse Treatment (2009) https://www.samhsa.gov/sites/default/files/partnersforrecovery/docs/ATR_Approaches_to_ROSC.pdf ~ DEA Drugs of Abuse (2017) https://www.dea.gov/pr/multimedia-library/publications/drug_of_abuse.pdf#page=42 ~ White, W. & Cloud, W. (2008). Recovery capital: A primer for addictions professionals. Counselor, 9(5), 22-27. ~ Davidson, L & Roe, D (2007) Recovery from versus recovery in serious mental illness: One strategy for lessening confusion plaguing recovery. Journal of Mental Health, August 2007; 16(4): 459 – 470

Documenting the treatment process ~ The client file is the official legal record of the treatment process and is subject to numerous legal and administrative requirements as well as clinical practice standards ~ HIPPA states that clients have the right to: ~ Receive a copy of their record ~ Request at any mistakes corrected ~ Receive a notice about how their health information is used ~ Specify how one where they want to be contacted by the service provider ~ File a complaint if they think any of these rights have been violated

Documenting continued ~ The HIPPA security role requires that Health Care provider said a physical and administrative and technical safeguards to protect Electronic Health information ~ Some safety measures that may be built into electronic health records include: ~ Access controls like passwords and pin numbers ~ Encrypting stored information ~ An audit trail that records to access information

Measuring Client Progress ~ Progress can be measured in terms of: ~ Achievement of goals set out on the clients treatment plan ~ Scores on pre and post test measures ~ Many instruments designed to measure client progress are cumbersome and costly to administer ~ The most frequent indicator that is measured as abstinence from alcohol or other drugs, but that indicator alone is not sufficient to measure client progress or document recovery since the person often has problems in multiple life domains

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Addiction Counselor Exam Review Podcast Episode 21 Ethics Host: Dr. Dawn-Elise Snipes Executive Director: AllCEUs Counselor Education Podcast Host: Counselor Toolbox and Addiction Counselor Exam Review

Objectives ~ Define ethics ~ Review the rationale for ethics ~ Explore ethical issues that counselors need to be aware of ~ Learn a model of ethical decision making. Professional and ethical responsibility ~ Ethics is designed for the protection of four distinct groups: ~ The client ~ The clinician ~ The profession ~ The community ~ When they are unclear or conflicting needs between the four groups ethical conflicts arise ~ The primary responsibility for ethical practice and for identifying ethical breaches rests with the addiction counselor in the clinical supervisor Ethics ~ Scope of Practice ~ Activities and procedures that can be performed legally by members of a licensed or certified profession Professional and ethical responsibility ~ Addiction professionals have a responsibility for self governance ~ Many questions of professional ethics rely on subjective interpretation ~ Clear communication is essential in the counseling relationship to avoid ethical problems ~ Ethical standards both prescribed and prohibit specific behaviors on the part of a professional ~ Often more attention is paid to the ethical breaches that deal with prohibited behavior than to prescribe behaviors ~ Counselors have a professional responsibility to seek in utilize appropriate supervision and complete continuing professional education Ethics continued ~ The code of ethics defines a standard of expected behavior ~ Codes are helpful for giving clients and the public in a sense of the level of professional behavior ~ Codes may not provide a practical or detailed guidance needed ~ Simply following a list of specific rules of conduct is not ensure that a counselor will practice and ethical manner

Ethics continued ~ Contracts defined provider duties and responsibilities ~ Negligence is a failure to uphold ones contractual duties ~ Requirements must be treated in the following order of precedence: ~ Law ~ Precedent by case law ~ Reasonable person test ~ Regulations or administrative rules ~ Contracts ~ Use of public funds creates an obligation to fulfill the public trust and result in higher standards than those required in private industry Ethics continued ~ Ethics can be thought of as a set of principles that define our actions ~ Seven criteria for defining ethics ~ Require other people, they’re about relationships ~ Intense makes a difference ~ Ethics and result the lemons ~ Thinking is necessary for ethics and morality ~ Ethics ask you to be impartial ~ Ethics require us to care about the suffering of others ~ Ethics judge human behavior ~ Columns reflect what most members of the profession have agreed on in some kind of formal process rather than reflecting ideal standards Ethics Principles ~ Autonomy ~ Fidelity ~ Justice ~ Beneficence ~ Including efficiency and effectiveness ~ Nonmalfesience Personal Qualities ~ Empathy ~ Sincerity ~ Integrity ~ Resilience ~ Respect ~ Humility ~ Competence ~ Fairness ~ Wisdom ~ Courage ~ Commitment ~ Concern Ethics continued ~ Published codes of ethics may lag behind the needs and demands of dated a practice this is why it’s important for professionals to understand the principles that lie behind their respective codes ~ Most code to general in nature and reflect the consensus of professionals in a given field and a single point in time ~ There may be inconsistencies within code of ethics or between codes of ethics that govern the same profession ~ While there is no universally accepted code of ethics for the addiction field clinician should be familiar with the ethics codes from his or her state territory or tribe

Ethics continued ~ Foundations of ethics ~ Ethics are based on moral values, a sense of what is right and wrong ~ Professional ethics focus is on the intersection between client rights and professional duties ~ Ethical conflicts or dilemmas occur when the perception of what is appropriate conduct within a particular context is not shared between the parties of bad interaction ~ Ethical conflicts arise and three basic contexts: ~ Failure to comply with the law, governing policies, or codes ~ Personal dilemmas where an individual knows what is right that is tempted to do wrong, such as dual relationships ~ Moral dilemmas when there are conflicting rights or conflicting wrongs ~ When compliance with the law or policy is mandatory failure to comply becomes an ethical issue ~ When both positions in an ethical question are wrong one will prevail, the lesser of two evils

Ethics continued ~ There are three elements to ethical or moral decision-making ~ The counselor as a person with a sense of self awareness ~ Moral sense which means having a conscience and an understanding of the difference between right and wrong ~ And values that reflect what we believe in our life ~ Counselor value show up in their choice of theories strategies and interventions ~ It is neither possible nor desirable for counselors to be neutral in the values they demonstrate ~ It is important for counselors to be clear about their own values and how the info as the therapeutic relationship ~ Counselor should not try to persuade clients to adopt their values and should it knowledge and label their own values Ethics continued ~ Six general guidelines for daily ethical conduct ~ Provide informed consent ~ Operate in a competent and theoretically sound banner ~ Ensure confidentiality ~ Maintain appropriate relationship boundaries ~ Utilize adequate consultation ~ Honor diverse personal and cultural values Ethics continued ~ Operating in a confident and theoretically sound manner ~ The scope of practice defines the actions that a member of the profession a strained and authorized to perform ~ Counselors have an ethical responsibility to identify and evaluate client issues that are outside of their scope of practice and refer to other professionals as indicated ~ Competence can be indicated by education, experience, training and certification ~ Understanding your strengths and weaknesses and having the level of self awareness about why you do things you do in your counseling practice and strengthen your professional competence ~ Competence and one clinical area doesn’t necessarily translate to another Ethics continued ~ Operating in a confident and theoretically sound manner ~ Continuing professional development through education, self a valuation, clinical supervision, and consultation helps addiction counselor to maintain confidence and enhance professional effectiveness ~ Counselors have an ethical responsibility to understand the theory in research that underlies their work and to know how to choose appropriate interventions on the basis of that theory ~ Counselors were making their own choices about the theoretical approach they will use must examine ethical considerations including cultural appropriateness, counselor training and competence anclient needs Confidentiality ~ One of the highest ethical charges for the addiction counselor is maintaining confidentiality ~ This includes protecting the client’s privacy and guarding information contained in the clinical record ~ Federal law 42 CFR outlines the provisions which must be followed ~ Unauthorized disclosure of client information is prohibited regardless of whether the person is seeking disclosure already has the information sought, has other means of it obtaining it, is a law enforcement officer or other official, has attained a subpoena, or asserts any other justification or basis for disclosure not expressly permitted by this regulation ~ The regulations apply equally to present and former program personnel ~ Violation will result in a fine up to $5000 ~ The prohibition of disclosure covers all records and communications, whether written or not, about clients who apply for or have been diagnosed, treated, or referred for treatment Confidentiality ~ Federal law 42 CFR outlines the provisions which must be followed cont… ~ Written records must be kept secure ~ At the time of admission each program is required to tell clients that the records are confidential and protected by the Federal law and regulation. Clients must be given a written summary of the laws and regulations ~ If state law permits a minor acting alone to apply for and obtain treatment that are written consent for the release of confidential information may be given only by the minor client. In many states minors must sign all informed release consents ~ Client information can be released in three ways: with clients written consent, without clients consent as specified in the regulations, or with a court order. Confidentiality continued ~ A written consent form us contain all of the following elements ~ The name or general designation of the program making the disclosure ~ The name of the individual or organization who will receive the disclosure ~ The name of the participant who is the subject of the disclosure ~ The purpose of or need for the disclosure ~ A description of how much and what kind of information will be disclosed ~ The pages right to revoke consent in writing and any exceptions to the right to revoke

Confidentiality continued ~ A written consent form us contain all of the following elements, cont.. ~ The program’s ability to condition treatment, payment, enrollment, or eligibility of benefits on the patient’s agreeing to sign the consent ~ The date event or condition upon which the consent expires if not previously revoked ~ The signature of the patient in or other authorized person ~ the date on which the consent assigned ~ Each disclosure must be accompanied by a written statement prohibiting further disclosure of the information unless authorized in the original release-and in in

Confidentiality continued ~ There are special provisions for the release of information were a client has involvement with the criminal justice system ~ State laws may differ ~ In general a signed release of information is still required ~ Releases of information for criminal justice clients differ in the following ways: ~ Information made a release to those persons within the criminal justice system who have a need for information in connection with their duty ~ The release must state an end date. It will remain in effect taking into account the length of treatment and type of criminal proceeding ~ The provider may RE disclose information to those within the criminal justice system to carry out official duties ~ Criminal justice client information may be disclosed to those persons within the criminal justice system when participation in the program is a required condition and to those individuals who need the information in connection with their duty to monitor the client’s progress including prosecutors, court officials, and probation and parole officers Confidentiality continued ~ Disclosures without client consent ~ Reports of suspected child abuse and neglect ~ Crimes on program premises or against program personnel ~ Medical emergencies ~ Research activities conducted by qualified researchers ~ Audit and evaluation activities including third party payers and peer review organizations ~ Qualified service organizations ~ Court order in Informed consent ~ Informed consent is one of the most basic and important concepts and ethical practice because it established as the client’s independence and right to self determination in receiving services ~ Client director treatment focus is on the assumption that the client has the right to choose or refuse treatment, to set goals for treatment outcomes and to define his or her recovery ~ To make good decisions the client is to fully understand what will happen in the treatment process, the proposed length of treatment, the conditions for termination, the policy for making complaints or resolving disputes, the cost of services, how to access third party payments, the risks and benefits of accepting or refusing treatment and the possible outcomes of treatment ~ They have the right and the power to consent to and more importantly to refuse to consent to treatment Informed consent continued ~ Informed consent is more than signing the right forms ~ Informed consent is an ongoing collaborative effort between client and counselor for establishing and continuously monitoring the goals and strategies of counseling ~ Critical elements: ~ Clients rational capacity to provide consent ~ Clients comprehension ~ Clients sense of self determination or voluntariness ~ Cultural issues are important considerations in determining whether truly informed consent has been obtained. Lack of understanding of professional terminology, linguistic barriers, and pour literacy skills may inhibit a client’s a true understanding and may also affect a client’s willingness to ask questions

Counselor self-disclosure ~ In in order to maintain appropriate boundaries and clear roles, a counselor should limit sharing personal information the circumstances when doing so is clearly relevant to the client’s treatment goals ~ Choose the parts of their experience there helpful to the client and monitor how this disclosure effects the clinical relationship ~ Only reveal information about a personal life problem well after it has been resolved Dual Relationships ~ Dual relationships are common, although not ethical in substance abuse counseling ~ Counselors in recovery cannot ~ Sponsor or be sponsored by a client ~ It is discouraged when possible to attend the same meetings as clients ~ See, in a clinical capacity, a client whom they have known as a sponsee or fellow person in recovery Summary ~ Ethics is aspirational and encourages clinicians to reach beyond legal mandates ~ Ethics helps ensure counselors are doing things in the best interest of the client ~ Ethical violations can lead to fines, suspensions or license revocation by the board ~ It is imperative for counselors to observe the principles of: Beneficence, nonmalfesience, fidelity, justice, and autonomy

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Addiction Counselor Exam Review Episode 20 Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC Executive Director: AllCEUs Counselor Education Podcast Host: Addiction Counselor Exam Review, Counselor Toolbox and Happiness Isn’t Brain Surgery

Specific population considerations ~ Aspects of the client’s identity may influence the client’s substance using behavior, the responsiveness to treatment, and the recovery process ~ These factors include race, ethnicity, age, sexual orientation, and the presence of co-occurring disorders including trauma ~ Rather than placing a person and established treatment slot treatment providers are learning the importance of modifying in adapting services to meet an individual client’s needs ~ SAMHSA has produced multiple publications that dealt in depth into the treatment needs and recommended practices for specific types of disorders and or populations Specific populations continued ~ Substance abuse treatment programs typically reported 50 to 75% of their clients have co-occurring disorders ~ Medical settings site proportions of 20 to 50% ~ The term co-occurring disorders replaces the terms dual disorder or dual diagnosis ~ Co-occurring disorders refers to co-occurring substance use and mental disorders ~ A diagnoses of a co-occurring disorder occurs when at least one disorder of each type can be established independent of the other ~ Review SAMHSA TIP 42 for more information Specific populations continued ~ Criminal justice ~ For many people in need of substance abuse treatment contact with a criminal justice system is the first acknowledgment of the need for treatment or opportune did you receive services ~ Longstanding patterns of poor coping skills, criminal values and beliefs, lack of education, and minimal job skills may require an intensive treatment approach particularly among offenders with a prolonged history of substance abuse and crime ~ Addiction professionals must be able to communicate effectively with judges, probation officers, and other criminal justice system personnel functioning as a community treatment team ~ Leaders in both criminal justice and treatment systems need to develop shared goals and clear systems of care for addicted offenders both while they are incarcerated in after their release Specific populations continued ~ HIV and AIDS ~ HIV is most efficiently transmitted through the exposure to contaminated blood ~ injection drug users represent the largest HIV infected substance abusing population in the United States ~ Sexual contact is another route of HIV transmission ~ Substance use treatment can play an important role in helping individuals reduce risk taking behavior ~ Substance use treatment serves as a HIV prevention ~ HIV and AIDS, substance abuse disorders, and mental disorders interact in a complex fashion, each acting as a potential catalyst or obstacle in the treatment of the other two ~ Treatment goals include living substance free, slowing or halting the progression of the disease, and reducing risk taking behavior

Specific populations continued ~ HIV and AIDS ~ Treating HIV and AIDS is extremely complex ~ Individuals with substance use disorders whether or not they are HIV infected are subject to the higher rates of mental disorders than the rest of the population ~ Counseling is an important part of treatment ~ Risk reduction allows for a comprehensive approach to HIV and AIDS prevention which promotes changing the substance-related and such related behaviors ~ Substance use treatment programs can help reduce the spread of other blood borne infections including hepatitis B and C viruses ~ Counselor should be familiar with Federal and state laws protecting information about client and substance abuse treatment, and state laws protecting HIV and AIDS related information Specific populations continued ~ Physical and cognitive disabilities ~ People with physical and cognitive disabilities are more likely to have a substance use disorder and are less likely to get effective treatment ~ 20% of persons with disabilities have a substance use disorder ~ These individuals are less likely to complete treatment because physical, attitudinal or communication barriers limit their treatment options or render their treatment experience is unsatisfactory ~ The Americans with disabilities act states that both public and private facilities must be equally accessible ~ Barriers to communication must be removed and discriminative policies and practices eliminated ~ Accommodating people with coexisting disabilities in treatment for substance use disorders include such things as adjusting counseling schedules, providing interpreters, suspending the no medication rules, and overcoming people’s fears and ignorance

Specific populations continued ~ Physical and cognitive disabilities ~ People disabilities are more likely to use substances in part because they experienced unemployment, lack of recreational options, social isolation, homelessness, and victimization or physical abuse more frequently than the general population ~ People who are deaf and identify with deaf culture will usually prefer specialized treatment programs ~ People with intellectual disabilities may find it easier to understand and participate in discussions with others with similar disabilities and may be more inclined to ask questions ~ Other disability conditions that may warrant some standalone services include traumatic brain injury, spinal cord injury, or severe or multiple disabilities Specific populations continued ~ Women ~ Gender differences play a role in drug selection, use and treatment patterns ~ Women and men tend to abuse different drugs ~ The effects of drugs are different for women and men ~ Some approaches to treatment are more successful for women than men ~ Women used significantly more prescription drugs than men ~ Women and men appear to differ in their vulnerability to certain drugs ~ Women advance more rapidly from initial use to regular use to the first treatment episode ~ Women experience an effect call telescoping whereby they progress faster than men from initial use to alcohol and drug related consequences even when using a similar or lesser amount of substances ~ Women are more likely than men to have co-occurring substance use and mental health disorders including anxiety disorders and major depression ~ Women’s substance use problems are more stigmatized and less likely to be acknowledged than men Specific populations continued ~ Women ~ Issues impacting women with substance use disorders ~ Shame and stigma ~ Physical and sexual abuse ~ Relationship issues including fear of losing children, fear of losing a partner, or needing a partner’s permission to obtain treatment ~ Treatment issues include lack of services for women, not understanding women’s treatment, long waiting lists, and lack of childcare services ~ Systematic issues include lack of financial resources, lack of clean and sober housing, lack of pregnancy/postpartum services, and poorly coordinated services Specific populations continued ~ Women ~ Three primary types of services for women ~ Clinical treatment ~ Clinical support ~ Community support which includes everything from child care and transportation to housing services, family strengthening, recovery support services, employment services, vocational and academic services ~ Development of substance use disorders is viewed as a disconnection ~ Treatment stresses the development and repair of connections to others, oneself, ones beliefs and one’s culture Specific populations continued ~ Pregnant women ~ Substance abuse often creates or is accompanied by an array of social problems including violence, child abuse and neglect, and family dysfunction ~ 5.4% of babies are born to illicit drug users ~ Substance abuse during pregnancy increases the risk of problems for both the mother and the fetus. ~ The March of Dimes web site has detailed information about these risks by the drug used ~ Pregnancy creates a window of opportunity to enter treatment, become abstinent, quit smoking, eliminate risk taking behaviors, and lead a healthier life ~ Additional specialized treatment needs include improving nutrition, childcare, financial support and identification and treatment of infectious diseases in both women and infants

Specific populations continued ~ Older adults ~ Nearly one in five have mental health and substance use conditions ~ Depressive disorders and dementia related behavioral and psychiatric symptoms are the most prevalent but substance use is a significant problem as well ~ Age alters the way people metabolize alcohol and drugs ~ Issues that trigger symptoms can include losses that frequently occur in old age ~ Differentiating between major depression and grief in the person with significant losses is often difficult ~ Cognitive functional and sensory impairments may complicate detection and diagnoses of mental health and substance use Specific populations continued ~ Adolescents ~ The national institute on drug abuse has published a version of the principles of Adolescence substance use disorder treatment: a research based guide ~ Adolescent’s brains are still developing ~ Exposure to neurochemical changes and health consequences associated with addictive behaviors appear to cause more significant and long lasting brain changes for adolescents ~ It is important to remember too that adolescents are often in a very tumultuous life stage---ending childhood, developing identity, leaving home Other Special Needs ~ Trauma Informed Care ~ Non-abstaining addictive behaviors (shopping, food, sex)

Summary ~ Just like it is vital to be aware of the special needs of persons from different races and ethnicities, it is also vital to recognize that there are other factors that require specialized skills. ~ Gender and age differences themselves produce a range of special issues that need to be considered in ~ Prevention ~ Assessment ~ Engagement ~ Treatment setting recommendations ~ Treatment approaches More Resources ~ AllCEUs.com/YouTube ~ Adolescents ~ Older Adults ~ Pregnant and Postpartum ~ Cultural Competence ~ Store.SAMHSA.gov ~ Drugabuse.gov/publications

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Addiction Counselor Exam Review Episode 19 Therapeutic Approaches Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC Executive Director: AllCEUs Counselor Education Podcast Host: Addiction Counselor exam review, Counselor Toolbox and Happiness Isn’t Brain Surgery Objectives ~ Review different therapeutic approaches including CBT, MET, Contingency Management and Trauma Informed ~ Types of treatment (individual, group, family) and benefits and drawbacks of each ~ Culturally appropriate strategies ~ Family Engagement ~ Overview of Crisis Intervention ~ Relapse Prevention Therapeutic Approaches ~ Behavioral and cognitive behavioral approaches are grounded in social learning theories and principles of operant conditioning ~ Emphasis is on ~ Functional analysis of behaviors to understand them within the context of their antecedents and consequences ~ Skills training through which people recognize the situations or states in which they are most vulnerable and how to avoid high-risk situations ~ Using a range of behavioral and cognitive strategies to cope effectively with those situations if they cannot be avoided ~ Cognitive behavior therapy is based on the idea that feelings and behaviors are caused by a person’s thoughts ~ People may not be able to change their circumstances but they can change how they think about them and therefore change how they feel and behave ~ The goal of cognitive behavioral therapies to teach the person to recognize situations with their most likely to use, avoid these circumstances if possible, and cope with other problems and behaviors which may be to use Therapeutic approaches continued ~ Contingency management therapy uses motivational incentives to facilitate behavior change and has improved treatment retention and abstinence rates ~ Motivational enhancement therapy is a client centered counseling approach for initiating behavior change and has successfully been used with people with alcohol and marijuana use disorders Therapeutic approaches continued ~ Trauma Specific ~ Trauma Specific Models are an essential part of treatment as misidentified or misdiagnosed trauma related symptoms interfere with help seeking and hamper engagement in treatment, lead to early drop out, and make a relapse more likely ~ Trauma-Informed and Trauma specific approaches take into account knowledge about the trauma, its impact, interpersonal dynamics, and relation to recovery. ~ The primary goals of trauma specific services are focused to address directly the impact of trauma on people’s lives and to facilitate trauma recovery and healing ~ The Addictions and Trauma Recovery Integration Model or ATRIUM, seeking safety, and trauma recovery and empowerment model are all examples Therapeutic approaches continued ~ Couples and family approaches ~ The defining feature couples and families treatments is that they’re treating substance using individuals in the context of the family and social systems in which the substance use may develop or be maintained ~ Prevailing models: ~ Brief strategic family therapy ~ Structural or strategic family therapy ~ Multidimensional family therapy ~ Multi systemic therapy ~ Behavioral and cognitive behavioral family therapy ~ Solution focused brief therapy Culturally appropriate strategies ~ Two areas of concern with regard to cultural competence in addiction counseling are ~ the competence of the individual practitioner ~ the cultural appropriateness of specific intervention strategies ~ Culture includes much more than race and ethnicity ~ Culturally appropriate treatment can include the language used, the format of the program, the goals set for produce events, and specific program activities ~ Additionally, risk in protective factors may not be relevant for all cultural groups Culturally appropriate strategies ~ Programs and practices that have been tested and found effective with one cultural group can be modified to fit other groups ~ These modifications take two forms: ~ cultural accommodation: modifying the way practices delivered to that it can be utilized with a particular culture or community ~ cultural adaptation: reviewing in changing the structure of the programmer practice to more appropriately fit the needs and preferences of a particular cultural group or community Levels of Treatment: Benefits and Drawbacks ~ Family Counseling ~ Effects of SUD go beyond the nuclear family ~ Feelings of abandonment, fear, anger, embarrassment or guilt ~ Requires knowledge about the effects of family interactions on SUD and SUD on family interactions ~ Assists members in identifying and interrupting harmful interaction patterns ~ Presents an opportunity for members to focus on their own goals and issues to create a healthier system Engaging the family ~ A change in any part of the system may bring about changes and other part of the system ~ Family counseling in addiction treatment has two main purposes: ~ To use family strengths and resources to help find or develop ways to live without substances of abuse ~ To ameliorate the impact of addiction on both the client and family ~ The person of using substances is regarded as a subsystem within the family ~ The familial relationships within this subsystem are the point of therapeutic interest and intervention Engaging the family ~ Goals of family counseling include ~ Helping families become more aware of their own needs ~ Providing genuine and during healing for family members ~ Working to shift power to the parental figures in a family ~ To improve communication ~ Helping the family make interpersonal, intrapersonal, and environmental changes ~ Keeping substance abuse and mental health issues from moving from one generation to another. Engaging the family continued ~ Co dependency refers to people who are in a close relationship with the addicted individual and are overly involved with the other person and the other persons problematic behavior, sometimes to their own detriment ~ Enabling is when the co dependent person unintentionally helps an addict to continue in their addiction by repeatedly putting out little fires for the addicted person ~ Addiction treatment programs that involve family generally use family interventions that differ from those used by family counselors or therapists ~ An intervention refers to confrontations that a group of family and friends have with the person abusing substances in order to convey the impact of the substance abuse and to urge entry into treatment Levels of Treatment: Benefits and Drawbacks ~ Individual Counseling ~ Privacy ~ Elicitation of strong emotions ~ Flexible pacing ~ Individualized to the client ~ Brief Interventions ~ Typically 3 - 6 sessions (less than 90 days); generally effective ~ FRAMES ~ Feedback ~ Responsibility ~ Advice ~ Menu ~ Empathy ~ Self-efficacy Levels of Treatment: Benefits and Drawbacks ~ Group Counseling ~ Most effective for treating SUD ~ Clients learn about themselves by interacting with others ~ Provides peer support ~ Helps many clients at once ~ Reinforces discipline ~ Inspires hope

Levels of Treatment ~ Group Counseling—Types of Groups ~ Psychoeducational ~ Skills development ~ Cognitive behavioral ~ Support ~ Interpersonal process ~ Relapse Prevention ~ Cultural focus groups ~ Art therapy ~ Specific issue groups (depression, self-esteem) Medicaton Assisted Treatment: Who Benefits from Meds ~ Clients who face health risks as part of withdrawal ~ Clients who will not quit using because of withdrawal ~ Clients who have tried everything else, keep returning to treatment, but continue to relapse ~ Clients who believe they are unable to quit using on their own ~ Clients who often feel overwhelmed by cravings ~ Clients who believe that medication will help them engage or benefit from psychosocial treatment ~ Clients without medical, addiction, or family history risks Crisis Prevention and Intervention ~ The crisis is a situation in which there’s a risk of harm to the client and less intervention occurs ~ Crisis can be emotional or physical ~ The crisis has five components: ~ A stressful traumatic event ~ A vulnerable or unbalanced eight ~ The precipitating factor ~ An active crisis state-based on the person’s perception ~ The resolution of the crisis Crisis Intervention ~ A stressful event alone does not constitute a crisis ~ Crisis is determined by the individual’s view of the event, encompassing a personality and temperament, life experiences, physical state, and varying degrees of stress and coping skills, and the response to it ~ Crisis represents a time of danger and opportunity ~ In all models of crisis intervention involve constructs of safety, stabilization, processing a crisis event, and drawing conclusions from the process that the individual can integrate is a learning experience Crisis Intervention ~ The best way to handle a crisis situation is to prevent it ~ Early assessment of clients for their potential for agitated or assaultive behavior is essential ~ Client should be taught strategies aimed at helping them manage their own behavior such as stress and anger management groups ~ Prevention of violent and aggressive behavior needs to started admission ~ Clients need to be assessed and asked about past violent incidents, whether they’ve been put in seclusion a restraint, and whether they’d ever experienced abuse as a child or adult ~ One of the most recommended intervention strategies is verbal crisis the escalation which is aimed at meeting the agitated persons immediate needs and calming the situation Crisis Intervention ~ Steps in crisis intervention • Assess the severity of the crisis • Form a connection demonstrating and that they • Explore the problem focusing on the immediate situation using active listening and paraphrasing. The goal is to restore the person to his or her previous level of functioning • Deal with feelings and emotions including not only the content of the material presented but also the feelings • Generate alternative solutions and summarize your understanding of the situation • Develop an action plan which is very specific regarding time. The personal crisis is desperately looking for some relief to give them hope • Develop a specific follow-up plan Understanding and preventing relapse ~ Relapse certainly can be a type of crisis ~ A lapse or a recurrence of use is thought to have a cognitive and behavioral processes that are different from relapses. ~ Interventions designed to stop a lapse may prevent a full blown relapse ~ Lapsing back into use indicates the treatment needs to be reinstated or adjusted or that another treatment should be tried ~ Similar drug and alcohol addiction treatment, treatment for chronic illnesses are effective but require strict adherence to medical and behavioral regimens. Clients with these diseases often do not comply with their treatments. Relapse continued ~ Three key points forming a comprehensive view of relapse ~ Relapses are common and clients should understand that they are likely to be vulnerable. Merely mentioning the R word will not cause a client to relapse ~ Relapse is reasonably predictable when examining general precipitants as well as people’s own personal triggers including social situations, HALT, personal emotions and situations that will be danger zones and need to be anticipated ~ Relapses are preventable with the use of self monitoring and abstinence maintenance activities including AA or other self help groups, personal counseling, and active involvement with the recovery community, religious congregation, health club for fitness group, or any lifestyle that is inconsistent with use (remember this for treatment planning)

Relapse continued ~ Relapse prevention is an umbrella term encompassing most skills based treatments that incorporate cognitive behavioral, skills building and coping responses ~ The overall goal of relapse prevention is to help people create more positive habits and positive changes in their lives in order to prevent relapse and sustained recovery ~ Relapse prevention therapy, or RPT is a behavioral self control program which teaches clients to: ~ Understand relapse is a process ~ Identifying cope effectively with high-risk situations ~ Cope with urges and craving ~ Implement the damage control procedures during the lapse ~ Stay engaged in treatment even after relapse ~ Identify when and how to create a more balanced lifestyle

Relapse continued ~ Cognitive techniques provide clients with a way to reframe the habit change process as a learning experience with errors and setbacks expected ~ Behavioral techniques include the use of lifestyle modifications such as meditation, exercise, and spiritual practices to strengthen a client’s overall coping capacity ~ The CENAPS model of relapse prevention therapy is also based on the belief that total abstinence plus personality and lifestyle changes are essential for full recovery ~ 5 components ~ Assessment ~ Warning sign identification ~ Warning sign management ~ Recovery planning ~ Relapse early intervention training Summary ~ There are many approaches to treatment including cognitive, behavioral, motivational, trauma informed, relapse prevention and family approaches. ~ These approaches can be applied in individual, group or family settings ~ Counselors must constantly remain aware of the impact on culture in choosing treatment settings and interventions ~ Family engagement is crucial in the recovery process ~ Crisis has 5 components and what causes a crisis can be different for each person, but counselors need to be aware of the 7 steps in crisis intervention ~ Most relapse prevention theories address relapse triggers, unpleasant emotions, interpersonal conflict, and social pressure. ~ These triggers account for almost ¾ relapses. ~ Antecedents to relapse can be found within an individual such as a person’s mood or coping style, or may be triggered by interpersonal events Counselor Toolbox Podcast ~ Stay up to date with our current episodes and get notified about live broadcasts by subscribing to our youtube channel at AllCEUS.com/youtube, or by joining our Faceboook group: Facebook.com/groups/CounselorToolbox/

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Review for the Alcohol and Drug Counselor Exam Episode 18: Counseling Skills Objectives ~ Identify the purpose and function of counseling ~ Define skills a counselor needs ~ Identify necessary attitudes for counselors ~ Explore how to develop the therapeutic alliance ~ Discuss motivation and how to increase it

Counseling—Purpose & Functions ~ Develop therapeutic relationship with clients, families and significant others to facilitate transition into the recovery process ~ Provide information regarding the structure, expectations and purpose of counseling ~ Continually evaluate the client’s safety, relapse potential and need for crisis intervention ~ Apply ebps to facilitate progress ~ Document counseling activity and progress ~ Provide information on issues of identity, ethnic background, age etc as they influence behavior, prevention and recovery ~ Provide information about addiction and related health and psychosocial consequences Counseling —Purpose & Functions ~ Counseling is a collaborative, professional relationship that empowers diverse individuals, families and groups to accomplish mental health, wellness, education and career goals ~ Competence is built on understanding various models of treatment, an ability to implement appropriate EBPs with individuals, families, and SOs ~ Counselors facilitate self-exploration, disclosure, problem solving and behavioral change ~ Counselors help clients ~ Explore and enhance motivation ~ Set appropriate treatment goals ~ Understand structure, expectations, purpose and limitations of the counseling process ~ Mobilize resources to resolve problems and modify attitudes ~ Counselors respond to crisis situations by identifying and practicing ways to avoid and cope with high risk situations Therapeutic Allicance ~ Strength of the TA depends on the facilitative qualities of the counselor and the strategies used to create a positive environment for exploration and change ~ Facilitative qualities ~ Empathy ~ Genuineness ~ Respect ~ Self-Disclosure ~ Warmth ~ Immediacy “Focus on the here and now” ~ Concreteness: Identify specific problems and interventions ~ Cultural Sensitivity Counseling: Therapeutic Alliance ~ Components of the Therapeutic Alliance ~ Bond between therapist and client characterized by warmth, genuineness and respect ~ Consensus between counselor and client regarding ~ Treatment approaches ~ Goals of treatment ~ Primary responsibility for developing and maintaining the TA rests with the counselor ~ 80% of positive outcomes are due to TA ~ TA must be continually monitored and nurtured to prevent premature discharge and enhance treatment effectiveness ~ Adapting the relationship to several patient characteristics, not just dx, enhances the TA Counselor Skills ~ Engage the client ~ Develop and individualize treatment and recovery plans ~ Effectively describe and negotiate access to the continuum of care ~ Adapt counseling strategies ~ Apply culturally and linguistically responsive communication styles ~ Provide nonjudgmental, respectful acceptance of cultural, behavioral and value differences ~ Elicit client’s perspectives on progress ~ Maintain contact with referral services ~ Assist the client in monitoring and maintaining motivation ~ Document all relevant aspects of treatment clearly and concisely ~ Provide education regarding how to change risk behaviors, adopt protective, healthy practices and make appropriate use of service systems Counseling Skills—Active listening ~ Helps the client and counselor clarify what is going on ~ Clear listening—listen without judgement and without immediately trying to correct the client’s thoughts ~ Reflecting—Summarizing and repeating ~ Asking open-ended questions ~ Using effective body language (SOLER) ~ Watching for nonverbal cues Counselor Attitudes ~ Appreciation of strengths-based approaches which emphasize client autonomy and skills development ~ Respect for the client’s right to self-determination ~ Appreciation of the roles of the SOs ~ Appreciation of the difficulties families and SOs face in seeking help ~ Appreciation of cultural differences ~ Willingness to be flexible

Counseling- Setting Expectations ~ The counselor generates curiosity and engagement by being honest and open and setting the frame and expectations for treatment ~ Areas of Expectations ~ What outcomes does the client expect ~ What proportion of clients report their issues improve at this level of treatment ~ What will treatment involve ~ What are the rules and responsibilities ~ Client rights ~ What specific outcomes can the client expect Counseling- What is Motivational Interviewing ~ Treatment is a process of intentional change ~ MI uses specific techniques that engender engagement and empowerment ~ MI is more effective than intervention

Counseling—Motivation Assumptions ~ Ambivalence about change is normal and creates a significant obstacle to the recovery process ~ Ambivalence can be resolved by working with intrinsic motivations and values ~ In the collaborative partnership between client and counselor each brings own expertise ~ An empathic, supportive, directive style provides the conditions for change ~ Direct argument and confrontation increase client defensiveness Counseling- 5 Motivational Principles • Express Empathy • Develop Discrepancy • Avoid Argument • Roll with Resistnace • Support Self-Efficacy and Optimism Counseling Motivational Elements ~ Partnership/collaboration ~ Avoid the expert role ~ Acceptance/Autonomy ~ Respect client autonomy and strengths ~ Compassion ~ Keeping the client’s best interests in mind ~ Evocation ~ Best ideas come from the client ~ MI techniques are designed to “get at” internal ambivalence providing a place for discussion of the pros and cons of change Counseling Motivational Strategies ~ OARS ~ Open ended questions ~ Affirmation ~ Reflective Listening ~ Summarize ~ Elicit self-motivational statements Other Videos ~ Motivational Interviewing ~ Counseling Skills Summary

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Addiction Counselor Exam Review Treatment Approaches & Settings Instructor: Dr. Dawn-Elise Snipes Executive Director AllCEUs.com Podcast Host: Addiction Counselor Exam Review, Counselor Toolbox and Happiness Isn’t Brain Surgery

~ This presentation is available on our youtube channel at allceus.com/youtube or you can subscribe to the Addiction Counselor Exam Review Podcast on your favorite podcast app. Objectives ~ Learn ASAM Dimensions ~Review Self help approaches ~ Identify different approaches to and levels of treatment ~ Define evidence based practices and clinical guidelines and identify where you can find them ASAM Dimensions ~ Acute Intoxication/Withdrawal Potential (consider protracted withdrawal (PAWS)) ~ Opioids, methamphetamine, marijuana, benzodiazepines and cocaine ~ Biomedical Conditions ~ Emotional, Behavioral and Cognitive Conditions ~ Readiness for Change ~ Relapse and Continued Use Potential ~ Recovery Environment Self- Help Approaches ~ Types ~ 12-Step (Emotions, Alcohol, Schizophrenics…)/Double Trouble ~ Admitting that one cannot control one's alcoholism, addiction or compulsion; ~ Recognizing a higher power that can give strength; ~ Examining past errors with the help of a sponsor (experienced member); ~ Making amends for these errors; ~ Learning to live a new life with a new code of behavior; ~ Helping others who suffer from the same alcoholism, addictions or compulsions.

Self-Help ~ Key Features of 12-Step Programs ~ Accessibility ~ Anonymity ~ Social support and mutual aid ~ Promotion of self-esteem and efficacy ~ Introspection and insight ~ Spiritual recovery ~ Advocacy to promote social and legal remediese Self-Help AA ~ Founded by Bill W and Dr. Bob ~ 1 million people estimated to have achieved recovery through AA ~ Main purpose to stay sober and help others ~ Abstinence is the only treatment ~ 3 legacies of AA ~ Recovery ~ Unity ~ Service Self-Help Al-Anon ~ For SOs of people with addictions ~ Lessons ~ Not to suffer because of the actions or reactions of others ~ Not to allow ourselves to be used or abused by others ~ Not to do for others what they can do for themselves ~ Not to cover up for other’s mistakes ~ Not to create a crisis not to prevent a crisis if it is the natural order of events Self- Help Approaches ~ Types ~ Rational Recovery ~ The primary force driving an addict's predicament is what Trimpey calls the "addictive voice". When the desires of this "voice" are not satiated, the addict experiences anxiety, depression, restlessness, irritability. ~ The RR method is to first make a commitment to planned, permanent abstinence from the undesirable substance or behavior, and then equip oneself with the mental tools to stick to that commitment

Self- Help Approaches ~ Types ~ Women for Sobriety ~ Positive reinforcement (approval and encouragement) ~ Cognitive strategies (positive thinking) ~ Letting the body help (relaxation techniques, meditation, diet and physical exercise) ~ Dynamic group involvement.

Self- Help Approaches ~ Types ~ SMART Recovery ~ Teaches self-empowerment and reliance by ~ Point 1: Building and Maintaining Motivation ~ Point 2: Coping with Urges ~ Point 3: Managing Thoughts, Feelings and Behaviors ~ Point 4: Living a Balanced Life

Self- Help Approaches ~ Types ~ Celebrate Recovery ~ Realize I’m not God; I admit that I am powerless to control my tendency to do the wrong thing and that my life is unmanageable. (Step 1) ~ Earnestly believe that God exists, that I matter to Him and that He has the power to help me recover. (Step 2) ~ Consciously choose to commit all my life and will to Christ’s care and control. (Step 3) ~ Openly examine and confess my faults to myself, to God, and to someone I trust. (Steps 4 and 5) ~ Voluntarily submit to any and all changes God wants to make in my life and humbly ask Him to remove my character defects. (Steps 6 and 7) ~ Evaluate all my relationships. Offer forgiveness to those who have hurt me and make amends for harm I’ve done to others when possible, except when to do so would harm them or others. (Steps 8 and 9) ~ Reserve a daily time with God for self-examination, Bible reading, and prayer in order to know God and His will for my life and to gain the power to follow His will. (Steps 10 and 11) ~ Yield myself to God to be used to bring this Good News to others, both by my example and my words. Self- Help Approaches ~ Benefits ~ Provide network outside of treatment ~ Teach recovery skills ~ Helps clients take responsibility for recovery ~ Provides a sense of belonging ~ Helps develop a new identity Break ~ Addiction Counselor Exam Review is produced by AllCEUs ~ AllCEUs offers unlimited Continuing Education for $59 as well as precertification training in addictions and behavioral health starting at $99 Types of Treatment ~ Detox (ambulatory or residential) ~ Minimize physical harm ~ Point of first contact ~ Alcohol, benzodiazepine and opioid withdrawal may require 24-hour medical care for safety or humanitarian concerns ~ 3 components ~ Evaluation ~ Stabilization ~ Fostering client entry into treatment

Types of Treatment ~ Outpatient Treatment (ASAM Level I) ~ Suitable for individuals who are working and have sufficient social support ~ Lasts between 3 months and 1 year ~ Can be highly structured or “drop-in” ~ Intensive outpatient (ASAM II.1) and PHP (ASAM II.5) provide ~ Pharmacotherapy ~ Relapse prevention planning ~ Individual counseling ~ Family therapy ~ Vocational counseling Types of Treatment- MAT ~ MAT can be provided in an outpatient setting or physician’s office ~ Combines pharmacotherapy with a full program of assessment, intervention and support ~ MAT Outcomes ~ Improve treatment retention ~ Decrease illicit opioid use ~ Increase abstinence from opioids and alcohol ~ Decrease criminal justice involvement ~ Increase employment ~ Improve mental health

Types of Treatment- MAT ~ MAT Drugs ~ Naltrexone (vivitrol) ~ Disulfram (Antabuse) ~ Acamprosate (Campral) Reduces symptoms of protracted W/D from alcohol (insomnia, anxiety) ~ Methadone ~ Buprenorphine (suboxone/subutex) ~ Bupropion and Varenicline (Nicotine withdrawal) ~ MAT is available for ~ Opioids ~ Alcohol ~ Tobacco

Types of Treatment ~ Residential (ASAM Level III.5) ~ 24-Hour intensive medical, psychiatric, psychosocial treatment ~ Duration of treatment 28 days to 1 year ~ Therapeutic Community ~ Highly structured 6month to 2 year program ~ Heirarchical model: Increased individual and social responsibility ~ System of rewards and punishments ~ Tends to be more confrontational

Types of Treatment ~ Half-way houses (Recovery residences: NARR Level 4) ~ Clients live at the house, work and receive treatment at the residence

Treatment approaches and evidence based practice ~ Evidence based practices have been shown through available scientific evidence to consistently improve measurable client at comes ~ The goal of evidence based practices to integrate clinical expertise, external scientific evidence, an client values to provide high quality services ~ Available evidence based practices can be found on SAMHSA’s national registry of evidence based programs and practices nrepp.samhsa.gov Examples Of Evidence Based Practices ~ Seeking Safety ~ Motivational Interviewing ~ 12 Step Therapy ~ Behavioral Couples Therapy ~ Cognitive Behavioral Therapy ~ Solution Focused Brief Therapy ~ Community Of Reinforcement Approach With Vouchers ~ Dialectical Behavior Therapy Evidence Based Practices Continued ~ Successful implementation of evidence based practices includes ~ Changes in professional behavior ~ Changes in organizational structures and cultures ~ Changes in relationships to service recipients and other potential partners ~ There can be significant implementation failure of programs and practices that are not delivered with fidelity ~ Programs often lose their fidelity to new protocols over time or when they are implemented in unique settings ~ Fidelity checklist can be used to identify critical components of an approach ~ Many evidence based practices today require extensive supervision and certification in that evidence based practice Clinical Practice Guidelines ~ The purpose of clinical guidelines is the same as for the evidence based practices, to translate research into practice, increase the effectiveness of treatment, provide a framework for collecting data about treatment, ensure accountability to funding sources, and encourage some consistency in practice ~ Where to find them…. Break ~ If you are looking for curriculum based group and individual activities for clients, Journey to Recovery By Dr. Dawn-Elise Snipes is available on Amazon and provides over 350 pages of activities. Summary ~ Treatment serves are available in a range of settings from outpatient to full hospitalization based on client’s ASAM ratings ~ Self help provides a network of support outside of treatment ~ Evidence Based Practices are research based approaches designed to translate theory into practice. ~ Clinical Guidelines are freely available through SAMHSA, the APA and other professional associations

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WRITING EFFECTIVE TREATMENT PLANS: The Pennsylvania CASSP Model Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP Executive Director: AllCEUs.com Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery and Addiction Counselor Exam Review Objectives • Learn the principles of the CASSP model • Review the difference between goals, objectives and interventions • Identify qualities of good goals, objectives and interventions

• Services are planned to meet the individual needs of the child, rather than to fit the child into an existing service. • Services • Consider the child’s family and community contexts • What resources are available • What are their capabilities and needs • Are developmentally appropriate and child- specific (not little adults) • Build on the strengths of the child and family to meet the mental health, social, and physical needs of the child.

• Services recognize that family is the child’s primary support system • The family is a full partner in all stages of the decision-making and treatment planning process, including implementation, monitoring, and evaluation. • A family may include biological, adoptive, and foster parents, siblings, grandparents and other relatives, and other adults committed to the child. • Examine the people with whom the youth spends the most time. (runaways/homeless youth; youth in boarding school) • What is the family’s perception of: • Functioning • Strengths • Priorities • Cultural values

• Whenever possible, services are delivered in the child’s home community, drawing on formal and informal resources to promote the child’s successful participation in the community. • Community resources include not only mental health professionals and provider agencies, but also social, religious, and cultural organization and other natural community support networks

• Services are planned in collaboration with all the child-serving systems involved in the child’s life. • Representatives from all these systems and the family collaborate to • Define the goals with the child • Develop a service plan • Develop the necessary resources to implement the plan • Provide appropriate support to the child and family • Evaluate progress.

• Culture determines our world view and provides a general design for living and patterns for interpreting reality that are reflected in our behavior. • Services that are culturally competent are provided by individuals who have the skills to recognize and respect the behavior, ideas, attitudes, values, beliefs, customs, language, rituals, ceremonies, and practices characteristic of a particular group of people. • Questions that must be answered • What is the view of the child in this culture? • What are cultural expectations for functioning in this area? • What is the cultural perception for need for help and who from? • What are cultural strengths that can be capitalized on? • What does the culture perceive as the child and family’s strengths?

• Services take place in settings that are the • most appropriate and natural for the child • and family and are the least restrictive and • intrusive available to meet the needs of the • child and family.

Treatment Plan Characteristics • An effective treatment plan should be both informative and practical. • A person reading a treatment plan should be able to grasp the major concerns and how they are being addressed. • The initial treatment plan identifies the work to be done. • Subsequent treatment plans identify • what is currently being done • what has recently been achieved, • work and services planned for the future. • By defining goals and objectives which can be monitored, the treatment plan becomes an instrument of accountability. • Identified goals, objectives and outcomes can be actively tracked by the team, and modifications in treatment made as needed.

Components • Brief Description of the Child • Tony is a thirteen-year-old Caucasian male living with his mother and four sisters in a three bedroom mobile home. Tony is currently in the seventh grade and attends special classes for reading. Tony has been referred to counseling on multiple occasions for behavioral issues at school but has yet to keep an appointment; he says, “Counseling is dumb, and school is useless.”

Components cont… • Needs, Concerns and Problems • Identifies why the child was referred to the service and includes reasons for intervention. • Likelihood of failure as evidenced by… • *Major depression as evidenced by… • Incorporates the child’s and family’s perception of the needs and concerns. • Specific targets for intervention are clearly stated and prioritized. • Forms the basis for the specific intervention • Problems not related to the reason for referral should be omitted • Tony was referred to treatment to help increase his chances of school success. Tony is frequently truant and in danger of failing. Tony’s mother is also concerned that Tony doesn’t come home in the evenings until after midnight. Tony expresses no interest in school and feels school activities aren’t relevant to him

Components cont… • Child and Family Strengths • Areas of strength might include • Interests (e.g., sports, music, extended family) • Abilities (art, listening skills, making new friends) • Activities (hunting, church, family reunions) • Capacities (empathy, pride) • Note: Avoid including “disguised weaknesses” such as “performs well if highly supervised.” • Tony is interested in rap music ( Snoop Doggy Dog), motorcycles (Harleys) and social injustice. He relates to older adult males, and participates in activities with his sisters. He writes rap lyrics, makes friends easily (both male and female), and knows how to relate to the opposite gender. Tony’s family members look out for each other and defend each other in public. Tony’s mother is interested in her children graduating from high school.

Components cont… • Statement of Goals and Objectives • A goal is a global statement that (SMART) • Reflects a positive resolution to the identified need or problem • Indicates the specific area of functioning to be addressed • Includes an outcome measure or expectation

Goals • What the person wants to achieve stated in positive, observable, measurable, achievable terms • Will be nicotine free and have identified 3 other strategies for dealing with stress and boredom within 3 months • Not: Will quit smoking • Will be happier as evidenced by a rating of a 3 or better on a 5 point scale of happiness at least 80% of the time (use an anchored Likert Scale) within 2 months. • Not will stop being depressed • Will be calmer and more self confident as evidenced by getting at least 7 hours of quality sleep at least 6 nights/week, a rating of a 3 or better on a 5 point scale of contentment at least 70% of the time from both client and significant other within 1 month. Components cont… • Statement of Goals and Objectives • An objective (short-term goal) is directly related to a specified goal but highly specific and reflecting small attainable steps toward a goal. (Like a recipe) • Critical components of goals and objectives are that both the child and family want the goal/objective attained • Goals and objectives must clearly relate to the needs and priorities agreed upon by the team and identified in the treatment plan.

Objectives • Identifies steps toward achieving the goals in positive, observable, measurable, achievable terms • Only one outcome per objective (Hint: Use Excel) • Uses client’s current strengths to help achieve goals (Mind-map on a whiteboard) • Nicotine free • Remove nicotine products from house • Identify a triggers for use • Identify 3 alternative behaviors for each trigger • Identify ways to deal with cravings

Components cont… • Statement of Goals and Objectives cont.… • A goal might be the completion of seventh grade. • The objectives could include: • Attendance in class at least 95% of the time • Completion of homework at least 95% of the time • Appropriate classroom behavior 98% of the time • Passing tests with a C or better 90% of the time • Measurable objectives ensure that each child has an individualized treatment plan. • Measurable objectives convey to all persons on the team the same expectation and approach to the behavior being changed. • Measurable objectives determine what approaches are used and their effectiveness i.e. the success of the interventions.

Components cont… • Methods and Interventions • Descriptive statements of treatment that specify • Who • What in observable terms. • Where • When • How often • Staff, child, and family responsibilities and activities are clearly stated and the identified strengths are used to obtain the objectives.

Example 1 • A goal might be the completion of seventh grade. • The objective is: • Passing tests with a C or better 90% of the time • Interventions • Tony will keep a log of his homework assignments daily beginning Monday. • Tony will bring home all relevant materials for study daily beginning Monday • Tony will begin his homework by 6pm daily beginning Monday. • Tony’s mother will prompt him to start and encourage him to stay focused • Tony will write (or find) rap lyrics to help him learn his material (maybe even teach the class a song) • Tony will mark with a yellow highlighter areas he is struggling with • Tony will meet with his teachers after school to get questions answered beginning Monday and teachers will initial next to the highlighted areas when Tony has developed an understanding of the concept (Tony can ride the late bus home)

Example • Nicotine free (Goal) • Remove all nicotine from house (Objective) • Sally will go through the house and car and discard all nicotine products within 3 days • Sally will clean the car and house cleaning everything that smells like smoke within 14 days • Identify a 35 triggers for use • Sally will make a list of the top 5 sights, sounds, smells, tastes, feelings, activities and times that trigger her to want to use within 7 days and will add to it as necessary • Identify 3 ways of coping with each trigger • Sally will make a list of 3 ways of coping with each trigger within 7 days • Sally will keep an emergency card in her wallet with those 3 strategies within 7 days • Identify 3 ways to deal with cravings/urges • Sally will make an appointment to get smoking cessation meds from her doctor within 14 days • Sally’s therapist will give her a handout on distress tolerance skills today • Sally will make a list of distress tolerance skills she can use to urge surf within 14 days • Identify at least 2 vulnerabilities that make her more likely to be triggered • Sally will keep a mindfulness journal for 30 days, noting her mood, diet, sleep, exercise and the weather to identify things that make her more vulnerable to stress beginning today Example 3 • To Feel Calmer • Identify 10 sources of stress/anxiety • June will make a list of the top 10 things that cause her anxiety by 3/2 • June will identify what parts of each of those things she can control and which parts she cannot. By 3/2 • Identify at least 6 ways to deal with anxiety • To feel calmer, June will process that list with her therapist on 3/2 • June’s therapist will help her identify unhelpful thoughts that keep her stuck using the Challenging Questions Worksheet on 3/2 • June will identify at least 5 ways she has successfully dealt with anxiety in the past by 3/2 • June will create an emergency card to keep in her wallet with 3 coping strategies by 3/2

Summary • Treatment plans are like recipes • Goals must be stated in positive terms (what are you going to achieve (make) • Objectives are like the steps in a recipe. • Objectives identify what each step is (combine all wet ingredients) • Interventions identify who, what, when, where, why, how and how often something is to be done (1/2 t. vanilla, 3 eggs, ½ c. milk, ¼ c. coconut oil and blend on medium for 1 minute) • Goals, objectives and interventions must be specific, observable, measurable, achievable, time limited and clearly related to the overall goal for treatment

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Treatment Planning with the MATRS and ASI Instructor; Dr. Dawn-Elise Snipes Executive Director, AllCEUs Counselor Education and Training Podcast Host: Counselor Toolbox, Addiction Counselor Exam Review & Happiness Isn’t Brain Surgery Objectives • Examine how Addiction Severity Index information can be used for clinical applications and assist in program evaluation activities. • Identify differences between program-driven and individualized treatment planning processes. • Gain a familiarization with the process of treatment planning including considerations in writing and prioritizing problem and goal statements and developing measurable, attainable, time-limited, realistic, and specific (M.A.T.R.S./SMART) objectives and interventions. • Define basic guidelines and legal considerations in documenting client status.

ASI • Medical Status • Life interference • Due to addiction • Assessed need for medical intervention • Education, Employment, Finances • Level of education • Occupational hx forever and last 30 days • Drivers license/transportation • Sources of financial support • Dependents • Perception of employment / financial issues • Assessed need for employment counseling ASI • Alcohol/Drug Use • Drugs (addictive behaviors) used, pattern and method • Amount of money spent • Which drugs (behaviors) most problematic • Voluntary abstinence – When, for how long, how and what triggered relapse • Hx of medical problems due to use • Treatment Hx • Perception of the need for treatment • Assessed need for treatment ASI • Legal status • Probation or parole • Is treatment court mandated • Are you awaiting trial / pending charges • Catalog charges and frequency • How many charges are addiction related • How many charges resulted in convictions • How many times have you been incarcerated? • How many days in the last 30 have you been in jail • Perception of legal problems • Assessed need for legal services/counseling

ASI • Family/Social History • Identify history of addiction or psychiatric issues in 1st and 2nd degree family members • Marital status and satisfaction • Living arrangements and satisfaction (Recovery environment) • Use of alcohol or drugs in the household • With whom do you spend most of your time • Who are your close friends • Have you had serious difficulty getting along with any first degree family member, coworker or friend • Trauma/abuse history • Perception of interpersonal problems • Assessed need for family/social counseling

ASI • Psychiatric • How many times hospitalized • Number of times ever and 30 days you have experienced depression, anxiety, hallucinations, cognitive difficulties, suicidal ideation, • Are you on or have you ever been on psychiatric medications • Perception of psychiatric issues • Assessed need for mental health counseling Process Review • An assessment is conducted. • Data and information are collected from the client, collateral sources, and assessment scales. • Problems are identified. • Readiness for change for each problem is identified • Problem statements are prioritized. • Goals are created that address the problems. • Objectives to meet the goals are defined • Interventions are revised or changed based on client response to treatment

Treatment Plan Overview • Developed at admission and continually updated • Individualized • Problem statements are • Nonjudgmental • Not jargony “denial” “resistant” “Codependent” • Goals must be • Specific • Measurable (as evidenced by) • Achievable • Relevant • Time limited (achievable by the end of treatment)

Treatment Plan Overview • Program-driven plans • Are one-size-fits all • Reflect the components and/or activities and services available in the program • Individualized Treatment Plan is “Sized” to Match Client Needs • Not all clients have the same needs or are in the same situation. • The individualized treatment plan is made to “fit” the client based on her/his unique: • Abilities • Goals • Lifestyle • Socioeconomic realities • Work history • Educational background • Culture • When treatment programs do not offer services that address specific client needs, referrals to outside services are necessary.

• “Client has low self-esteem.” • Client averages 10 negative self-statements daily • “Client is in denial.” • Client reports two DWIs in the past year but states that alcohol use is not a problem. • “Client is resistant to treatment.” • In the past 12 months, the client has dropped out of 3 treatment programs prior to completion. (other possibilities?) • “Client is on probation because he is a bad alcoholic.” • Client has legal consequences because of alcohol-related behavior.

Terms • What Components Are Found in a Treatment Plan? • Problems identified during assessment • Goals reasonably achievable in the active treatment phase • The term objectives used in this training is defined as what the client does to meet the goals • The term intervention used in this training is defined as what the staff will do to assist the client

Prioritizing Problems Writing a Specific Goal • Recovery is not a specific goal • When a goal is specific, the person can objectively evaluate the data to determine that it has been achieved. • What problems are you experiencing as a result or your condition? (Problem statement) • High blood pressure • Insomnia • Relationship problems • Depression • Financial problems---Job loss and difficult with employment due to felony conviction Writing a Specific Goal • How will you know when each of those problems is resolved? (Goal statement) • Blood pressure will be 135/80 or better • I will be able to sleep restfully at least 7 hours each night • At least 5 out of every 7 days I will not get into fights with my partner • At least 5 out of every 7 days I will rate my happiness at a 3 or better. • I will acquire a job that pays at least $15/hour Making it Measurable • Measurable means an third person can look at the data and say “yes” it was accomplished or “no.” • Frequency (of the new behavior) • Number of days per week (went to work, went to meetings…) • Number of times per day (used a positive coping strategy) • Intensity (of the new behavior) • Anchored likert scale (use different words) • 1=extremely depressed 2=moderately depressed 3=content 4=happy 5=elated • 1= none 2=a little 3=feeling confident 4=I’ve got this Making it Measurable • Duration (of the new behavior) • Will resolve within 5 minutes (tantrum, panic attack) • Will pass in less than 30 minutes (urge, grief, anger) • Number • List 10 examples… • Scales • Beck Depression Inventory will drop 2 points

Achievable/Attainable • What can the person realistically do in the given time (i.e. 90 days) • Enroll in school • Get a job • Stay clean for 30 days • Rate her mood a 3 or better on the depression scale 5 out of 7 days • Increase the frequency that unhelpful thoughts are identified and effectively disputed to at least 70% Relevant • Objectives need to clearly related back to goals which need to clearly relate back to the reason for the referral. • Anyone reading the plan must be able to easily understand why each objective and intervention are there • In the goal statement, after the as evidenced by, add a statement, this is important to my [recovery] because… Time-Limited • All goals need to be able to be completed within the treatment period. • Objectives need to be constructed so they can be completed • For children through 5th grade…daily (even if just a star chart) • For youth 12 and up …weekly. Documentation • Plans are constructed WITH the client • Clients get a copy of their plan Progress Notes • If it isn’t documented, it didn’t happen. • Notes are dated, signed, and legible. • Client name and identifier are included on each page • Referral information has been documented. • Sources of information are clearly documented. • Client strengths and limitations in achieving goals are noted and considered. • Documentation should reflect changes in client status including response to and outcome of interventions • Entries should include the clinician’s professional assessment and continued plan of action

Progress Notes • Client review sheets can be helpful (complete at the end of session with the client) • Identify the problems and objectives you worked on this week. • Problem # ___ • Objective: _____ • Did you complete it? Yes No If no, why not? • What help do you need with this objective, if any? • Was it useful? Yes No If no, why not? • What else could you do to address this problem that would be more useful? • What problems and objectives are you going to work on next week? • Give a copy to the client.

Progress Notes • Progress Notes (S.O.A.P.) • Subjective – the client’s observations or thoughts; a client’s direct statement • Objective – the clinician’s objective observations during the session. • If you must use a subjective term like “withdrawn,” follow it with as evidenced by… • Mental-status: Orientation (person, place, time), memory, language, future plans • Assessment of Progress • Should identify each goal/objective worked on and outcome • Plans for next session

Progress Notes • D.A.P. • D= Describe (or Data) • A= Assess • P= Plan

• B.I.R.P. • B= Behavior • I= Intervention • R= Response • P= Plan

Progress Notes • C.A.R.T. • C= Client condition • A= What action did the counselor do in response to client condition? • R= Client response to treatment plan • T= How response relates to treatment plan

• C.H.A.R.T. • C= Client condition • H= Historical significance of client condition (i.e. relapse warning sign) • A= What action did the counselor do in response to client condition? • R= Client response to treatment plan • T= How response relates to treatment plan

Summary • Addiction Severity Index can be used for clinical applications and assist in program evaluation activities because it assesses multiple domains of functioning which can be linked to Maslow’s heirarchy • Program-driven plans fit the patient into services. • Individualized plans fit the services to the patient • Treatment plan goals and objectives should be positive, Specific, Measurable, Attainable, Relevant and Time Limited • It is important to tie the treatment plan to the assessment and the interventions and client progress to the plans. • Why is the action being taken • How does it benefit the client in achieving goals • What was done this past week (include client activities and referral contacts) • What was the client response to those activities • What are the plans for next week • What referrals were made (if any) and why

Additional Videos • Treatment Planning • Using Clinical History to Identify Motivation and Reinforcers • Goal Setting and Motivation • Behavior Modification

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Addiction Counselor Exam Review Podcast Hosted by Dr. Dawn-Elise Snipes Executive Director: AllCEUS.com Counselor Training Unlimited CEUs $59 and Addiction Counselor Precertification Training $149 Objectives • Examine the counselors function in providing client, family and community education • Identify the benefits of outreach and education • Identify qualities of effective education efforts Client, family and community education • Learning is defined as a change in behavior that can occur at any time or in any place as a result of exposure to environmental stimuli • The teacher and learner jointly perform teaching and learning activities • Counselors are often called upon to teach daily living skills to increase patients’ level of independence • Health educators provide information to individuals and communities on a variety of important topics including biological, medical, and physical aspects of substance use, safety, HIV and STDs, nutrition, General Medical conditions, smoking, pregnancy, and mental health • Success is measured not by how much content has been imparted but how much the person has learned

Client, family and community education • Client family and community education is the process of providing client’s families, significant others and community groups with information on a variety of topics • The role of educator encompasses many knowledge and skill sets such as • understanding and applying the principles of learning theory • using specific teaching skills to accommodate individual learning styles • making adaptations for culture, age and linguistic ability among learners • Educational groups help engage the client in treatment and recovery and is much less threatening because it is easier to learn than to change Client, family and community education • Characteristics of adult learners • They are engaged in multiple roles • They have more life experiences • They need a safe environment in which they do not have to be afraid of being wrong • They're self directed and don’t want to be spoon fed • They are relevancy oriented • Their problem solvers and want to know how new information can be applied in a practical setting • They need to feel part of a learning community which provides both encouragement and serves as a sounding board for ideas, anxieties, and concerns • Adults are motivated to learn • In order to cope with specific life changing events • Because they have a use for the knowledge or skill being sought Effective education efforts • Education is provided in a variety of ways including formal classes, handouts and informal meetings • Print electronic and other multimedia educational materials have become increasingly available • A client education program must be sensitive to the following: • Characteristics and needs of the client, their family, and significant others • Physical/environmental • Time/scheduling • Cognitive/learning abilities • Language • Cultural Effective education efforts • Educational sessions are typically offered in 60 to 90 minute blocks • Sessions usually consist of a lecture, an exercise, and are presented with media supplements • Educational topics include: • Addiction as a Biopsychosocial disease • The recovery process • Life skills • Health • Relapse warning signs and triggers • Resources available for clients family’s and community members • Recovery planning Effective education efforts continued • Learning styles • Each learner absorbs and retains information differently • A learning style is the primary way person tends to learn and can be auditory, visual, or kinesthetic • Challenges to learning • Learning and memory deficits attributable to substance use • Consideration should be given to the teaching approach used and the amount of information given at any one time • The matrix model of outpatient treatment illustrates an approach that recognizes impairments and delivers information to the client accordingly • Progress is gradual • The focus is on the present • Court issues are not immediately addressed • Complex information is provided in smaller units and presented in steps Effective education efforts continued • Challenges to learning • The age of the learner • Older learners may experience a decline in vision, hearing, short term memory skills, and reaction time • Moderate the pace of the presentation • Have both visual and auditory formats • Look for nonverbal signs of confusion • Provide enough time to complete assignments • Provide enough time to complete psychomotor tasks Effective education efforts continued • Challenges to learning • The age of the learner • Younger learners may not have the same level of cognitive, emotional or social development, nor the attention span. • Moderate the pace of the presentation and chunk it • Use developmentally appropriate materials and activities • Have both visual/pictorial and auditory formats • Look for nonverbal signs of confusion and boredom • Make activities interactive and encourage participation • Provide enough time to complete psychomotor tasks (coloring a picture) Effective education efforts continued • Teaching strategies, Dale’s cone of experience • Adults generally remember: • 90% of what they do • 70% of what they say and write • 50% of what they hear and see • 30% of what they see alone • 20% of what they hear • 10% of what they read Effective education efforts continued • Teaching from a multicultural perspective recognizes that there’s a classroom of learners who vary according to their social and cultural characteristics • Culturally responsive teaching • Is defined by how the educator develops teaching approaches to address the cultural knowledge, prior experiences and performance styles of diverse students • Acknowledges the legitimacy of the cultural heritage of different ethnic groups • Builds bridges of meaningfulness between social and learning experiences • Uses a wide variety of instructional techniques that are connected to different learning styles • Teaches students to know and embrace their own and each other’s cultural heritages • Incorporates multicultural information, resources and materials in the subjects and skills • Diversity And Motivation: Culturally Responsive Teaching is a text that provides specific culturally responsive teaching strategies

Effective education efforts continued • Culturally responsive teaching guidelines: • Communicate respect • Give yourself permission to feel uncomfortable with a culture that is new to you • Develop listening skills • Never be shy about asking if you’re being understood or asking for the client’s cultural perspectives. “How is this viewed or approached in your culture?”

• For more information on cultural competence, view the videos Improving Cultural Competence Parts 1, 2 & 3 on our YouTube channel. https:Allceus.com/youtube

Effective education efforts continued • Psychoeducation • Is health education combined with behavioral counseling • The counseling component of psychoeducation deals with emotions or perceptions, coping, relaxation and self care • It teaches people about their problems, how to treat them and recognize signs of relapse • It teaches coping strategies and problem solving skills to families, friends, and or caregivers to help them deal more effectively with the individual • Typically consists of a highly structured format providing problem-focused or skill building education in one or 2 hour time limited groups • There is opportunity for discussion of the presented material but there’s very little true processing of personal issues • Groups are not a good option for people who are unable to maintain confidentiality, people who continue to engage in antisocial behaviors and people who are not motivated to participate in treatment Effective education efforts continued • Psychoeducation • Counseling groups have more ambiguity, emphasize emotions and learning outcomes are individualistic not for the group as a whole • Effective psychosocial educational interventions need to contain elements of • Practicality • Concrete problem solving • Incremental shaping of social an independent living skills • Specific attainable goals • Benefits derived from psychoeducation include mastery experiences and increased levels of empowerment • Psychoeducation strategies enhance a person’s sense of dignity and self esteem due to the increased responsibility for self care and levels of trust placed in his or her hands • Psychoeducation increases in individual’s resilience to distress, coping skills, ability to comprehend and manage life, and their sense of meaning in life Effective education efforts continued • Delivering Psychoeducation • Facilitators are responsible for fostering the following goals • Information transfer • Emotional discharge • Support of a medication or other treatment regimen • Assistance towards self help • Family psychoeducational groups help family members prevent the individual with the substance use or co-occurring disorder from relapsing and provides them with information they need and the coping skills that will help them with their loved ones disorder. • Associated goal is support for the client’s family’s burdens including financial, social and psychological in dealing with a loved one’s substance abuse issues Summary • Counselors function in providing client, family and community education to aid in prevention, early intervention and post-treatment transition. • Outreach and education are cost effective and can be provided in a variety of places within the community. • Effective education efforts are developmentally appropriate, culturally responsive, presented continuously throughout the continuum of services and designed to provide practical information to clients, their significant others and community members

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Addiction Counselor Exam Review Models of Treatment Objectives Models of Treatment • Psychological (self-medication) Model • Addiction and mental health issues result from deficits in learning, thinking or emotion regulation • Treatments • Behavioral self-control • Individual and group counseling (Multiple EBPs) • Pharmacotherapy for mental health issues Psychological: Behavioral Self Control • Goals • Strengthen internal mechanisms (self-awareness) • Establish external controls • Coping skills • Goal setting • Behavioral contracting (What would you contract for?) • Trigger management (What are MH triggers) • Functional Analysis (of behaviors NOT diagnosis) • Relapse prevention (What are relapse prevention strategies for MH? Addiction?)

Psychological: Psychotherapeutic • Dialectical Behavior Therapy • Why • Clients unintentionally rewarded ineffective treatment while punishing their therapists for effective therapy. • The sheer volume and severity of problems presented by clients made it impossible to use the standard CBT format. • Clients found the focus on change inherent to CBT invalidating. (How might this be true in addiction?) • Clients felt their suffering was being underestimated, and therapists were overestimating their helpfulness • “You are doing it, or feeling incorrectly.” Psychological: Psychotherapeutic • Dialectical Behavior Therapy • Over Riding Themes • Mindfulness (wise mind) • Distress tolerance • Emotion regulation • Interpersonal effectiveness & problem solving Psychological: Psychotherapeutic • Matrix Model for Stimulant Use • A 45 session treatment program • Goals: • Learn about issues critical to addiction and relapse • Receive direction and support from a trained therapist • Become familiar with self-help programs. • The therapist functions simultaneously as teacher and coach, fostering a positive, encouraging relationship Psychological: Psychotherapeutic • Motivational Enhancement Therapy • Helps resolve ambivalence about treatment & abstinence • This therapy consists of: • Initial assessment battery • Followed by 2-4 individual sessions with a therapist Psychological: Psychotherapeutic • Motivational Enhancement Therapy • This therapy consists of (cont…): • First treatment session (FRAMES) • Feedback about the initial assessment • Responsibility • Elicits self-motivational statements • Strengthens motivation and builds a plan for change • Advice: Coping strategies for high-risk situations are suggested Psychological: Psychotherapeutic • Motivational Enhancement Therapy • This therapy consists of (cont…): • First treatment session • Menu of Options • Empathy • Self-Efficacy • Subsequent sessions: therapist monitors change, reviews change strategies being used, encourages change Psychological: Psychotherapeutic • Family Behavior Therapy (FBT) • Demonstrated positive results in both adults and adolescents • Addresses not only substance use and mental health problems but other co-occurring issues (i.e. conduct disorders, child mistreatment, family conflict, and unemployment) • FBT involves the patient along with at least one significant other such as a cohabiting partner or a parent Psychological: Psychotherapeutic • Family Behavior Therapy (FBT) • FBT combines behavioral contracting with contingency management. • Therapists seek to engage families in applying the behavioral strategies taught in sessions and in acquiring new skills to improve the home environment.

Psychotherapeutic • Seeking Safety • Present-focused therapy for trauma/PTSD and addiction • Available as a book, with guidance for clients and clinicians • Can be done in individual or group Psychological: Psychotherapeutic • Introduction/Case Management • Safety, PTSD: Taking Back Your Power • When Substances Control You • Honesty, Asking for Help • Setting Boundaries in Relationships • Getting Others to Support Your Recovery • Healthy Relationships • Community Resources • Compassion • Creating Meaning • Discovery • Integrating the Split Self • Recovery Thinking • Taking Good Care of Yourself • Commitment • Respecting Your Time • Coping with Triggers • Self-Nurturing • Red and Green Flags • Detaching from Emotional Pain (Grounding) • Life Choices Models of Treatment • Sociocultural model • Emphasis is placed on the socialization process, culture, observational learning and reinforcement of behaviors • Recovery involves: • Building new social and family relationships • Developing social competency/interpersonal effectiveness • Working within one’s cultural infrastructure Models of Treatment • Relapse Prevention • Adopt strategies designed to help clients • Become aware of cues or “triggers” that make them more likely to abuse substances or become symptomatic • Develop alternative coping responses to those cues Medication Assisted • Addiction • Methadone • Suboxone • Vivitrol • Antabuse • SSRIs • Mental Health • SSRIs • Atypical antipsychotics

Harm Reduction • Acceptance that drug use and mental health issues are a reality • Preventing the harm caused by them • 4 Ls: Liver, Lover, Livelihood, Law • Interventions • Low-threshold pharmacological interventions • Needle exchange programs • Emphasis on non-injection routes • Involvement of those with a history of use or distress in program development

Multidisciplinary (Biopsychosocial-Spiritual) • Psychotherapeutic interventions fro co-occurring issues • Medication assisted therapy for both addictive and mental health issues • Wrap around services to ensure people have access to necessary resources to achieve their goals • Family therapy to improve the interpersonal environment of the person

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Review for the Alcohol and Drug Counselor Exam Intake and Orientation Screening and Assessment • Demonstrate verbal and nonverbal skills to establish rapport and promote engagement • Discuss with clients the rationale, purpose and procedures associated with screening and assessment • Assess clients immediate needs including detoxification • Administer evidence based screening and assessment instruments to determine client strengths and needs • Obtain relevant history to establish eligibility and appropriateness of services • Screen for physical needs, medical conditions, co-occurring mental health issues • Interpret results of screening and assessment and integrate information to formulate a diagnostic impression and determine appropriate course of action • Develop a written integrated summary to support diagnostic impressions Intake • Intake • Is the process of enrolling a client in a specific course of treatment • A series of activities designed to organize information about the client and their significant others • Ensures eligibility • Completes basic data collection • Identifies barriers and assets • Establishes a treatment approach • Primarily administrative in nature • Needs to be standardized in nature • It is an extension of the screening and assessment process • Can be used to engage the client in treatment and enhance motivation for change Orientation • Can be conducted in individual, family or group settings • Completed after the intake • Describes specific aspects of treatment • Schedule • Goals • Rules and responsibilities • Hours of service • Medication • Drug testing • Treatment costs • Client rights Client Rights • Florida Statute 381.026 • Individual dignity • Confidentiality • Right to nondiscriminatory services • Standard (Age, race, gender, sexual orientation, disability) • Prior service departures • Number of relapses • Level of psychotropics • Ability to pay (public agencies) Client Rights • Quality services • Communication • With informed consent communication may be limited • Personal effects • unless for to do so would infringe upon the right of another patient or is medically or programmatically contraindicated for documented medical, safety, or programmatic reasons • May be temporarily held by the agency but must be returned at the end of treatment • Minors to be educated • Counsel (involuntary proceedings) • Habeus corpus (full evidence of what is being alleged) Client Rights • (Florida Specific) • A patient has the right to a prompt and reasonable response to a question or request. • A patient receiving care in a health care facility or in a provider’s office has the right to bring any person of his or her choosing to the patient-accessible areas of the health care facility or provider’s office to accompany the patient while the patient is receiving inpatient or outpatient treatment or is consulting with his or her health care provider, unless doing so would risk the safety or health of the patient, other patients, or staff of the facility • A patient has the right to refuse any treatment • A patient has the right to express grievances to a health care provider, a health care facility, or the appropriate state licensing agency regarding alleged violations of patients’ rights. Client Rights • (Florida Specific) • A patient has the right to know the name, function, and qualifications of each health care provider who is providing medical services to the patient. A patient may request such information from his or her responsible provider or the health care facility in which he or she is receiving medical services. • A patient in a health care facility has the right to know what patient support services are available in the facility. • A patient has the right to be given by his or her health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis, unless it is medically inadvisable or impossible to give this information to the patient • A health care provider or health care facility shall respect a patient’s legal right to own or possess a firearm and should refrain from unnecessarily harassing a patient about firearm ownership during an examination.

Recovery Planning • Recovery Management focus • Collaboration between traditional and nontraditional service providers and clients with the goal of stabilizing and actively managing the ebb and flow of symptoms • Treatment goals à Recovery Goals • Provide appropriate stabilization à Reduction and elimination of symptoms • Meet established outcomes  Improve wellness and health • Reduce vulnerabilities and increase resilience Rejoin and Rebuild life in the community • Components of Recovery • Abstinence and symptom reduction • Improved psychological and physical health • Improved relationships Recovery Support • Recovery is a process of change through which an individual achieves abstinence as well as improved health, wellness and quality of life • Recovery is • long-term • wellness centered • Recovery involves • ongoing growth self-discovery • creation of a new identity Recovery Support • Planning and Linkages • Relapse Prevention Education • Medicaiotns and Other Treatments • Mutual Self-Help • Exercise • Nutrition • Activities of Daily Living • Spiritual Practices and Affiliations • Supported Community Activities • Homeopathic and Naturopathic Remedies • Cultural Healers Counselor Functions in Developing the Recovery Plan • Formulate recovery goals • Identify objectives to meet those goals • Facilitate linkages to support services • Establish measures to mark progress • Monitor client progress • Provide support • Create emergency (relapse prevention) plans Peer Recovery Support • Recovery support services link professional treatment with a natural support network in a structured way to maximize the likelihood of long-term success • Peer-based recovery support provides nonprofessional, nonclinical assistance by people who are experientially credentialed • Peer recovery services may be offered • while a patient awaits entry into treatment • During treatment to provide a connection to the community • After treatment to assist people in managing recovery Common Pathways to Recovery • Transitional Stages • In the community using • In the community not using • Incarcerated • In Treatment • Pathways • Self-Help • Peer Support • Formal Treatment

12 Principles of Recovery • There are many pathways to recovery • Recovery is self-directed and empowering • Recovery involves personal recognition of the need for change • Recovery is holistic • Recovery has cultural dimensions • Recovery exists ona continuum of improved health and wellness • Recovery emerges from hope and gratitude • Recovery involves a process of healing and self-redefinition • Recovery involves addressing discrimination and transcending shame and stigma • Recovery is supported by peers and allies • Recovery involves rejoining and rebuilding a life in the community • Recovery is a reality Summary of the Treatment/Recovery Process • Formal Treatment begins with the development of an individualized treatment plan (roadmap) with the client • Treatment plans are continually updated and reassessed to address developing treatment needs and match them with community resources • Counselors communicate client needs to referral sources to ensure a smooth transition and engage in follow up and advocacy • The counselor must document treatment progress, outcomes, continuing care plans and use multiple pathways of recovery

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Review for the Alcohol and Drug Counselor Exam

• Past 30 Day statistics, According to the 2012 National Survey on Drug Use and Health, • 6.5% of the population over 12 reported heavy drinking • 9.2% reported illicit drug use • The majority of people who use recreationally will not need treatment • Addiction is characterized by compulsive craving for the substance and using that substance despite negative consequences • Cravings and compulsive behavior are caused in large part as a consequence of substance use or addictive behaviors on the brain causing • Emotional • Cognitive • Physical • Behavioral changes Definition of Addiction • Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. • Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations reflected in pathological pursuit of a reward and/or relief by a substance. • Without treatment and/or engagement, addiction is progressive and can result in disability or premature death. (ASAM 2011, NIDA 2007) Characteristics of Chronic Disease • Disrupts normal functioning • Have serious, harmful consequences • Are preventable and treatable • Can last a lifetime • May be fatal if untreated Addiction—A description, not a Diagnosis • Addiction is a description, not a diagnostic term. • Addiction erodes a person’s self-control and ability to make sound decisions • The DSM V has 2 diagnostic categories • Substance abuse • Substance dependence (The medical definition of addiction) • Dependence is always characterized by dependence and withdrawal Factors Influencing Addiction • No single factor is causative • General Categories • Biological/genetic makeup • Gender • Ethnicity • Developmental stage/early use • Social environment • Proximal (neighborhood, school/work, friends, family) • Cultural/Media/Availability • Method of administration Factors Influencing Addiction • Genetic Factors • 40-60 % of a person’s vulnerability is genetic. • Expression of these genes is influenced by: • Effects of the environment • Reactions/effects of addictive behaviors • Genetic predisposition to mental health issues (self-medication) • Social Environment & Peer and School • Access • Social learning of acceptability and use patterns • Exposure to peers/family who engage in criminal behavior • Academic/work failure • Poor social skills / unstable relationships

Factors Influencing Addiction • Developmental/Early Use • The earlier the initiation, the greater the likelihood it progresses to addiction • Addictive behaviors have a stronger impact on the developing brain (esp. the prefrontal cortex) • Indicative of a set of vulnerabilities/triggers • Genetics • Mental Illness • Unstable family relationships • Exposure to abuse

Factors Influencing Addiction • Method of Administration • Smoking and injection increase addictive potential due to • Rapid transit to the brain (seconds) • Rapid fade of effects (crash)

Theories of Causation • Moral Model • Addiction is the result of defects of character • Rejects any biological basis • Focuses on individual choices and values retraining • Disease Model • Addiction is an illness resulting from an impairment of neurochemical or behavioral processes • Presented by Jellinek leading the APA and AMA adopting the disease model • Addiction is a primary disease and not caused by anything else Theories of Causation • Genetic Model • Individuals have a genetic predisposition • Difficult to separate social causes from family and genetic causes • Cultural Model • Cultural attitudes and availability impact which addictions people develop • Blended Model • Addiction develops in each individual as a result of a unique set of factors Continuum of Addiction • Social – risky/problematic –abuse –dependence • Many individuals never progress beyond risky consumption • Recovery from addiction is a multidimensional process which differs between people and changes over time. • Risky/problematic users have some amount of control and can learn methods to cope. • Dependent users seem to have no control over their use. • One and done • Progression over time

Reinforcers Within the Cycle of Addiction • Reinforcers • Add to the benefits of use • Become less important as the drug causes neurochemical imbalances • Psychological • Enhance the rewards of other experiences (Sex, social) • Boosts self-confidence • Alleviates stress and dysphoria • Reduces pain • Coping skills fail to develop or atrophy as addictive behaviors substitute • Confidence in dealing with life on life’s terms diminishes • Avoided problems worsen and increase anxiety Reinforcers Within the Cycle of Addiction • Social Aspects • Social lubricant • Social bonding • Biological Aspects • Impact the reward/pleasure centers in the mesolimbic system • Brain begins producing less dopamine or letting less dopamine through the system • Person becomes dependent on surges of dopamine to feel pleasure • Sobriety produces feelings of dysphoria until the brain can rebalance itself • Self-medication of mental health disorders

What is Recovery • Improvement of health and wellness in order to live a self-directed life and strive to reach one’s full potential. • Recovery involves the interaction between • Race/ethnicity • Gender • Sexual orientation • Family history • Developmental stage • Environment • Culture • Individual strengths, values and needs What is Recovery • Recovery • Begins with accepting there is a problem and that • Help is needed to overcome it • Responsibility for recovery from the problem and associated issues lies with the person • Is individualized and lifelong • Abstinence is often the goal • Harm reduction can be considered as an alternate goal • Relapse occurs when a person • Is unaware of the process of recovery • Unable to accomplish the tasks required at each stage of recovery • Lacks adequate access to treatment/support

Recovery Capital • Resources necessary to achieve sustained recovery • Personal • Family/social • Community Recovery Capital • Personal Recovery Capital • Physical Health • Financial stability • Health insurance and prescription coverage • Safe shelter conducive to recovery • Clothing • Food • Transportation Recovery Capital • Personal Recovery Capital • Values • Knowledge/education/skills • Problem solving abilities • Interpersonal effectiveness and communication skills • Self-awareness, esteem, efficacy • Hope and optimism • Sense of meaning and purpose • Perception of the past, present and future Recovery Capital • Family of Choice/Social Recovery Capital • Supportive relationships • Community Recovery Capital • Emphasis on efforts to address and reduce stigma • Availability of diverse local role models • Continuum of recovery-focused substance abuse, mental health and medical treatment • Available resources (food, shelter, clothing, transportation, childcare, training, employment) • Multiple recovery support organizations

• American Society of Addiction Medicine (ASAM) 2017 https://www.asam.org/resources/definition-of-addiction • University of Oklahoma Department of Medicine (2017) http://www.drugdetection.net/PDF%20documents/Dubowski%20-%20stages%20of%20alcohol%20effects.pdf • Center for Substance Abuse Treatment (2009) https://www.samhsa.gov/sites/default/files/partnersforrecovery/docs/ATR_Approaches_to_ROSC.pdf • DEA Drugs of Abuse (2017) https://www.dea.gov/pr/multimedia-library/publications/drug_of_abuse.pdf#page=42 • White, W. & Cloud, W. (2008). Recovery capital: A primer for addictions professionals. Counselor, 9(5), 22-27. • Davidson, L & Roe, D (2007) Recovery from versus recovery in serious mental illness: One strategy for lessening confusion plaguing recovery. Journal of Mental Health, August 2007; 16(4): 459 – 470

Engagement, Screening and Assessment • Demonstrate verbal and nonverbal skills to establish rapport and promote engagement • Discuss with clients the rationale, purpose and procedures associated with screening and assessment • Assess clients immediate needs including detoxification • Administer evidence based screening and assessment instruments to determine client strengths and needs • Obtain relevant history to establish eligibility and appropriateness of services • Screen for physical needs, medical conditions, co-occurring mental health issues • Interpret results of screening and assessment and integrate information to formulate a diagnostic impression and determine appropriate course of action • Develop a written integrated summary to support diagnostic impressions Engagement • Establish rapport and an effective working alliance in which the client feels heard and understood • Respectful • Nonjudgmental • Attentive • Motivate and engage the client in identified service needs • Engagement puts the clinician in the best position to negotiate with the client about what to do and how to do it. • Engaged clients are more likely to • Participate willingly • Be treatment compliant • Successfully complete treatment Engagement • Create a welcoming environment • Pleasant physical environment sensitive to • Age • Gender • Disability • Sexual orientation • Religion • Socioeconomic status

Factors Impacting Engagement • Stigma • About the diagnoses • About help seeking • Expectations • About the effectiveness of treatment • About one’s role/power in the treatment process • About the treatment process itself • Likeableness • Client’s social skills • Client’s attentiveness • Client’s attractiveness Factors Impacting Engagement • First Impression • Professional presentation • Promptness • Courtesy • Smooth handling of paperwork • Environment • Calm, clean, comfortable • Not too formal or informal • Avoids interruptions • Provides appropriate privacy

Skills for Building the Helping Relationship • Rapport—Sense of connection • Both parties contribute to the relationship • Active listening • Demonstration of credibility and dependability • Being respectful and responsive • Support • Encourage the client and build self-esteem • Encourage appropriate expression of feelings • Validate and recognize, but don’t encourage negative feelings or behaviors Skills for Building the Helping Relationship • Empathy—Shared feelings of hope • Acceptance– Unconditional positive regard Communication Techniques • Active Listening • Reflecting • Clarifying • Focusing/directing to a particular topic • Summarizing • Questioning • Open-ended • One and a time • Avoid “why” and confrontational questions • Observing nonverbals Communication Techniques • Nonverbals (information and congruency) • Rate of speech • Volume of speech • Posture • Gestures • Eye contact • Facial expressions

Communication Techniques • Observing nonverbals • Dress and presentation may communicate • State of mind • Cultural values • Body image • Self-concept • Look for bodily signs of • Drug use • Physical abuse • Poor nutrition

Goals of the Initial Interview • Establish trust and develop rapport • Be empathetic • Convey warmth and respect • Explore client strengths and skills • Facilitate client’s understanding of rationale, purpose and procedures of the screening and assessment process • Explore the client’s problems and expectations regarding treatment and recovery • Determine whether a further assessment is needed Screening • The process by which the counselor, client and SOs review the current situation, symptoms and collateral information to determine the probability of a problem • Used by all types of human service personnel to determine eligibility and appropriateness of services and needed referrals • Screening helps determine the immediacy of need • Must be a transparent process • Requires informed consent • Identification of early warning signs helps provide early intervention services and/or resources Screening • Screening is the first opportunity to engage the client in the therapeutic relationship and treatment process • Sometimes, based on observation or other circumstances people may be referred directly for assessment. • The client’s internal motivation is the primary reason for engaging in treatment. • Internal motivation may be fleeting, so rapid engagement is vital. Screening • Successful screening should be • Brief • Conducted in a variety of settings by a range of professionals on persons deemed to be at risk • A collaboration among a multidisciplinary team • Sensitive to racial, cultural, socioeconomic and gender related concerns • Developed from information gathered from multiple sources when possible

Screening • Assess signs and symptoms of intoxication and withdrawal • 3 key elements • Verify that behavior deviates from the norm • Rule out all non-drug related causes • Use diagnostic procedures to determine the types of drugs being used • Assess clients • Mental health/trauma history • Safety/environmental needs • Physical health needs • Other wrap-around needs • Danger to self or others Screening Methods • Interview (client, SOs) • Screening instruments • Lab tests Signs of SUDs or Mental Health Issues • Circumstances of contact • Client’s demeanor and behavior • Signs of acute intoxication or withdrawal • Physical signs of drug use or self-injury • Information spontaneously offered by the client or SOs Screening Instruments for SUD • Can be developed by the agency or use standardized instruments • CAGE (Cut Down, Annoyed, Guilty, Eye Opener) • GAIN-SI • Michigan Alcohol Screening Test • SASSI • Must clearly detail what action should be taken based on received scores Screening for Mental Health • Screen for • Acute symptoms such as hallucinations, delusions or depression • Suicidal thoughts and behaviors • Other mood and thought disturbances • Time, place, purpose, person • Short and long term memory • Prior involvement in mental health treatment • Use of prescription medication • Recent traumas • Family history of mental illness Screening Instruments for Mental Health • Modified mini screen • Mental Status Exam • Mini Mental Status Exam • Brief Symptom Inventory • Brief Psychiatric Rating Scale • Symptom Checklist 90-R

12 Assessment Steps • Engage • Get authorizations and gather information from collateral sources • Screen for co-occurring disoders • Determine the severity of mental and SUDs • Determine appropriate level of care • Determine diagnoses • Determine disability and functional impairment • Identify strengths and supports • Identify cultural and linguistic needs and supports • Identify additional problem areas (medical, housing, education…) • Determine readiness for change • Plan treatment Assessment • Screening determines the possible presence. • Assessment • Is an ongoing process • Determines the nature and severity • Develops specific treatment recommendations • Surveys client strengths and resources for addressing “life problems.” (wrap-around) • Substance Abuse Assessment Foci • Historical and situational factors contributing to or triggering use • Patterns of use • Common signs and symptoms • Consequences of use Assessment • Examines the context(s) in which the disorder(s) manifest • Explores reciprocal interactions of… • Family/marital life • Social support/interpersonal functioning • Physical health needs • Spirituality • Employment • Financial issues • Legal issues • Other issues which may impact treatment (transportation, childcare)

Assessment • Explores reciprocal interactions cont… • Gender, cultural, linguistic issues • Readiness for change • Relapse risk • Recovery support • Special life circumstances (single parent) • Medical conditions • Client centered—respecting • The client’s perceptions of his problems • Goals he wishes to accomplish • Strengths he has Assessment Instruments • Forms • Standardized interviews • Limits interviewer to a script • Requires limited training • Collects the same information on all clients • Structured interviews • Probing questions can be asked • Requires additional training/knowledge • Self-administered tests/questionnaires • Require some motivation and reading ability on the client’s part • Standardized instruments have: • Reliability • Validity information Assessments • Sources of information (with written consent) • Personal reports • Family • Other professionals/prior treatment experiences • May be the most objective resource • Employment history • Criminal records • Drug tests • Collateral information gathered should be confirmed to the extent possible • Accurate assessment requires the coherent integration of multiple sources of information to avoid under- or over-estimation of the problem.

Drug Testing in SUD Treatment • Drug testing is • Part of the initial assessment • Used to identify drugs to make most appropriate treatment recommendations • Screen to prevent adverse effects of prescribed medications • Component of the treatment plan • Way to monitor use of substance and compliance with medications • Method to assess efficacy of treatment • Method to document abstinence for legal matters, disability, custody etc. • Drug testing cannot replace an assessment to diagnose a substance use disorder. Drug Testing in SUD Treatment • Drug Testing • Can accurately reveal drugs in the system • Time frame for detection is limited • Dependable for identifying frequent users • Less accurate for infrequent or binge users Types of Drug Tests • Breathalizer (hours) • Urine (up to a month) • On-site • Gas chromatograph • Can produce false positives • Saliva (past day) • Sweat and hair • drug use patterns over periods of time • Cannot discriminate between recent and past drug use • Not able to identify use within past 3-8 days • Blood Risk Assessment • One of the most important functions at both screening and assessment • Presence of any risk warning signs • Requires immediate referral (detox, CST, ER) • Screening and assessment are inappropriate • Assess for: • Intoxication • Substance toxicity • Withdrawal • Aggression/danger to others • Potential for self-harm or suicide • Co-existing mental health issues Risk Assessment • Signs of Drug Toxicity or Intoxication • Nausea • Vomiting • Diarrhea • Agitation • Lethargy or stupor • Increased or decreased heart rate • Lack of coordination • Slurring words

Risk Assessment • Signs of Violence • Previous violence • Young age at first incident • Relationship instability • Employment problems • Substance use problems • Major mental illness • Personality traits that deviate from social norms (exploitation, manipulation…) • Early maladjustment or trauma • Paranoia • Failure to respond to treatment in the past Risk Assessment • Suicidality • Alcoholism (a factor in 30% of suicides) • Psychiatric disorder • 90% of people who die by suicide have a mental health disorder • 60% of people who die by suicide have depression • For alcoholics who are depressed the rate is 75% • 3 Domains for Assessment • Current presentation of suicidality • History • Risk management Risk Assessment • Signs of Suicidality • Suicidal or self-harming thoughts, plans, behaviors or intent • Specific methods identified • Evidence of hopelessness, impulsiveness, panic attacks or anxiety • Lack of future plans • Signs of “tying up loose ends.” • Alcohol or other substance use • Thoughts, plans or intentions of violence toward others • Psychiatric illnesses Risk Assessment • Signs of Suicidality • Previous attempts or aborted attempts at suicide or self-harm • Family history of suicide attempts, suicide, mental illness, addiction • Acute psychosocial crises including financial or changes in socioeconomic status • Chronic psychosocial stressors including actual or perceived interpersonal losses • Family discord, domestic violence, current or pase sexual or physical abuse • Absence of external supports Mental Health Disorders Common in Co-D • Borderline Personality Disorder • Pervasive pattern of instability in personal relationships, self image and affect in addition to impulsivity. • Antisocial Personality Disorder • Pervasive disregard for and violation of the rights of others • Inability to form meaningful relationships • Lack of empathy

Mental Health Disorders Common in Co-D • Major Depressive Disorder • Lack of pleasure in most things most days for at least 2 weeks • Changes in sleep, appetite, energy, concentration • Excessive feelings of worthlessness and/or guilt • Suicidal ideation • Bipolar Disorder • Fluctuations between elation (mania) and depression

Mental Health Disorders Common in Co-D • Anxiety Disorders • Panic attack • Distinct period of intense fear usually peaking within 15 minutes • Significant fear-related physiological symptoms • Panic disorder • Panic attacks + persistent fear of recurrence of attacks • Obsessive Compulsive Disorder • Anxiety disorder involving obsessive thoughts which cause anxiety and compulsive behaviors to address those thoughts

Mental Health Disorders Common in Co-D • Post Traumatic Stress Disorder • Exposure to an stressor which involved the threat of death or significant injury to self or another in which there was significant helplessness and horror. • Can occur when learning about a trauma which occurred to someone else, especially a significant other • Eating Disorders • Person is intensely afraid of gaining weight and exhibits a disturbance in the perception of the shape of size of his or her body. • Types • Anorexia • Bulimia • Binge Eating Disorder

Mental Health Disorders Common in Co-D • Schizophrenia and Psychotic Disorders • Psychosis is the term for a severely incapacitated mental and emotional state involving thinking, perception and emotional control • Hallucinations –False perceptions • Delusions –False beliefs and a deterioration in thinking, judgement or self-control • Schizophrenia is the most common psychotic disorder • NOT multiple personality • Symptoms (often begin to develop before the first psychotic episode) • Hallucinations or delusions • Disorganized speech • Disorganized or catatonic behavior • Deficits in functioning

Diagnosis and the DSM • The Diagnostic and Statistical Manual is created to • facilitate communication between and within professions regarding mental health and substance use disorders • Improve interrater reliability regarding diagnosis • Improve sharing of information about client presentation and needs ICD-10 • International Classification of Disease is used for diagnosis (like the DSM)

Diagnosis of Substance Use Disorders • The DSM V recognizes 10 separate classes of drugs • Alcohol • Inhalants • Opioids • Sedatives • Hypnotics/Barbiturates • Anxiolytics • Stimulants • Caffeine • Tobacco • Cannabis • Hallucinogens • Other/Unknown substances SUD Diagnosis • Although how each types of drug acts in the brain differs, they all activate the brain’s reward system • Two groups of substance disorders • Substance use • Substance induced SUD Diagnosis • Diagnosis • Using in larger amounts or for longer than intended • Wanting to cut down or stop but failing • Spending increased time getting, using or recovering from use • Cravings and urges • Neglecting work, school, family, social obligations because of use • Continue to use even when it causes problems in relationships • Giving up important social, occupational, recreational activities because of use • Using in risky situations • Continuing to use despite knowing that it is making a physical or psychological problem worse • Tolerance • Withdrawal

Diagnosis of Substance Use Disorders • SUD severity is dependent on how many symptoms are present • 2-3 symptoms = Mild • 4-5 = Moderate • More than 5 severe • Qualifiers • In early remission • In sustained remission • On maintenance therapy • In a controlled environment

Substance-Induced Disorder Diagnosis • Result from effects of the use of a substance • Intoxication • Withdrawal • Anxiety or depressive disorders • Bipolar and related disorders • Psychotic disorders (hallucinations, delusions) • Sleep disorders • Sexual dysfunctions • Neurocognitive disorders • The teeter-totter principle helps predict symptoms in the withdrawal period (Polysubstance complicates things) Substance Induced vs. Mental Illness Dx • Substance induced means that the current presenting symptoms are likely the result of use of a substance not an underlying (pre-existing) mental disorder • Concurrent mental disorders can (and often do) occur ASAM Treatment Criteria • 6 Dimensions • Acute Intoxication/Withdrawal Potential • Biomedical Conditions and Complications • Emotional/Behavioral or Cognitive conditions • Readiness for Change • Relapse Potential • Recovery/Living Environment ASAM Treatment Criteria • Levels of Treatment (Placement) • Level .05 Early Intervention • Level 1: Outpatient Treatment • Level 2: Intensive Outpatient Treatment/PHP • Level 3: Residential Treatment • Level 4: Medically Managed Intensive Inpatient Treatment

Integrated (Interpretive) Summary- Simple • Weaves together the information gathered using a theoretical approach to infer or identify themes and treatment priorities Integrated (Interpretive) Summary--Detailed • Identifying information • Presenting problems • Sources of data • Problem history • Substance use history • Family history • Personal and Educational history • Employment and vocational skills • Spiritual and religious involvement • Health conditions • Psychiatric history • Social, community and recovery supports • Legal concerns • Strengths • Previous treatment history • Diagnostic impression • Treatment and other service recommendations

Recovery Oriented Systems of Care • Affirms the real potential for permanent resolution of behavioral health problems • Offers solutions to behavioral health problems on a community and cultural level • Shift away from risk management and relapse prevention toward encouraging clients to self-define goals and take responsibility for achieving them • A shift from emergency room/acute care model to one of sustained recovery management which include wrap-around recovery support services Recovery Oriented Systems of Care • Emphasis on • Post-treatment monitoring • Stage-appropriate recovery education • Peer recovery coaching • Assertive linkages to recovery communities • Early re-intervention • Maintaining functional ability in all life activities • Recovery in illness instead of recovery from illness Recovery Oriented Systems of Care • Goals • Foster health and resilience activities • Increase permanent housing and sense home/belonging • Ensure gainful employment and access to education to provide a sense of purpose • Enhance communities by increasing availability of necessary supports from and for peers/family/community • Reduce barriers to social inclusion • Counselor functions • Identify gaps in services • Identifying emerging trends and needs • Monitor system effectiveness Recovery Oriented Systems of Care • Guiding principles of Recovery emerges from hope and is… • Person-centered - self-efficacy, self-direction • Non-linear, and occurs via many pathways (methods) • Holistic – mind, body, spirit, community • Supported by peers and allies (counselors/case workers) • Supported through relationships and social networks (family, peers, faith groups, community) • Culturally based and influenced • Supported by addressing trauma • Based on respect of individual, family and community strengths and responsibilities

Recovery Oriented Systems of Care • 3 core components • Collaborative decision making /individual empowerment • Continuity of services and supports • No wrong door • Services available as long as needed • Service quality and responsiveness • Evidence based • Developmentally and culturally appropriate • Gender specific • Trauma informed • Family focused • Stage appropriate

Recovery Management • Treatment does not need to be voluntary, but success depends on personal engagement • Full recovery often comes from episodic, nonlinear treatment • Previous treatment and relapse is not indicative of poor prognosis • Relapse is viewed as evidence of the severity of the condition rather than a cause for discharge • Recovery management is a time-sustained, recovery focused collaboration between consumers and service providers with the goal of stabilizing and managing the ebb and flow of co-occurring disorders until full recovery is achieved or self-management is possible. Recovery Management • Spans 3 phases • Prerecovery identification and engagement • Recovery initiation and stabilization • Recovery maintenance Referral • Dual-diagnosis or co-occurring disorders indicates the presence of both mental health and addiction issues. • People with co-occurring issues often experience more severe emotional, social and physical problems than someone with only one issue • Medical, Mental health and Addictive disorders all influence each other • Use and withdrawal can both cause mood, social and physical conditions • Continuum: Disorders vary in terms of… • Severity • Chronicity • Disability/degree of impairment in functioning

Diagnosis of Substance Use Disorders • The DSM V recognizes 10 separate classes of drugs • Alcohol • Inhalants • Opioids • Sedatives • Hypnotics/Barbiturates • Anxiolytics • Stimulants • Caffeine • Tobacco • Cannabis • Hallucinogens • Other/Unknown substances Drugs of Abuse • Alcohol • Classified as a sedative-hypnotic, CNS depressant • Ethanol/Ethyl alcohol 8 stages of effect as BAC increases • Subclinical • Euphoria • Excitement • Excitement/confusion • Confusion stupor • Coma • Death Drugs of Abuse • Alcohol • Men drink more • Women more likely to • Develop drinking problems • Experience alcohol related organ damage at lower levels • Women’s BAC reaches higher levels with same amounts of alcohol as men • Alcohol mixes with water and men tend to have more body water

Drugs of Abuse • Alcohol related medical conditions • Loss of control of eye muscles • Hypoglycemia • Gastritis / Pancreatitis • Reduced immunity • Cardiac arrhythmia • Anemia • Constant flushing • Peripheral neuritis • Fatty liver • Cirrhosis • Blood pressure increases • Wernicke/Korsakoff’s syndrome / Alcohol related dementia Drugs of Abuse • Cannabis • As of 2016, still considered a schedule 1 by the DEA • Schedule 1 substances have no medicinal use and high risk of abuse • Legal in 29 states for medical use and in 8 of those states for recreational use • 9-17% of occasional users become addicted • 25-50% of daily users become addicted • Methods of administration • Smoked (pipes, bongs, blunts) – rapid action • Consumed (tea, brownies) –slower action • Acts on cannabinoid receptors which influence memory, pleasure, concentration, sensory perception Drugs of Abuse • Synthetic Marijuana (Spice/K2) • Synthetic cannabinoids refer to a growing number of man-made mind-altering chemicals sprayed on dried, shredded plant material or vaporized to get high. • Synthetic cannabinoids are sometimes misleadingly called "synthetic marijuana" (or "fake weed") because they act on the same brain cell receptors as THC • The effects of synthetic cannabinoids can be unpredictable and severe or even life-threatening. Drugs of Abuse • Synthetic Marijuana (Spice/K2) • Synthetic cannabinoid users report some effects similar to those produced by marijuana: • elevated mood • relaxation • altered perception • symptoms of psychosis • Synthetic cannabinoids can also cause serious mental and physical health problems including: • rapid heart rate • vomiting • violent behavior • suicidal thoughts Drugs of Abuse • Cannabis • Effects • Respiratory illness • Heightened heart attack risk • Neurobehavioral effects on fetus • Increased depression, anxiety and suicidal thoughts, esp. in adolescents • Loss of motivation • Exacerbation of schizophrenia • Impaired judgement • Impaired motor coordination • Reduced life satisfaction • Lower academic/career success

Drugs of Abuse • Prescription Drugs • Opiates • Ranks #2 behind marijuana as most abused drug • 60% of people who abuse it got it free from friends/relatives • Treat • Pain • Depression • Depressants (Benzos / Barbiturates) • Anxiety • Sleep disorders • Stimulants • Narcolepsy • ADHD • Obesity Drugs of Abuse • Prescription and OTC (i.e. DXM, pseudoephederine) drugs can be abused by: • Taking medication prescribed for someone else • Taking drugs in a higher amount or via a different method than intended • Taking drugs for a different purpose than intended • Combining drugs • Same class • Different class Withdrawal from Drugs of Abuse • Sustained use of addictive substances of behaviors causes reversible adaptations within the body • Reduce the effects of the drug (tolerance, dependence) • Withdrawal • Euphoria producing drugs act on the nucleus accumbens (pleasure center) • Alcohol and benzodiazepine withdrawal can be life threatening Post Acute Withdrawal Syndrome Intake • Intake • Is the process of enrolling a client in a specific course of treatment • A series of activities designed to organize information about the client and their significant others • Ensures eligibility • Completes basic data collection • Identifies barriers and assets • Establishes a treatment approach • Primarily administrative in nature • Needs to be standardized in nature • It is an extension of the screening and assessment process • Can be used to engage the client in treatment and enhance motivation for change Orientation • Can be conducted in individual, family or group settings • Completed after the intake • Describes specific aspects of treatment • Schedule • Goals • Rules and responsibilities • Hours of service • Medication • Drug testing • Treatment costs • Client rights Client Rights • Florida Statute 381.026 • Individual dignity • Confidentiality • Right to nondiscriminatory services • Standard (Age, race, gender, sexual orientation, disability) • Prior service departures • Number of relapses • Level of psychotropics • Ability to pay (public agencies) Client Rights • Quality services • Communication • With informed consent communication may be limited • Personal effects • unless for to do so would infringe upon the right of another patient or is medically or programmatically contraindicated for documented medical, safety, or programmatic reasons • May be temporarily held by the agency but must be returned at the end of treatment • Minors to be educated • Counsel (involuntary proceedings) • Habeus corpus (full evidence of what is being alleged) Client Rights • (Florida Specific) • A patient has the right to a prompt and reasonable response to a question or request. • A patient receiving care in a health care facility or in a provider’s office has the right to bring any person of his or her choosing to the patient-accessible areas of the health care facility or provider’s office to accompany the patient while the patient is receiving inpatient or outpatient treatment or is consulting with his or her health care provider, unless doing so would risk the safety or health of the patient, other patients, or staff of the facility • A patient has the right to refuse any treatment • A patient has the right to express grievances to a health care provider, a health care facility, or the appropriate state licensing agency regarding alleged violations of patients’ rights. Client Rights • (Florida Specific) • A patient has the right to know the name, function, and qualifications of each health care provider who is providing medical services to the patient. A patient may request such information from his or her responsible provider or the health care facility in which he or she is receiving medical services. • A patient in a health care facility has the right to know what patient support services are available in the facility. • A patient has the right to be given by his or her health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis, unless it is medically inadvisable or impossible to give this information to the patient • A health care provider or health care facility shall respect a patient’s legal right to own or possess a firearm and should refrain from unnecessarily harassing a patient about firearm ownership during an examination.

Treatment Plan • Is a contract between the client, counselor and treatment team, each being responsible for its development and implementation • The clinician should recognize that • Treatment occurs in different settings over time • Much of the recovery process occurs outside of or immediately following treatment • Treatment is often divided into phases • Engagement • Stabilization • Primary treatment • Continuing care

Treatment Planning • Plots out a roadmap for the treatment process • Treatment plans are completed once • A diagnosis is made • Level of care is determined • Client is admitted to the program • Level of care is determined based on • Diagnosis • Client’s strengths and assets

Treatment Planning • Treatment plans address all biopsychosocial needs • Establish what changes are expected through achievable goals • Clarifies what interventions and counseling methods will be used to help the patient achieve those goals • Sets the measures that will be used to gauge success • Incorporates the clients strengths, needs, abilities and preferences • Referrals are made to other agencies as needed • When referrals are made, collaboration is essential to keep clients from falling through the cracks Treatment Planning and Confidentiality • Information, even within the agency, is restricted to need-to-know. • Treatment plans may have to be co-signed by a clinician who is already certified or licensed. Treatment Planning: Function • Action-oriented process that lays out a logical, goal-directed strategy for making positive changes • Establishes collaboration between client and counselor so they can prioritize mutually agreeable goals. Treatment Planning: Structure • Achievable goals are selected by assessing and prioritizing clients needs, taking into account • Level of impairment • Motivation • Real-world influences on needs • Treatment plans consider client • Needs • Readiness • Preferences and prior treatment history (what did and didn’t work) • Personal goals • Obstacles Treatment Planning: Structure • Defines • SMART Goals • Objectives • Anticipated type, duration and frequency of services • Who is responsible for what • Time table • Incorporates client input and participation in development • Have client prioritize presenting issues • Get input on goals and objectives • Both counselor and client sign the plan • The clinician may also facilitate and manage referrals (i.e. housing, legal, medical) Treatment Planning: Issues • At minimum, the plan is a flexible document that uses a stage-match process to address: • Identified Substance Use Disorders (SUDs) • Recovery support environment • Potential mental health conditions • Potential medical issues • Employment • Education • Spirituality • Social needs • Legal needs Elements of an Initial Treatment Plan • Done at admission (or within 24 hours) • Based on information from assessment and screening • Serves as the initial roadmap • Includes • Presenting problems • Preliminary goals • Type, frequency and duration of service • Signature and date of client and counselor w/credentials Elements of an Individualized Treatment Plan • Problem and problem description “Why are you here” • Strengths • Concrete, measurable goals • Objectives • Strategies w/ frequency and duration • Diagnosis • Signature of the client and counselor • Signature of clinical supervisor if required Treatment Planning: Ongoing and Review • Ongoing assessment and collaboration is used to regularly review the treatment plan and make necessary modifications • Review should be completed at minimum at major or key points in the clients treatment course • Admission or readmission • Transfer • Discharge • Major change in condition • After 12 months

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Tips for Individual and Group Counseling Instructor: Dr. Dawn-Elise Snipes LPC-MHSP, LMHC Podcast Host: Counselor Toolbox and Addiction Counselor Exam Review

Objectives • Review techniques to start and facilitate individual sessions • Learn ways to facilitate • Process groups • Random and planned psychoeducational groups General • How you start and manage individual and group sessions depends largely on • the counselor’s theoretical approach • the personal characteristics of the client (age, cognitive functioning, distracting factors, presenting issue) Individual Sessions • The first session— • Develop rapport/empower the client • Ask the client what he or she hopes to accomplish • Share your understanding of his/her situation to make sure you are on the same page • Ask the client to prioritize which problem he/she wants to address first/which is most important • Ask the client what he/she thinks might be helpful to approach the issue • Share your theoretical approach and, based on the client’s responses, outline a proposal for the next steps. Individual Sessions • Subsequent sessions • Humanistic approaches • Acknowledge that people have within themselves the answers to improving their own lives. • Recognize and respect the ability of human beings to employ reason, science, intuition, and creativity as tools for the achievement of goals. • Don’t get unnecessarily side tracked. Stay on the issue at hand. • Assert that wellness and health is best achieved through personal growth. • Strategies • Begin by summarizing what was covered in the last session • Ask the client to share what has happened in the past week, emphasize positive changes and explore stuck points/challenges • Use socratic questioning to draw connections between the last weeks events, current presenting issues and current skills

Individual Sessions • Subsequent sessions • Humanistic approaches • Acknowledge that people have within themselves the answers to improving their own lives. • Recognize and respect the ability of human beings to employ reason, science, intuition, and creativity as tools for the achievement of goals. • Assert that wellness and health is best achieved through personal growth. • Strategies • Begin by summarizing what was covered in the last session • Ask the client to share what has happened in the past week, emphasize positive changes and explore stuck points/challenges • Use socratic questioning to draw connections between the last weeks events, current presenting issues and current skills

Individual Sessions • Subsequent sessions • Cognitive Approaches • Assert that issues are caused by unhelpful thoughts and/or unhelpful behaviors. • Seek to identify those thoughts and behaviors and help the client become more mindful of how these things impact their mood. • Strategies • Cognitive approaches tend to be much more structured. • Begin by summarizing what was covered in the last session • Review homework • Ask the client to share what has happened in the past week, emphasize positive changes and explore stuck points/challenges • Help client identify and address unhelpful thoughts and behaviors perpetuating stuck points. Group Sessions • Process Groups • Psychoeducational Groups • Structured • Unstructured

Group Sessions • Process Groups • Central to the group process is the opportunity for members to talk as openly as they possibly can about their interactions and experiences of each other as well as any aspects of the group experience that may come to mind. (microcosm) • Can be an excellent adjunct to psychoeducational groups which teach knowledge and skills. • Process groups translate and generalize those skills to practice “How did it feel last week when you…” “What came up for you when…” • Techniques • Theme your modules (abandonment, grief and loss, shame and guilt, mothers/fathers empowerment, etc.) • Consider choosing a book to give structure (Seeking Safety, Toxic Parents, Growing Up with a Borderline Parent, Journey to Recovery) • Draw connections between members experiences • Encourage mutual support and hope Group Sessions • Psychoeducation • Detailed vs. Broad Concepts (Overview and Outline) • Communicate Effectively • Auditory • Visual • Kinesthetic • Respect Process: Active and Reflective Learners • Make it Relevant: Thinking vs. Feeling • Make it Engaging: Gameify/Skits/Group Teaching Group Sessions • Psychoeducation • Structured • Follow a syllabus or workbook • Begin by reviewing what was discussed last week and any homework (10 minutes) • Present the topic for this week (10-20 minutes) • Have the clients practice the new skill, use scenarios (20 minutes) • Have clients share for the last 30 minutes… • How this skill would have been useful last week • How they think it will benefit them next week • How they will remember to use it/integrate it

Group Sessions • Psychoeducation • Random • Begin with a check in • Identify common theme to serve as foundation for group • Roomba philosophy. (List of topics) • Identify the topic you will be discussing and how it is relevant to the majority presenting issues • Present the topic for this week in an engaging way (15-20 minutes) • Have clients share • How this skill would have been useful last week • How they think it will benefit them next week • How they will remember to use it/integrate it

Progress Notes for Individuals • At the beginning • Have the client identify what goals he or she achieved or progress made over the prior week • At the end of the individual • Have the client summarize what the most salient points were for him or her in the session and how they will help him/her meet identified goals • Have the client identify tasks/goals for the next week • Remind the client of any referrals that were made during session Progress Notes for Group • Have each client fill out a worksheet • Have a check sheet for the client to identify mood • Have the client summarize what the most salient points were for him or her in the session and how they will help him/her meet identified goals • Have the client identify tasks/goals for the next week with regard to the topic • Have the client identify any necessary resources or problems he or she is having

Summary • Translating everything learned in class to working with clients can be a daunting task

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Models of Treatment for Co-Occurring Disorders Dr. Dawn-Elise Snipes PhD, LMHC Executive Director, AllCEUs.com Learner Objectives ~ Identify the most common settings for co-occurring disorders treatment ~ Differentiate between the levels of treatment from intervention to residential level IV. ~ Identify specific characteristics of treatment in problem solving courts, jails

Settings ~ Health Departments and Social Services ~ Behavioral Healthcare Centers ~ Private Practice Offices ~ Hospitals ~ Schools ~ Jails

Prevention ~ Averting problems before they begin through modifying risk and protective factors in the following domains: ~ Individual ~ Family ~ School ~ Community ~ Examples ~ Educating children about drugs and their effects ~ Improving communication among families ~ Ensuring children are able to engage in school ~ Improving community stability, organization and attachment. Intervention ~ Providing resources to prevent worsening of addiction or other biopsychosocial issues that could lead to addiction. ~ Methods ~ Psychoeducational groups and classes ~ Early identification of persons with risk factors for mental health, stress related or substance abuse issues ~ Frequency: Once per week ~ Setting: ~ School ~ Church ~ Community Center ~ Clinic ~ Home ~ Online/phone Outpatient ~ Individual and group counseling sessions ~ Frequency: 1 to 3 times per week ~ Setting: ~ Clinic ~ School ~ Online/Telephone ~ Home ~ Issues ~ Coping skills ~ Maladaptive emotions/reactions; thoughts and/or behaviors ~ Relationship and interpersonal issues ~ Past traumas and losses

Intensive Outpatient ~ Individual and group counseling sessions ~ Frequency: 3 to 5 times per week for a minimum of 3 hours per day ~ Setting: ~ Clinic ~ Online ~ Issues ~ Coping skills ~ Maladaptive emotions/reactions; thoughts and/or behaviors ~ Relationship and interpersonal issues ~ Past traumas and losses Partial Hospitalization ~ Individual and group counseling sessions ~ Frequency: Daily ~ Setting: Clinic (Patient sleeps off campus) ~ Issues ~ Coping skills ~ Maladaptive emotions/reactions; thoughts and/or behaviors ~ Relationship and interpersonal issues ~ Past traumas and losses

Short-Term Residential ~ Individual and group counseling sessions ~ Frequency: Daily for up to 60 days ~ Setting: Clinic (Patient sleeps on campus) ~ Issues ~ Coping skills ~ Maladaptive emotions/reactions; thoughts and/or behaviors ~ Relationship and interpersonal issues ~ Past traumas and losses

Long Term Residential ~ Individual and group counseling sessions ~ Frequency: Daily for up to 1 year ~ Setting: Clinic (Patient sleeps on campus) ~ Issues ~ Coping skills ~ Maladaptive emotions/reactions; thoughts and/or behaviors ~ Relationship and interpersonal issues ~ Past traumas and losses ~ Medication management ~ Establishment of wrap around services

Criminal Justice ~ Individual and group counseling sessions ~ Frequency: Daily ~ Setting ~ Jail ~ Intensive outpatient as with problem solving courts ~ Issues ~ Coping skills ~ Maladaptive emotions/reactions; thoughts and/or behaviors ~ Relationship and interpersonal issues ~ Past traumas and losses ~ Changing criminogenic thinking ~ Reintegration services Case Management and linkages with wrap around services Job and life skills

Problem Solving Courts ~ Created to assist consumers whose illegal behaviors are thought to be a result of an underlying substance abuse or mental health issue. ~ Involve ~ Weekly monitoring by the court ~ Daily contact with a counselor ~ Provision of sanctions based on noncompliance ~ Progression through phases based on demonstrated improvements in behaviors, reactions and relationships

Summary ~ Consumers should be placed in the least restrictive environment ~ There are benefits and drawbacks to all levels of care ~ Outpatient ~ Intensive outpatient ~ Short term residential ~ Long term residential ~ Problem solving courts have demonstrated much success

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Life Skills Instructor; Dr. Dawn-Elise Snipes, PhD, LPC-MHSP Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Review common life skills Communication Skills

~ Types ~ Written ~ Nonverbal ~ Oral Communication Skills

~ Assertiveness ~ Being open in expressing wishes, thoughts and feelings and encouraging others to do likewise. ~ Listening to the views of others and responding appropriately, whether in agreement with those views or not. ~ Accepting responsibilities and being able to delegate to others. ~ Regularly expressing appreciation of others for what they have done or are doing. ~ Being able to admit to mistakes and apologize. ~ Maintaining self-control. ~ Behaving as an equal to others, respecting that their opinions and needs are equally important to yours.

Communication Skills

~ 6 main characteristics of assertiveness ~ Eye contact: demonstrates interest, shows sincerity ~ Body posture: congruent body language will improve the significance of the message ~ Gestures: appropriate gestures help to add emphasis ~ Voice: a level, well modulated tone is more convincing and acceptable, and is not intimidating ~ Timing: use your judgement to maximize receptivity and impact ~ Content: how, where and when you choose to comment is probably more important than WHAT you say ~ Use of “I” statements Communication Skills

~ Conflict management and dialectics ~ We respond to conflicts based on our perceptions of the situation, not necessarily to an objective review of the facts. Our perceptions are influenced by our life experiences, culture, values, and beliefs. ~ Conflicts trigger strong emotions. If you aren’t comfortable with your emotions or able to manage them in times of stress, you won’t be able to resolve conflict successfully. ~ Conflicts are an opportunity for growth. When you’re able to resolve conflict in a relationship, it builds trust. You can feel secure knowing your relationship can survive challenges and disagreements. Communication Skills

~ Conflict management and dialectics ~ Skills ~ Get the facts ~ Empathize with the other person/try to understand their feelings and point of view ~ Be respectful and objective in communications ~ Be aware of verbal and nonverbal cues of increasing frustration ~ Identify triggers for conflict ~ Seek compromise/embrace dialectics ~ Win/lose ~ Competent/incompetent ~ Right/wrong ~ Be creative Communication Skills

~ Negotiating ~ Stages ~ Preparation ~ Discussion ~ Clarification of goals ~ Negotiate towards a Win-Win outcome ~ Agreement ~ Implementation of a course of action ~ Creating a win/win ~ Saying No, Asking for something

Communication Skills

~ Interviewing ~ Dress for the job ~ Listen more than you talk ~ Ask questions more than you tell ~ Answer questions asked of you ~ Use proper language ~ Speak confidently and clearly ~ Don’t be too cocky ~ Express optimism, enthusiasm and gratitude ~ Research and rehearse potential interview questions ~ Re-read the job description prior to the interview ~ Research the company

Communication Skills

~ Giving criticism ~ State the problem objectively ~ Phrase it in terms of how the solution can be helpful to the person. ~ Your paperwork has been very late. You are an excellent employee. Getting your paperwork in on time will go a long way to helping you get a raise/promotion etc. ~ Ask how you can help ~ Is there something that has changed that is causing the problem, or something I can help with?

Communication Skills

~ Handling criticism ~ Listen to hear what the critic is saying ~ Separate the criticism from the self ~ Don’t be defensive. Often the person is trying to help you. Thank the commenter for his criticism, acknowledge his point without being defensive (Separate criticism from abuse though) ~ Ask open ended questions for clarification ~ Admit your mistakes. ~ Take what is useful and leave the rest. (Sometimes it is about them) ~ Look at criticism as a challenge to do better. ~ Work on your self-esteem. Ultimately you need your own approval. You will not please anybody all of the time.

Communication Skills

~ Handling criticism ~ Mario Andretti was asked for his number one tip for success in race car driving. He said, “Don’t look at the wall. Your car goes where your eyes go.” ~ If you choose to focus on the anger and criticism instead of your strengths and the solutions, you will likely crash and burn. ~ Remember, people who criticize everything or make scathing remarks to be hurtful are the ones that need help

Communication Skills ~ Listening ~ Face the speaker and maintain eye contact ~ Be attentive—listen to hear, not defend and keep an open mind ~ Try to picture what the person is saying or understand it from their point of view ~ Don’t interrupt or impose your solutions ~ Interrupting sends a variety of messages. It says: ~ "I'm more important than you are." ~ "What I have to say is more interesting, accurate or relevant." ~ "I don't really care what you think." ~ "I don't have time for your opinion." ~ "This isn't a conversation, it's a contest, and I'm going to win.“ ~ Ask clarifying questions to ensure understanding ~ Summarize and check for understanding

Goal Setting ~ Begin with the end in mind ~ SMART Goals ~ Specific ~ Measurable ~ Achievable ~ Realistic ~ Time Limited

Critical Thinking and Decision Making ~ Critical Thinking ~ How research to assess the accuracy of something ~ How to question findings ~ How to arrive at your own conclusions ~ Decision Making ~ Identifying what and who is important in your life ~ Establish the facts in the situation ~ Identify your options and the positive and negative consequences of each ~ Choose the best option ~ Implement your decision ~ Evaluate the outcome Stress Management ~ Stress can mean anxiety, anger, or feeling overwhelmed ~ Know your stress triggers and try to prevent them when possible ~ Know the impact of stress on you emotionally, mentally, physically, interpersonally ~ Identify 5 healthy ways of dealing with unavoidable stress Anger Management ~ Anger represents a reaction to a threat. ~ Common threats ~ Rejection ~ Failure ~ Isolation ~ Loss of Control ~ The Unknown ~ What your triggers are and why ~ How to deal with those triggers ~ Ways to tolerate distress and resist urges ~ Effective ways you respond to anger

Mindfulness and Self-Awareness ~ Know your preferences ~ Know your temperament ~ Extrovert or Introvert (How you get and keep energy) ~ Sensing or iNtuitive (How you conceptualize things) ~ Thinking or Feeling (What motivates you) ~ Judging or Perceiving (Your time management style) ~ Know your cycles: When are you most energetic? ~ Know your happiness, anger, anxiety, depression triggers ~ Mindfulness ~ Check in with yourself to identify anything that may make you more vulnerable to distress ~ Take proactive steps to mitigate that. Time Management & Organization ~ Organization ~ Set aside cleaning/organizing time each day ~ Use bins (keys, bills) or folders (paperwork) ~ Put sheets inside a pillow case ~ Simplify ~ Time Management ~ Do all shopping once every two weeks ~ List, Eliminate, Prioritize, Delegate and Combine ~ Remember ADLs (eating, bathing) and travel time ~ If needed schedule in recreation and rest Study Skills ~ Know your learning style ~ Auditory ~ Tape record notes and listen to them ~ Discuss them with study group ~ Ask yourself questions ~ Kinesthetic ~ Apply it to your life ~ Make a quiz ~ Practice it (i.e. math) ~ Teach it to someone ~ Visual ~ Read more than once ~ Draw diagrams ~ Underline/highlight

Study Skills ~ Improve your concentration ~ Nutrition ~ Environment ~ Time of day ~ Gamify it ~ Chunk it

Study Skills ~ Improve note taking--- Find the main point of each paragraph ~ Don’t cram all your studying into one session ~ Try to study at the same time each day ~ Do 15 ~ Have a goal ~ Review your notes before starting an assignment

Job Skills ~ Appearance ~ Punctuality ~ Team work ~ Work ethic

Activities of Daily Living ~ Cooking ~ Finding and completing recipes ~ Shopping ~ Fry/sautee, boil, steam, broil, bake ~ Laundry ~ Doing ~ Colors vs. whites ~ Reading the label ~ How hot to wash/dry ~ Mending ~ Buttons ~ Seam rips ~ Other rips ~ Sweaters

Activities of Daily Living ~ Paying bills ~ Know what bills you have ~ Know when you get paid and how much

~ Work with creditors to change payment due dates ADLs ~ Paying bills ~ Balance your checkbook at least once a week ~ Don’t spend more on credit cards than you can pay off that month ~ Always have overdraft protection on your accounts ~ Set up auto-payment when possible ~ Try to have at least 3 months of money in reserve ~ Save $10 or more per week until you do ~ Avoid using debit cards ~ Don’t keep cash in your wallet

Using Community Resources ~ How to find ~ Help ~ Activities

Parenting (or Re-Parenting) Skills ~ Responding to infant’s needs ~ Helps child learn to trust caregivers ~ Unconditional positive regard ~ Love the child, dislike the choice ~ Addressing inappropriate behaviors ~ Positive redirection ~ Remove the reinforcement ~ Add a competing reinforce ~ Being consistent ~ Setting healthy boundaries ~ Encouraging independence ~ Finding resources/help Summary ~ There are a variety of skills people need to succeed independently ~ Without safe housing, nutritious meals, proper healthcare and a job people will not be independent for long. ~ These skills help them get their basic needs met.

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Recovery Oriented System of Care and Service Coordination Recovery Oriented Systems of Care ~ Affirms the real potential for permanent resolution of behavioral health problems ~ Offers solutions to behavioral health problems on a community and cultural level ~ Shift away from risk management and relapse prevention toward encouraging clients to self-define goals and take responsibility for achieving them ~ A shift from emergency room/acute care model to one of sustained recovery management which include wrap-around recovery support services Recovery Oriented Systems of Care ~ Emphasis on ~ Post-treatment monitoring ~ Stage-appropriate recovery education ~ Peer recovery coaching ~ Assertive linkages to recovery communities ~ Early re-intervention ~ Maintaining functional ability in all life activities ~ Recovery in illness instead of recovery from illness Recovery Oriented Systems of Care ~ Goals ~ Foster health and resilience activities ~ Increase permanent housing and sense home/belonging ~ Ensure gainful employment and access to education to provide a sense of purpose ~ Enhance communities by increasing availability of necessary supports from and for peers/family/community ~ Reduce barriers to social inclusion ~ Counselor functions ~ Identify gaps in services ~ Identifying emerging trends and needs ~ Monitor system effectiveness Recovery Oriented Systems of Care ~ Guiding principles of Recovery emerges from hope and is… ~ Person-centered - self-efficacy, self-direction ~ Non-linear, and occurs via many pathways (methods) ~ Holistic – mind, body, spirit, community ~ Supported by peers and allies (counselors/case workers) ~ Supported through relationships and social networks (family, peers, faith groups, community) ~ Culturally based and influenced ~ Supported by addressing trauma ~ Based on respect of individual, family and community strengths and responsibilities

Recovery Oriented Systems of Care ~ 3 core components ~ Collaborative decision making /individual empowerment ~ Continuity of services and supports ~ No wrong door ~ Services available as long as needed ~ Service quality and responsiveness ~ Evidence based ~ Developmentally and culturally appropriate ~ Gender specific ~ Trauma informed ~ Family focused ~ Stage appropriate

Recovery Management ~ Treatment does not need to be voluntary, but success depends on personal engagement ~ Full recovery often comes from episodic, nonlinear treatment ~ Previous treatment and relapse is not indicative of poor prognosis ~ Relapse is viewed as evidence of the severity of the condition rather than a cause for discharge ~ Recovery management is a time-sustained, recovery focused collaboration between consumers and service providers with the goal of stabilizing and managing the ebb and flow of co-occurring disorders until full recovery is achieved or self-management is possible. Recovery Management ~ Spans 3 phases ~ Prerecovery identification and engagement ~ Recovery initiation and stabilization ~ Recovery maintenance Service Coordination ~ Encompasses administrative, clinical and evaluative activities that bring the client , treatment services, community agencies and other resources together to focus on needs identified in the recovery plan ~ Service coordination includes: ~ Case management ~ Collaboration with client and SOs ~ Coordination of treatment and referral services to address issues contributing to and caused by addictive behaviors ~ Liaison activities with community resources ~ Ongoing evaluation of treatment progress and client needs ~ Client Advocacy

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Documentation Review Dr. Dawn-Elise Snipes PhD, LPC-MHSP Podcast Host: Counselor Toolbox and Addiction Counselor Exam Review Addiction Counselor Certification Training (400 Hours) $149 Documenting the Treatment Process ~ The client record is the most important tool to ensure continuity of care ~ Documentation contributes to service delivery by: ~ Reducing replication of services ~ Presenting a cohesive longitudinal record of clinically meaningful information ~ Ensuring reimbursement for services ~ Assists in guarding against malpractice ~ What was done ~ By whom ~ Were they adequately credentialed

Purposes of Clinical Documentation ~ Records professional services ~ Intake ~ Differential diagnosis ~ Placement criteria used in decision making ~ Treatment and other services provided ~ Response to treatment interventions ~ Referral services and outcome ~ Clinical course ~ Reassessment and treatment plan reviews ~ Records compliance with state, accreditation and payor requirements ~ Ease transition to other programs and to referral resources ~ Prevent duplication of information gathering when possible Purposes of Clinical Documentation ~ Facilitates Quality Assurance ~ Documenting the appropriateness, clinical necessity and effectiveness of treatment ~ Substantiating the need for further assessment and testing ~ Support termination or transfer of services ~ Identifying problems with service delivery by providing data to support corrective actions ~ Adding to methods to improve and assure quality of care ~ Providing information that is used in policy development, program planning and research ~ Providing data for use in planning professional development activities. ~ Fosters communication and collaboration between multidisciplinary team members Documentation: CFR 42 part 2 ~ Confidentiality of Alcohol and Drug Abuse Patient Records ~ 42 CFR Part 2 applies to all records relating to the identity, diagnosis, prognosis, or treatment of any patient in a substance abuse program in the US ~ Prohibition, data that would identify a patient as suffering from a SUD or undergoing SUD treatment ~ 42 CFR Part 2 allows for disclosure ~ where the state mandates child-abuse-and neglect reporting ~ when cause of death is being reported ~ with the existence of a valid court order Documentation – Release of Information ~ A written consent form requires ten elements (42 C.F.R. § 2.31(a); 45 C.F.R. § 164.508(c)): ~ 1. the names of the programs making the disclosure ~ 2. the name of the individual or organization that will receive the disclosure ~ 3. the name of the patient who is the subject of the disclosure ~ 4. the specific purpose or need for the disclosure ~ 5. a description of how much and what kind of information will be disclosed ~ 6. a patient’s right to revoke the consent in writing and the exceptions ~ 7. the program’s ability to condition treatment, payment, enrollment, or eligibility of benefits on the patient agreeing to sign the consent ~ 8. the date or condition when the consent expires if not previously revoked ~ 9. the signature of the patient (and/or other authorized person) ~ 10. the date on which the consent is assigned ~ When used in the criminal-justice setting, expiration of the consent may be conditioned upon the completion of, or termination from, a program

Documentation – Information Sharing ~ Information can be shared within an agency on a need to know basis with person on the treatment team ~ Information sharing can be done ~ With a release ~ To the client ~ Under specific circumstances ~ Agencies generally have policies for who is allowed to release information ~ Clients have the right to review and amend their records ~ If request to view or amend the record is denied, a written explanation must be provided to the client

HIPAA and HITECH Act ~ Protects insurance coverage of workers when they change or lose their job ~ Safeguards the privacy of information ~ Combats waste in healthcare delivery ~ Simplifies administration of health insurance HIPAA Records and Record Storage ~ Medical records are legal documents ~ All states have policies regarding record retention ~ Medical records of adults are retained for 7 years ~ Medical records of minors may be retained for longer ~ Agencies and solo practitioners should have policies identifying retention and storage policies ~ CFR 42 2.19, 2.16 ~ All records must remove patient identifying information ~ Sanitize software, printer ribbons, fax hard-drives, printer hard drives HIPAA Records and Record Storage ~ All client records and identifying information must be kept out of sight of unauthorized personnel ~ Lists/rosters ~ Attendance records ~ Appointment schedules ~ Computerized information ~ Client records ~ Phone messages Disposition of records by discontinued programs ~ If a program discontinues operations or is taken over or acquired by another program, it must remove patient identifying information from its records or destroy its records, including sanitizing any associated hard copy or electronic media, to render the patient identifying information non-retrievable in a manner consistent with the policies and procedures established under § 2.16, unless: ~ The patient who is the subject of the records gives written consent to a transfer of the records to the acquiring program or to any other program designated in the consent (the manner of obtaining this consent must minimize the likelihood of a disclosure of patient identifying information to a third party); or ~ There is a legal requirement that the records be kept for a period specified by law which does not expire until after the discontinuation or acquisition of the part 2 program. Disposition of records by discontinued programs ~ Records, which are paper, must be sealed in envelopes or other containers labeled as follows: “ Records of [insert name of program] required to be maintained under [insert citation to statute, regulation, court order or other legal authority requiring that records be kept] until a date not later than [insert appropriate date]” ~ All hard copy media from which the paper records were produced, such as printer and facsimile ribbons, drums, etc., must be sanitized to render the data non-retrievable Disposition of records by discontinued programs ~ Records, which are electronic, must be: ~ (i) Transferred to a portable electronic device with implemented encryption to encrypt the data at rest so that there is a low probability of assigning meaning without the use of a confidential process or key and implemented access controls for the confidential process or key; or ~ (ii) Transferred, along with a backup copy, to separate electronic media, so that both the records and the backup copy have implemented encryption to encrypt the data at rest ~ (iii) Within one year of the discontinuation or acquisition of the program, all electronic media on which the patient records or patient identifying information resided prior to being transferred to the device specified in (i) above or the original and backup electronic media specified in (ii) above, including email and other electronic communications, must be sanitized Disposition of records by discontinued programs ~ The portable electronic device or the original and backup electronic media must be: ~ (A) Sealed in a container along with any equipment needed to read or access the information, and labeled as follows: “ Records of [insert name of program] required to be maintained under [insert citation to statute, regulation, court order or other legal authority requiring that records be kept] until a date not later than [insert appropriate date];” and ~ (B) Held under the restrictions of the regulations in this part by a responsible person who must store the container in a manner that will protect the information (e.g., climate controlled environment); and

Documentation Regulations ~ Many agencies govern the content, scope and quality of documentation ~ Single State Authority (SSA) ~ State service and licensing rules ~ May include ~ time frames for documentation completion ~ Who needs to sign and credential the documents ~ Accreditation Bodies ~ Address quality from an organizational leadership and client care perspective (methadone, CARF, JCAHO)

Documentation Regulations ~ Many agencies govern the content, scope and quality of documentation ~ Third Party Payors (Level of Care Guidelines) ~ Provider Agencies Documentation Types ~ Screening ~ Referral source ~ Presenting problems ~ Background biopsychosocial information ~ Emotional/mental status ~ Client strengths and preferences ~ Recommendation for assessment or other referral

Documentation Types ~ Intervention Documentation ~ Client identifying information ~ Source of referral ~ Client placement information ~ Screening information ~ Informed consent for services including any drug testing (signed, dated, credentialed by client and counselor, witnessed) ~ Release of information (with all 10 necessary components (see below) ~ Intervention plan (signed, dated, credentialed by client and counselor, witnessed) ~ Summary of progress ~ Copies of correspondence or reports ~ Transfer or discharge summary Documentation Types ~ Administrative Documentation ~ Accurate, concise reports including recommendations, referrals, case consultations, legal reports, family sessions and discharge summaries ~ Conducted at admission and at specified intervals through out care ~ Types ~ Client identifying and demographic information ~ Referral source name and address ~ Financial information ~ Signed client rights ~ Informed consent for treatment ~ Releases of information ~ Orientation to program ~ Outcome measures ~ Client placement information

Documentation Types ~ Medical Documentation ~ Medical history ~ Nursing assessment ~ Physical exam ~ Lab tests (often including TB and preadmission physical for residential) ~ Records of medical prescriptions and changes in medications ~ Medication Administration Records (MAR) ~ Nursing notes

Documentation Types ~ Clinical Documentation ~ Screening ~ Assessment ~ Treatment Plan ~ Progress Notes ~ Discharge Summary

Electronic Health Records ~ Health Information Technology (HIT) is the secure management of health information on computerized systems ~ Electronic health records help to ~ Track data over time ~ Track progress of those who leave treatment ~ Monitor quality care within the practice ~ Behavioral Health lags in adoption because ~ Cost ~ Technical limitations ~ Lack of standardization of data elements ~ Lack of interoperability of systems ~ Attitudinal constraints ~ Organizational lack of expertise in HIT management Elements of Clinical Documentation ~ Ethically must be clear, concise, accurate, written in ink, time stamped and dated ~ Documentation is an ongoing responsibility for all professionals and should be completed as soon as possible after the contact ~ Documentation ensures accountability ~ The responsibility for accurately representing the client’s situation rests with the counselor and the clinical record, not the client ~ Good clinical documentation spares the client from repeating painful details ~ Language must be objective, but descriptive ~ Documentation must identify persons, places, direct quotations and sources of information ~ Clinical documentation is a legal record and the clinician’s signature indicates the truthfulness of it

Treatment Plan ~ Is a contract between the client, counselor and treatment team, each being responsible for its development and implementation ~ The clinician should recognize that ~ Treatment occurs in different settings over time ~ Much of the recovery process occurs outside of or immediately following treatment ~ Treatment is often divided into phases ~ Engagement ~ Stabilization ~ Primary treatment ~ Continuing care

Treatment Planning ~ Plots out a roadmap for the treatment process ~ Treatment plans are completed once ~ A diagnosis is made ~ Level of care is determined ~ Client is admitted to the program ~ Level of care is determined based on ~ Diagnosis ~ Client’s strengths and assets

Treatment Planning ~ Treatment plans address all biopsychosocial needs ~ Establish what changes are expected through achievable goals ~ Clarifies what interventions and counseling methods will be used to help the patient achieve those goals ~ Sets the measures that will be used to gauge success ~ Incorporates the clients strengths, needs, abilities and preferences ~ Referrals are made to other agencies as needed ~ When referrals are made, collaboration is essential to keep clients from falling through the cracks Treatment Planning and Confidentiality ~ Information, even within the agency, is restricted to need-to-know. ~ Treatment plans may have to be co-signed by a clinician who is already certified or licensed. Treatment Planning: Function ~ Action-oriented process that lays out a logical, goal-directed strategy for making positive changes ~ Establishes collaboration between client and counselor so they can prioritize mutually agreeable goals. Treatment Planning: Structure ~ Achievable goals are selected by assessing and prioritizing clients needs, taking into account ~ Level of impairment ~ Motivation ~ Real-world influences on needs ~ Treatment plans consider client ~ Needs ~ Readiness ~ Preferences and prior treatment history (what did and didn’t work) ~ Personal goals ~ Obstacles Treatment Planning: Structure ~ Defines ~ SMART Goals ~ Objectives ~ Anticipated type, duration and frequency of services ~ Who is responsible for what ~ Time table ~ Incorporates client input and participation in development ~ Have client prioritize presenting issues ~ Get input on goals and objectives ~ Both counselor and client sign the plan ~ The clinician may also facilitate and manage referrals (i.e. housing, legal, medical) Treatment Planning: Issues ~ At minimum, the plan is a flexible document that uses a stage-match process to address: ~ Identified Substance Use Disorders (SUDs) ~ Recovery support environment ~ Potential mental health conditions ~ Potential medical issues ~ Employment ~ Education ~ Spirituality ~ Social needs ~ Legal needs Elements of an Initial Treatment Plan ~ Done at admission (or within 24 hours) ~ Based on information from assessment and screening ~ Serves as the initial roadmap ~ Includes ~ Presenting problems ~ Preliminary goals ~ Type, frequency and duration of service ~ Signature and date of client and counselor w/credentials Elements of an Individualized Treatment Plan ~ Problem and problem description “Why are you here” ~ Strengths ~ Concrete, measurable goals ~ Objectives ~ Strategies w/ frequency and duration ~ Diagnosis ~ Signature of the client and counselor ~ Signature of clinical supervisor if required Treatment Planning: Ongoing and Review ~ Ongoing assessment and collaboration is used to regularly review the treatment plan and make necessary modifications ~ Review should be completed at minimum at major or key points in the clients treatment course ~ Admission or readmission ~ Transfer ~ Discharge ~ Major change in condition ~ After 12 months Progress Notes ~ Document ~ The client’s progress in relation to the treatment plan goals and objectives ~ Problem name and number ~ What client says and does ~ Counselor observations and assessments ~ Continued plans to address the problem ~ New information ~ Format ~ S/O: Specific/objective ~ A/P: Assessment (counselor interpretations)/Plan for how to proceed

Progress Notes ~ Document ~ The client’s progress in relation to the treatment plan goals and objectives ~ Problem name and number ~ What client says and does ~ Counselor observations and assessments ~ Continued plans to address the problem ~ New information ~ Format ~ S/O: Specific/objective ~ A/P: Assessment (counselor interpretations)/Plan for how to proceed

Progress Notes ~ Based on ~ What client says and does ~ What the clinician observes (attitude, demeanor, nonverbals) ~ Counselor’s knowledge and experience ~ Lapse vs. relapse ~ Differential diagnosis ~ Danger to self or others ~ Is not a verbatim transcript, but a cohesive summary

Discharge Summary ~ Discharge planning begins at admission ~ Discharge planning begins at admission and continues throughout treatment ~ Summarize ~ Services delivered ~ Accomplishment of goals and objectives ~ Discharge recommendations (referrals, continuing care etc)

Discharge Summary ~ Elements of the D/C plan ~ Referral source ~ Presenting problems and reason for services ~ Treatment goals, methods and outcomes ~ Outcomes generally pertain to ~ the person’s ability to attain recovery ~ build resilience ~ Work, learn, live and fully participate in the community of choice ~ Condition of client at discharge ~ Prognosis ~ Follow up recommendations (Continuing care/aftercare plan) ~ Counselor signature, date and credentials Discharge Summary ~ Reasons for discharge ~ Treatment completion ~ AMA ~ Treatment noncompliance ~ Treatment incomplete Organization of Documentaiton ~ Each page has the client’s name ~ All entries are signed ~ Errors are lined, initialed, dated and “error” written above it ~ Notes should never be removed from a file ~ Late entries and corrections should be noted as such and entered as a separate document Summary of Clinical Documentation Characteristics ~ Written knowing others will read it ~ Objective ~ Uses descriptive, behavioral terms ~ Avoids jargon/ Keep It Simple ~ Concise ~ Positive

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Diagnosis Dr. Dawn-Elise Snipes PhD, LPC-MHSP Podcast Host: Addiction Counselor Exam Review and Counselor Toolbox Objectives ~ Review the criteria for substance use disorder ~ Discuss substance induced disorders ~ Learn mnemonics to identify signs of intoxication and withdrawal as well as mental health symptoms Diagnosis and the DSM ~ The Diagnostic and Statistical Manual is created to ~ facilitate communication between and within professions regarding mental health and substance use disorders ~ Improve interrater reliability regarding diagnosis ~ Improve sharing of information about client presentation and needs ICD-10 ~ International Classification of Disease is used for diagnosis (like the DSM)

Diagnosis of Substance Use Disorders ~ The DSM V recognizes 10 separate classes of drugs ~ Alcohol ~ Inhalants ~ Opioids ~ Sedatives ~ Hypnotics/Barbiturates ~ Anxiolytics ~ Stimulants ~ Caffeine ~ Tobacco ~ Cannabis ~ Hallucinogens ~ Other/Unknown substances SUD Diagnosis ~ Although how each types of drug acts in the brain differs, they all activate the brain’s reward system ~ Two groups of substance disorders ~ Substance use ~ Substance induced SUD Diagnosis ~ Diagnosis ~ Using in larger amounts or for longer than intended ~ Wanting to cut down or stop but failing ~ Spending increased time getting, using or recovering from use ~ Cravings and urges ~ Neglecting work, school, family, social obligations because of use ~ Continue to use even when it causes problems in relationships ~ Giving up important social, occupational, recreational activities because of use ~ Using in risky situations ~ Continuing to use despite knowing that it is making a physical or psychological problem worse ~ Tolerance ~ Withdrawal

Diagnosis of Substance Use Disorders ~ SUD severity is dependent on how many symptoms are present ~ 2-3 symptoms = Mild ~ 4-5 = Moderate ~ More than 5 severe ~ Qualifiers ~ In early remission ~ In sustained remission ~ On maintenance therapy ~ In a controlled environment

Substance Induced vs. Mental Illness Dx ~ Substance induced means that the current presenting symptoms are likely the result of use of a substance not an underlying (pre-existing) mental disorder ~ Concurrent mental disorders can (and often do) occur Substance-Induced Disorder Diagnosis ~ Result from effects of the use of a substance ~ Intoxication ~ Withdrawal ~ Anxiety or depressive disorders ~ Bipolar and related disorders ~ Psychotic disorders (hallucinations, delusions) ~ Sleep disorders ~ Sexual dysfunctions ~ Neurocognitive disorders ~ The teeter-totter principle helps predict symptoms in the withdrawal period (Polysubstance complicates things) Depressants ~ Alcohol, Sedative, Hypnotic, or Anxiolytic Intoxication (SAM'S GIN) Slurred Speech Attention impairment Memory impairment Stupor or coma or death Gait unsteady Incoordination Nystagmus Depressants ~ Alcohol, Sedative, Hypnotic, or Anxioloytic Intoxication Withdrawal (PAST NITES) Psychomotor agitation Anxiety Seizures (Grand-Mal) Transient hallucinations Nausea or vomiting Insomnia Tremor increased (hand) Excitability-autonomic (Increased HR and BP) Sweating (diaphoresis) Stimulants ~ Amphetamine/Cocaine Intoxication (A CODE BLUE) Agitation or retardation (psychomotor) Cardiac (tachycardia or bradycardia) Opening of the pupil Diaphoresis (or chills) Encephalopathic-like changes (seizures, confusion, dyskinesias, dystonias, or coma) Blood pressure (elevated or lowered) Loss of stomach content Unstable muscle-associated changes (diaphramatic, cardiac, and skeletal) i.e., muscle weakness, respiratory depression, arrhythmias Evidence of weight loss

Stimulants Amphetamine/Cocaine Withdrawal (D-PANTS) Depression (suicidal) P -Psychomotor agitation or retardation A -Appetite increases N -Nightmares (vivid, unpleasant dreams) T -Tiredness (fatigue) S -Sleep (hypersomnia or insomnia)

Cannabis and Hallucinogens Hallucinogen Intoxication (DISTORT) Disoriented (blurred) vision Incoordination Sweating Tachycardia Opening of the pupil Racing heart (palpitations) Tremor Cannabis Intoxication (MEAT) Mouth dry Erythamatous conjunctiva Appetite increased Tachycardia

Opiates ~ Opioid Intoxication (SAD) Slurred speech Pinpoint pupils Attention (or memory) impairment Respiratory depression Euphoria Drowsiness

~ Withdrawal (ARMY FINDS) Aches (muscular) Rhinorrhea (or lacrimation) Mood-dysphoric (depression) Yawning Fever Insomnia Nausea/vomiting Diarrhea Sweating

Also…pupillary dilation or piloerection (goosebumps)

PCP ~ Phencyclidine Intoxication (MAP STAND) Muscle rigidity Acute sense of hearing (hyperacusis) Pain numbness Seizures (or coma) Tachycardia (or hypertension) Ataxia (loss of control of bodily movements) Nystagmus - horizontal and vertical Dysarthria –(problems with articulation) Depression ~ A Sad Face ~ Appetite change ~ Sleep disturbances ~ Anhedonia ~ Dysphoria ~ Fatigue ~ Agitation/restlessness ~ Concentration difficulties ~ Esteem (low) Mania/Hypomania ~ DIG FAST ~ Distractibility ~ Indiscretion ~ Grandiosity ~ Flight of ideas ~ Activity increase ~ Sleep deficit ~ Talkativeness Anxiety ~ GAD ~ WATCHERS ~ Worry ~ Anxiety ~ Tension in muscles ~ Concentration difficulty ~ Hyperarousal (or irritability) ~ Energy loss ~ Restlessness ~ Sleep disturbance PTSD ~ TRAUMA ~ Traumatic event ~ Re-experience ~ Avoidance ~ Unable to function ~ Month or more of symptoms ~ Arousal increased Summary ~ Some conditions are substance induced ~ Substance use can also be a condition in it’s own right ~ It is important to be able to differentially diagnose co-occurring disorders.

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Assessment Review for the Addiction Counselor Certification Exam Dr. Dawn-Elise Snipes, PhD, LPC-MHSP Podcast Host: Counselor Toolbox and Addiction Counselor Exam Review 12 Assessment Steps ~ Engage ~ Get authorizations and gather information from collateral sources ~ Screen for co-occurring disorders ~ Determine the severity of mental and SUDs ~ Determine appropriate level of care ~ Determine diagnoses ~ Determine disability and functional impairment ~ Identify strengths and supports ~ Identify cultural and linguistic needs and supports ~ Identify additional problem areas (medical, housing, education…) ~ Determine readiness for change ~ Plan treatment Assessment ~ Screening determines the possible presence. ~ Assessment ~ Is an ongoing process ~ Determines the nature and severity ~ Develops specific treatment recommendations ~ Surveys client strengths and resources for addressing “life problems.” (wrap-around) ~ Substance Abuse Assessment Foci ~ Historical and situational factors contributing to or triggering use ~ Patterns of use ~ Common signs and symptoms ~ Consequences of use Assessment ~ Examines the context(s) in which the disorder(s) manifest ~ Explores reciprocal interactions of… ~ Family/marital life ~ Social support/interpersonal functioning ~ Physical health needs ~ Spirituality ~ Employment ~ Financial issues ~ Legal issues ~ Other issues which may impact treatment (transportation, childcare)

Assessment ~ Explores reciprocal interactions cont… ~ Gender, cultural, linguistic issues ~ Readiness for change ~ Relapse risk ~ Recovery support ~ Special life circumstances (single parent) ~ Medical conditions ~ Client centered—respecting ~ The client’s perceptions of his problems ~ Goals he wishes to accomplish ~ Strengths he has Assessment Instruments ~ Forms ~ Standardized interviews ~ Limits interviewer to a script ~ Requires limited training ~ Collects the same information on all clients ~ Structured interviews ~ Probing questions can be asked ~ Requires additional training/knowledge ~ Self-administered tests/questionnaires ~ Require some motivation and reading ability on the client’s part ~ Standardized instruments have: ~ Reliability ~ Validity information Assessments ~ Sources of information (with written consent) ~ Personal reports ~ Family ~ Other professionals/prior treatment experiences ~ May be the most objective resource ~ Employment history ~ Criminal records ~ Drug tests ~ Collateral information gathered should be confirmed to the extent possible ~ Accurate assessment requires the coherent integration of multiple sources of information to avoid under- or over-estimation of the problem.

Drug Testing in SUD Treatment ~ Drug testing is ~ Part of the initial assessment ~ Used to identify drugs to make most appropriate treatment recommendations ~ Screen to prevent adverse effects of prescribed medications ~ Component of the treatment plan ~ Way to monitor use of substance and compliance with medications ~ Method to assess efficacy of treatment ~ Method to document abstinence for legal matters, disability, custody etc. ~ Drug testing cannot replace an assessment to diagnose a substance use disorder. Drug Testing in SUD Treatment ~ Drug Testing ~ Can accurately reveal drugs in the system ~ Time frame for detection is limited ~ Dependable for identifying frequent users ~ Less accurate for infrequent or binge users Types of Drug Tests ~ Breathalizer (hours) ~ Urine (up to a month) ~ On-site ~ Gas chromatograph ~ Can produce false positives ~ Saliva (past day) ~ Sweat and hair ~ drug use patterns over periods of time ~ Cannot discriminate between recent and past drug use ~ Not able to identify use within past 3-8 days ~ Blood Risk Assessment ~ One of the most important functions at both screening and assessment ~ Presence of any risk warning signs ~ Requires immediate referral (detox, CST, ER) ~ Screening and assessment are inappropriate ~ Assess for: ~ Intoxication ~ Substance toxicity ~ Withdrawal ~ Aggression/danger to others ~ Potential for self-harm or suicide ~ Co-existing mental health issues Risk Assessment ~ Signs of Drug Toxicity or Intoxication ~ Nausea ~ Vomiting ~ Diarrhea ~ Agitation ~ Lethargy or stupor ~ Increased or decreased heart rate ~ Lack of coordination ~ Slurring words

Risk Assessment ~ Signs of Violence ~ Previous violence ~ Young age at first incident ~ Relationship instability ~ Employment problems ~ Substance use problems ~ Major mental illness ~ Personality traits that deviate from social norms (exploitation, manipulation…) ~ Early maladjustment or trauma ~ Paranoia ~ Failure to respond to treatment in the past Risk Assessment ~ Suicidality ~ Alcoholism (a factor in 30% of suicides) ~ Psychiatric disorder ~ 90% of people who die by suicide have a mental health disorder ~ 60% of people who die by suicide have depression ~ For alcoholics who are depressed the rate is 75% ~ 3 Domains for Assessment ~ Current presentation of suicidality ~ History ~ Risk management Risk Assessment ~ Signs of Suicidality ~ Suicidal or self-harming thoughts, plans, behaviors or intent ~ Specific methods identified ~ Evidence of hopelessness, impulsiveness, panic attacks or anxiety ~ Lack of future plans ~ Signs of “tying up loose ends.” ~ Alcohol or other substance use ~ Thoughts, plans or intentions of violence toward others ~ Psychiatric illnesses Risk Assessment ~ Signs of Suicidality ~ Previous attempts or aborted attempts at suicide or self-harm ~ Family history of suicide attempts, suicide, mental illness, addiction ~ Acute psychosocial crises including financial or changes in socioeconomic status ~ Chronic psychosocial stressors including actual or perceived interpersonal losses ~ Family discord, domestic violence, current or pase sexual or physical abuse ~ Absence of external supports Mental Health Disorders Common in Co-D ~ Borderline Personality Disorder ~ Pervasive pattern of instability in personal relationships, self image and affect in addition to impulsivity. ~ Antisocial Personality Disorder ~ Pervasive disregard for and violation of the rights of others ~ Inability to form meaningful relationships ~ Lack of empathy

Mental Health Disorders Common in Co-D ~ Major Depressive Disorder ~ Lack of pleasure in most things most days for at least 2 weeks ~ Changes in sleep, appetite, energy, concentration ~ Excessive feelings of worthlessness and/or guilt ~ Suicidal ideation ~ Bipolar Disorder ~ Fluctuations between elation (mania) and depression

Mental Health Disorders Common in Co-D ~ Anxiety Disorders ~ Panic attack ~ Distinct period of intense fear usually peaking within 15 minutes ~ Significant fear-related physiological symptoms ~ Panic disorder ~ Panic attacks + persistent fear of recurrence of attacks ~ Obsessive Compulsive Disorder ~ Anxiety disorder involving obsessive thoughts which cause anxiety and compulsive behaviors to address those thoughts

Mental Health Disorders Common in Co-D ~ Post Traumatic Stress Disorder ~ Exposure to an stressor which involved the threat of death or significant injury to self or another in which there was significant helplessness and horror. ~ Can occur when learning about a trauma which occurred to someone else, especially a significant other ~ Eating Disorders ~ Person is intensely afraid of gaining weight and exhibits a disturbance in the perception of the shape of size of his or her body. ~ Types ~ Anorexia ~ Bulimia ~ Binge Eating Disorder

Mental Health Disorders Common in Co-D ~ Schizophrenia and Psychotic Disorders ~ Psychosis is the term for a severely incapacitated mental and emotional state involving thinking, perception and emotional control ~ Hallucinations –False perceptions ~ Delusions –False beliefs and a deterioration in thinking, judgement or self-control ~ Schizophrenia is the most common psychotic disorder ~ NOT multiple personality ~ Symptoms (often begin to develop before the first psychotic episode) ~ Hallucinations or delusions ~ Disorganized speech ~ Disorganized or catatonic behavior ~ Deficits in functioning

Summary ~ Assessment is an indepth process that involves information from the client and collateral sources to determine the nature, course and severity of the issues ~ Assessment is biopsychosocial in nature ~ Assessment must take into consideration cultural factors regarding having a mental illness, the participants in the treatment process and who the decision makers are for the client ~ It is important to evaluate for multiple-occurring disorders which may have overlapping symptoms. ~ The assessment will guide placement and the development of the treatment plan

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Screening Review Instructor: Dr. Dawn-Elise Snipes Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery & The Addiction Counselor Exam Review Objectives ~ Review key skills for engagement ~ Discuss factors impacting engagement ~ Define screening ~ Explore how to do a screening ~ Identify types of screening instruments

Engagement, Screening and Assessment ~ Demonstrate verbal and nonverbal skills to establish rapport and promote engagement ~ Discuss with clients the rationale, purpose and procedures associated with screening and assessment ~ Assess clients immediate needs including detoxification ~ Administer evidence based screening and assessment instruments to determine client strengths and needs ~ Obtain relevant history to establish eligibility and appropriateness of services ~ Screen for physical needs, medical conditions, co-occurring mental health issues ~ Interpret results of screening and assessment and integrate information to formulate a diagnostic impression and determine appropriate course of action ~ Develop a written integrated summary to support diagnostic impressions Engagement ~ Establish rapport and an effective working alliance in which the client feels heard and understood ~ Respectful ~ Nonjudgmental ~ Attentive ~ Motivate and engage the client in identified service needs ~ Engagement puts the clinician in the best position to negotiate with the client about what to do and how to do it. ~ Engaged clients are more likely to ~ Participate willingly ~ Be treatment compliant ~ Successfully complete treatment Engagement ~ Create a welcoming environment ~ Pleasant physical environment sensitive to ~ Age ~ Gender ~ Disability ~ Sexual orientation ~ Religion ~ Socioeconomic status

Factors Impacting Engagement ~ Stigma ~ About the diagnoses ~ About help seeking ~ Expectations ~ About the effectiveness of treatment ~ About one’s role/power in the treatment process ~ About the treatment process itself ~ Likeableness ~ Client’s social skills ~ Client’s attentiveness ~ Client’s attractiveness Factors Impacting Engagement ~ First Impression ~ Professional presentation ~ Promptness ~ Courtesy ~ Smooth handling of paperwork ~ Environment ~ Calm, clean, comfortable ~ Not too formal or informal ~ Avoids interruptions ~ Provides appropriate privacy

Goals of the Initial Interview ~ Establish trust and develop rapport ~ Be empathetic ~ Convey warmth and respect ~ Explore client strengths and skills ~ Facilitate client’s understanding of rationale, purpose and procedures of the screening and assessment process ~ Explore the client’s problems and expectations regarding treatment and recovery ~ Determine whether a further assessment is needed Screening ~ The process by which the counselor, client and SOs review the current situation, symptoms and collateral information to determine the probability of a problem ~ Used by all types of human service personnel to determine eligibility and appropriateness of services and needed referrals ~ Screening helps determine the immediacy of need ~ Must be a transparent process ~ Requires informed consent ~ Identification of early warning signs helps provide early intervention services and/or resources Screening ~ Screening is the first opportunity to engage the client in the therapeutic relationship and treatment process ~ Sometimes, based on observation or other circumstances people may be referred directly for assessment. ~ The client’s internal motivation is the primary reason for engaging in treatment. ~ Internal motivation may be fleeting, so rapid engagement is vital. Screening ~ Successful screening should be ~ Brief ~ Conducted in a variety of settings by a range of professionals on persons deemed to be at risk ~ A collaboration among a multidisciplinary team ~ Sensitive to racial, cultural, socioeconomic and gender related concerns ~ Developed from information gathered from multiple sources when possible

Screening ~ Assess signs and symptoms of intoxication and withdrawal ~ 3 key elements ~ Verify that behavior deviates from the norm ~ Rule out all non-drug related causes ~ Use diagnostic procedures to determine the types of drugs being used ~ Assess clients ~ Mental health/trauma history ~ Safety/environmental needs ~ Physical health needs ~ Other wrap-around needs ~ Danger to self or others Screening Methods ~ Interview (client, SOs) ~ Screening instruments ~ Lab tests Signs of SUDs or Mental Health Issues ~ Circumstances of contact ~ Client’s demeanor and behavior ~ Signs of acute intoxication or withdrawal ~ Physical signs of drug use or self-injury ~ Information spontaneously offered by the client or SOs Screening Instruments for SUD ~ Can be developed by the agency or use standardized instruments ~ CAGE (Cut Down, Annoyed, Guilty, Eye Opener) ~ GAIN-SI ~ Michigan Alcohol Screening Test ~ SASSI ~ Must clearly detail what action should be taken based on received scores Screening for Mental Health ~ Screen for ~ Acute symptoms such as hallucinations, delusions or depression ~ Suicidal thoughts and behaviors ~ Other mood and thought disturbances ~ Time, place, purpose, person ~ Short and long term memory ~ Prior involvement in mental health treatment ~ Use of prescription medication ~ Recent traumas ~ Family history of mental illness Screening Instruments for Mental Health ~ Modified mini screen ~ Mental Status Exam ~ Mini Mental Status Exam ~ Brief Symptom Inventory ~ Brief Psychiatric Rating Scale ~ Symptom Checklist 90-R

Summary ~ Screening is the initial contact to decide if a person may need a more in-depth assessment ~ Screening is brief but requires the person to be engaged in the process in order to get an accurate result. ~ How well the person is engaged in the screening process is a direct predictor of whether he or she will continue the process.

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Counseling Theories for Individuals Instructor: Dr. Dawn-Elise Snipes Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery & The Addiction Counselor Exam Review Objectives ~ Review the most common counseling theories and related interventions

Cognitive Behavioral ~ Premise ~ People respond to their representation of events rather than the events themselves ~ Learning is cognitively mediated ~ Thoughts impact emotional and behavioral reactions ~ Some types of thoughts can be monitored and modified ~ Modifying thoughts can help modify emotions and behavioral responses ~ Both behavioral and cognitive techniques are useful and can be integrated ~ Goal: ~ To identify and correct unhelpful cognitions by clarifying and challenging unhelpful or inaccurate cognitive schema and increase the client’s problem-solving abilities Cognitive Behavioral Assessment ~ Clinical interviews can clarify antecedents and consequences to emotions and behaviors and strategies that have and have not been helpful in the past ~ Inventories and questionnaires are helpful in identifying cognitive distortions ~ Self-monitoring can help identify the frequency, antecedents and consequences of unhelpful thoughts and/or reactions ~ Data from the assessment helps identify the client’s: ~ Problem solving ability ~ Attributional style (Global/Stable/Internal) ~ Underlying belief systems (Cognitive distortions)

Cognitive Behavioral Interventions ~ Daily mood and activity monitoring ~ Increase rewarding behaviors and establish a daily routine ~ Develop understanding of the relationship between feelings, thoughts and behaviors ~ Graded tasks to help clients start approaching and addressing seemingly overwhelming problems ~ Teach new skills and have client practice them between sessions ~ Address automatic thoughts ~ Teach the concept ~ Elicit the client’s thoughts ~ Label the distortion ~ Identify, challenge and modify maladaptive schemas ~ Develop helpful alternatives

Cognitive Behavioral Interventions ~ ABC-DE ~ Activating Event ~ Beliefs (Automatic) ~ Consequences (Emotional and behavioral reactions) ~ Dispute cognitive distortions and inaccurate schema ~ Evaluate the reaction/consequences for helpfulness ~ Cognitive Processing ~ Fact vs. emotional reasoning ~ Facts for and against ~ Big picture or tunnel vision (context/hindsight) ~ High vs. low probability ~ Cognitive distortions?

Cognitive Behavioral Interventions ~ Downward arrow (Follow it through) ~ If so, then what… ~ Questioning the evidence ~ Decatastrophizing ~ Cognitive rehearsal ~ Problem solving skills training ~ Thought stopping ~ Behavioral ~ Narrowing (unlinking) ~ Cue strengthening for positive behaviors ~ Self-reinforcement and punishment

Cognitive Behavioral Indicators ~ Indications ~ Mood disorders (depression, anxiety, phobias) ~ Fears of failure, rejection, abandonment ~ Eating disorders ~ Personality disorders ~ Counterindication ~ Significant cognitive dysfunction, psychosis or mania Behavioral Models ~ Premise ~ Emphasis on current behaviors which are under stimulus control ~ Reject the idea that maladaptive behaviors reflect underlying pathology ~ Elimination of the behavior is the primary goal of treatment ~ Assessment takes the form of a functional analysis ~ Antecedents, consequences and discriminative stimuli ~ Naturalistic observation ~ Self monitoring ~ Role playing ~ Rating scales Behaviorism Principles ~ Operant conditioning ~ Behaviors are increased or decreased through punishment and reinforcement ~ Observational learning Behavioral Therapy ~ Goal: Identify stimuli, reinforcers and punishments in the environment which are maintaining the problem behavior ~ Remove reinforcement and cues for target behavior ~ Increase reinforcement and cues for new behavior ~ Assessment ~ Emphasizes observable, measurable behaviors and patterns ~ Client and therapist agree on the definition of the problem behavior ~ Baseline data is acquired

Behavioral Therapy Interventions ~ Systematic desensitization ~ Relaxation training ~ Anxiety/Anger hierarchy ~ Assertiveness training to combat anxiety ~ Behavioral rehearsal ~ Aversion therapy ~ Flooding (in vivo exposure with response prevention)—Agorophobia ~ Increasing behaviors through reinforcement ~ Shaping Behavioral Therapy Interventions ~ Premack Principle ~ Response cost (having to give away something each time the target behavior occurs) ~ Smoking, speeding, nail biting, poor academic performance, aggression ~ Time out from reinforcement ~ Determine the function of the behavior (i.e. to get attention vs. because of boredom) Behavior Therapy Contracts ~ Contingency contract ~ Explicit definition of behavior (go to bed by 10pm) ~ Behaviors that can be monitored (observable, measurable) ~ Sanctions for failure (punishment) ~ Record keeping to provide feedback (logs) ~ Token Economy ~ Define target behaviors ~ Select the reinforcers ~ Monitor the behaviors ~ Fade out reinforcers Humanistic ~ Premise ~ To understand a person, one must understand her subjective experience ~ Emphasis on the uniqueness and wholeness of the individual ~ Belief in the persons inherent ability for growth and self-determination ~ Therapy involves authentic, collaborative interactions ~ Rejection of traditional assessment techniques and diagnostic labels Person Centered ~ The self is a consistent conceptual gestalt composed of perceptions of “I” and the relationships of “I” with the world and the values attached to those perceptions ~ To grow the person must remain unified and organized. ~ Disorganization occurs when there is incongruence between the self and experience. (conditions of worth) ~ I am lovable for who I am vs. You are lovable if you make me proud. ~ Therapeutic goals are to help clients achieve congruence between self and experience (eliminate the shoulds) by providing an authentic atmosphere with unconditional positive regard.

Person Centered Assessment ~ Assessment ~ Examine the difference between who the client IS and who the client perceives herself to be. ~ Believes the client to be the expert on herself ~ Techniques ~ Unconditional positive regard ~ Accurate empathy ~ Genuineness and congruence ~ Avoid interpretation, manipulation, probing or advice giving Gestalt Therapy ~ Premises ~ People seek closure ~ Peoples “gestalts” reflect current needs ~ Behavior represents a whole that is greater than the sum of it’s parts ~ Behavior must be understood in context ~ A focus on the here and now to increase self-awareness and help client’s live in the now ~ The self is the creative, forward moving aspect of self ~ The self-image is the part that imposes external demands ~ Historical information is only relevant to the extent that it is impacting the present “unfinished business” Gestalt Therapy ~ Problems ~ Arise from abandonment of the self for the self-image ~ Stem from disruption of the boundary between self and external environment resulting in failure to meet personal needs ~ Boundary Issues ~ Introjection: Accepting things from the environment without understanding or questioning ~ Projection: Disowning aspects of the self and putting them on other people ~ Retroflection: Do to the self what you want to do to others ~ Confluence: Intolerance of differences between self and others (guilt and resentment) Gestalt Techniques ~ Directed awareness ~ No questions (especially why) to prevent intellectualizing ~ Instead of “What is your foot trying to communicate” say, “Tell me about what your foot is communicating.” ~ Use I language ~ Assume responsibility ~ Empty chair ~ Role reversal ~ Role rehearsal ~ Dream work Psychodynamic therapy ~ Premises ~ Internal conflicts, and their relation to the problem are central themes of treatment ~ Psychopathology develops especially from early childhood experiences ~ Internal representations of experiences are organized around interpersonal relations ~ Life issues and dynamics will re-emerge in the context of the client-therapist relationship as transference and counter-transference ~ Distress is masked by defense mechanisms ~ Behavior is influenced by unconscious thought, and once vulnerable or painful feelings are processed the defense mechanisms reduce or resolve Psychodynamic therapy ~ Interventions ~ Use of free association as a major method for exploration of internal conflicts and problems ~ Focusing on interpretations of transference, defense mechanisms, and current symptoms and the working through of these present problems ~ Review emotions, thoughts, early-life experiences, and beliefs to gain insight into their lives and their present-day problems. ~ Encouraging clients to trust that insight about how their past is impacting their present is critically important for success in therapy ~ Interpretation of transference reactions ~ Examine ~ Acts of the self toward others ~ Expectations about others' reactions ~ Acts of others toward the self ~ Acts of the self toward the self (introjection)

Summary ~ Cognitive behavioral approaches address the connection between unhelpful thoughts, feelings and behaviors ~ The focus is often on changing thoughts and/or behaviors ~ Behavioral interventions focus only on observable, measurable behaviors, thoughts and feelings are irrelevant. ~ Humanistic therapist focus on helping people live as an authentic, integrated whole ~ Psychodynamic techniques focus on how the past is influencing current behaviors

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Introduction ~ Past 30 Day statistics, According to the 2012 National Survey on Drug Use and Health, ~ 6.5% of the population over 12 reported heavy drinking ~ 9.2% reported illicit drug use ~ The majority of people who use recreationally will not need treatment ~ Addiction is characterized by compulsive craving for the substance and using that substance despite negative consequences ~ Cravings and compulsive behavior are caused in large part as a consequence of substance use or addictive behaviors on the brain causing ~ Emotional ~ Cognitive ~ Physical ~ Behavioral changes Definition of Addiction ~ Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. ~ Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations reflected in pathological pursuit of a reward and/or relief by a substance. ~ Without treatment and/or engagement, addiction is progressive and can result in disability or premature death. (ASAM 2011, NIDA 2007) Characteristics of Chronic Disease ~ Disrupts normal functioning ~ Have serious, harmful consequences ~ Are preventable and treatable ~ Can last a lifetime ~ May be fatal if untreated Addiction—A Description, not a Diagnosis ~ Addiction is a description, not a diagnostic term. ~ Addiction erodes a person’s self-control and ability to make sound decisions ~ The DSM V has 3 categories – ~ Intoxication ~ Withdrawal ~ Substance Use Disorder Factors Influencing Addiction ~ No single factor is causative ~ General Categories ~ Biological/genetic makeup ~ Gender ~ Ethnicity ~ Developmental stage/early use ~ Social environment ~ Proximal (neighborhood, school/work, friends, family) ~ Cultural/Media/Availability ~ Method of administration Factors Influencing Addiction ~ Genetic Factors ~ 40-60 % of a person’s vulnerability is genetic. ~ Expression of these genes is influenced by: ~ Effects of the environment ~ Reactions/effects of addictive behaviors ~ Genetic predisposition to mental health issues (self-medication) ~ Social Environment & Peer and School ~ Access ~ Social learning of acceptability and use patterns ~ Exposure to peers/family who engage in criminal behavior ~ Academic/work failure ~ Poor social skills / unstable relationships

Factors Influencing Addiction ~ Developmental/Early Use ~ The earlier the initiation, the greater the likelihood it progresses to addiction ~ Addictive behaviors have a stronger impact on the developing brain (esp. the prefrontal cortex) ~ Indicative of a set of vulnerabilities/triggers ~ Genetics ~ Mental Illness ~ Unstable family relationships ~ Exposure to abuse

Factors Influencing Addiction ~ Method of Administration ~ Smoking and injection increase addictive potential due to ~ Rapid transit to the brain (seconds) ~ Rapid fade of effects (crash)

Continuum of Addiction ~ Social – risky/problematic –abuse –dependence ~ Many individuals never progress beyond risky consumption ~ Recovery from addiction is a multidimensional process which differs between people and changes over time. ~ Risky/problematic users have some amount of control and can learn methods to cope. ~ Dependent users seem to have no control over their use. ~ One and done ~ Progression over time

Summary

-Definition of addiction

-Characteristics of a chronic disease

-Factors Influencing Addiction

-Continuum of addiction

-Theories of causation

-Reinforcers within the cycle of addiction

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Surfing the Worry Imp's Wave * What prompted you to write this book? * I talk a lot in my classes about basic fears of rejection, isolation, failure, loss of control and the unknown triggering the fight or flight response. What types of things do children often worry about? * Why do children worry about things that adults don't worry about? * Why do some things (like a fight with your best friend) feel so unbearable....and why can't youth understand that, in the big scheme of things, this is not that big of a deal? * Mistakes and bad things happen. How does the concept of fault vs. responsibility impact a child's anxiety, for example, when parents divorce? * What are signs of anxiety and worry in children, and how do they differ by age 2-5, 6-10, 11-16? * After a traumatic event such as an earthquake or school shooting, what types of stress and anxiety reactions might we see? * Aside from reading this book with children and going through the discussion and activity guide, what can parents do to help children prevent anxiety? * I noticed on your website that you blog quite extensively on issues related to anxiety, attachment, discipline, self-regulation and resilience. How are all of these things related? * Where is the best place to get this book and the activity guide? (Your website, kickstarter, Amazon??)

Learn more at https://www.sharonselby.com/

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Etherapy Clinical Principles & Treatment Modalities Instructor: Dr. Dawn-Elise Snipes Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery Objectives ~ Review the different modalities and most common usages in counseling ~ Identify potential clinical and ethical issues ~ Learn about at least 3 unique ideas for doing online counseling ~ Define Treatment Structure Text Reading ~ Review Online Counseling: A Handbook for Mental Health Professionals ~ http://www.netlingo.com/ Modalities ~ Emails ~ Blogs ~ Secure Forms ~ Forums ~ Chat rooms ~ IM/Tweets ~ Video Chat ~ Second Life ~ Good ole telephone Tweets ~ This is a great way to push out positive thoughts for the day. ~ I have used this for morning focus meditations and evening roundup meditations. ~ It is NOT secure, so no PHI here. This includes graduation announcements or congrats. ~ Good way to get the word out about you and your approach. ~ This is not a therapy approach.

Emails ~ Technical ~ Use a secure service. ~ If you are not using a secure service, then make sure your email address does not give away who you are. ~ Services offering Secure Email: Hushmail, ZixMail, ~ Are considered part of the clinical record and can be subponeaed just like progress notes. ~ Provide clients with a response time frame ~ Benefits ~ Can provide a running “diary” of progress ~ Are excellent for people who like to write and ponder. (Introverts and Reflective learners)

Email Cont… ~ Drawbacks ~ Can miss a lot when you do not see the rate of responding (increase in rate or errors in typing etc) ~ Gives patients time to go back and edit which may remove some of the underlying meanings ~ Not appropriate for patients in crisis ~ Formats ~ Diary—freeform ~ Diary—Structured ~ Worksheet completion (i.e. CBT, relapse prevention) ~ Questions to ponder (i.e. Miracle Question) ~ Activities to do (digital collage)

Blogs ~ Provide information to people ~ Not secure or HIPAA compliant unless you make them that way ~ A secure blog can be a good place for clients to journal as an option to daily emails. ~ Excellent activity to inform patients about conditions, new treatments and new programs ~ Excellent for patients who have something to say to the world—Awareness/Advocacy Campaigns

Blogs cont… ~ Secure Blog Formats ~ Video Blog: ~ Can be used for daily check-ins for clients—excellent for addictions, eating disorders and major depression ~ Blog with pictures ~ Can be used to as a means of creative and therapeutic expression for some clients ~ Can also be created like an online scrap-book with pages for: What means the most to me, My Goals, My accomplishments, About Me (Best with teens) ~ Text Blog ~ Can be used as a running diary ~ Blogs must be regularly checked ~ Rules for appropriate use of blogs must be set forth

Forums ~ Forums are a good place to ask a question to a group and let them provide answers ~ Forums must be moderated ~ Appropriate forum behavior must be communicated and maintained ~ Group members can see each others responses and comment and/or learn ~ More than some other modalities, it is imperative to be clear about appropriate behavior in the forums. ~ If you do not have something nice or constructive to say, don’t say anything at all ~ This is not a place for Borderline behavior Secure Forms & Worksheets ~ Useful to get information quickly such as intakes, client’s week in review and CBT or DBT worksheets ~ Can be created as fillable PDFs and securely emailed to you. ~ Used as an adjunct to therapy for people who like using workbooks etc. Instant Messaging (IM) ~ Mainstream communication for the younger generation ~ Can be done via mobile devices ~ Whether SMS or Internet Texting you must have a business associate agreement ~ Can provide real-time text-based interaction (can be asynchronous as well) ~ Nonverbals include ~ Color, font, size of text ~ Emojis ~ Speed of response and error rate ~ You must set boundaries ~ You must know the lingo Video Chat ~ Next best thing to face-to-face ~ Can connect patients and clinicians at a distance ~ Must be done on a secure connection from a provider who has SIGNED a business associate agreement ~ Provided internet connection is adequate, provides nonverbals ~ Drawbacks—You must have a backup plan for: ~ Internet issues ~ Software issues ~ Firewall issues ~ Power issues Second Life ~ Appealing due to avatars ~ Does not meet HIPAA security standards ~ Has had incidents of being hacked and losing user data ~ Does not provide subtle nonverbals ~ May reinforce a fantasy persona in those with an unfavorable or unstable sense of self Phone ~ Most people are comfortable talking on the phone ~ It requires a high amount of concentration on your part ~ Traditional nonverbals are not available ~ Format ~ Cell Phone ~ Data is minimally available when it hits cell towers ~ Low risk of being “hacked” or “breeched” ~ Land Line ~ Excellent as a backup in the event of a power or internet outage Clinical Principles ~ Above All Do No Harm ~ Evaluating appropriateness (diagnosis, crisis, age, comfort with computer technologies) ~ Developing a safety plan ~ Making appropriate referrals ~ Netiquette ~ Master the lingo

Above All Do No Harm ~ Evaluate appropriateness ~ Can you and the patient type? ~ If no, look into video or phone counseling ~ Is the condition appropriate for that level of treatment?

~ Develop a safety plan ~ Make appropriate referrals ~ Ensure confidentiality and privacy of PHI ~ Ensure your communications are encrypted ~ In transit ~ On your computer (whole disc encryption)

Netiquette ~ General ~ All CAPS= YELLING ~ Don’t overuse exclamation points!!!!!!!!!!!!! ~ Use italics, different colors, fonts and font weight to emphasize ideas ~ This is awful! I am totally over it. ~ This is awful! I am TOTALLY over it. ~ Paraphrase and check your understanding B4 U get offended ~ Email ~ Return emails in a timely fashion ~ Add responses within the persons email to you Netiquette cont… ~ Chat Rooms ~ No Lurking ~ Say hello and Goodbye ~ If you step away, say BRB as appropriate ~ Use private messaging for “side” conversations if allowed ~ Ensure rooms are moderated ~ IM ~ Never have multiple private chats going at the same time ~ Respond quickly ~ If you have to step away from a chat, tell the client BRB ~ Video ~ Ensure you have a signed business associate agreement with the provider ~ Conduct therapy in a private room

Treatment Structure ~ Options ~ Email/IM/Phone/Video Only ~ Email/IM/Phone/Video + weekly or monthly F2F ~ Email/IM/Phone + weekly/monthly Video ~ Considerations ~ Cost ~ Time effectiveness ~ Patient preference ~ Acute issues: Crisis, medication changes, impending triggers

Neat Techniques and Tricks ~ Have people review their emails or chat logs for patterns or improvements ~ Use information documented in email and chat logs as “evidence” when confronting a client ~ Have a client do a video tribute to someone who has passed away ~ Have someone do a blog or email in the words of someone they have lost…What Mom would have said ~ Have clients tweet commitments and/or statuses

Tips and Tricks cont… ~ Have clients research ~ 3 famous people who have encountered similar situations ~ About depression, temperament, CBT etc. ~ Resources for coping with _____ ~ How nutrition and/or exercise can help them ~ Different hobbies ~ Local clubs and social groups ~ And the list goes on….

~ See TIP 60: Using Technology-Based Therapeutic Tools in Behavioral Health Services for more tips, tricks and tools Summary ~ Online Counseling and etherapy make it possible for patients to access services ~ Easier ~ With Greater Confidentiality ~ With experts who are not accessible in person ~ *Note in most states the therapist has to be licensed in the state in which he/she practices AND the state in which the client resides ~ It appeals to the younger generation and those who are very visual. ~ Just like any other new modality, etherapy has its own techniques, language and netiquette. ~ It will be important for etherapists to stay in tune to the evolving regulations regarding online services

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You Don’t Know What You Don’t Know Interview with Cecilia Briseno, LCSW Intro ~ Cecilia Briseno is a bilingual Licensed Clinical Social Worker at Bright Side Family Therapy, in Arlington, TX. ~ Following the completion of her Master’s program, Cecilia went on to study Marriage and Family Therapy in a doctoral program at Texas Woman’s University, which helped her to broaden her knowledge of SFT and family systems. ~ Cecilia has found her niche in working with families navigating through the immigration process. Cecilia provides evaluations explaining the hardships they face when separated from their loved ones. She is now also providing training for clinicians interested in working with immigrants. Path to your LCSW

~ How can this help someone who has recently graduated or will be graduating in the Spring? ~ What types of topics do you usually cover in this workshop? ~ What things do you wish someone would have told you after your graduated? ~ Is this ever offered online as a webinar?

Hardship evaluations ~ What are hardship evaluations and who needs them? ~ How did you get into doing them? ~ How does the average therapist get into doing them? ~ Do you have to be bilingual or can you use an interpreter? ~ What is the demand like for these evaluations? ~ How much do they pay, on average? ~ What do you cover in your webinar? ~ Is the process the same for people in other states? ~ What if you know someone who needs a hardship evaluation...how do you get them in touch with the right people?

Concluding Remarks Cecilia Briseno, LCSW-S Bright Side Family Therapy

~ Path to Your LCSW ~ https://allceus.com/BrightSide

~ Hardship Evaluations ~ https://allceus.com/Hardship

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Opiate Commission Preliminary Report Dr. Dawn-Elise Snipes Executive Director: AllCEUs Counseling Education https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf

Training on basic addiction counselor competencies or Addiction Counselor Certification Training

Intro ~ In 2015, 27 million people reported current use of illegal drugs or abuse of prescription drugs. ~ Only 10 percent of the nearly 21 million citizens with a substance use disorder (SUD) receive any type of specialty treatment ~ With approximately 142 Americans dying every day, America is enduring a death toll equal to September 11th every three weeks. Recommendations ~ Rapidly increase treatment capacity. Grant waiver approvals for all 50 states to quickly eliminate barriers to treatment resulting from the federal Institutes for Mental Diseases exclusion within the Medicaid program. ~ This exclusion prohibits federal Medicaid funds from reimbursing services provided in an inpatient facility treating “mental diseases” (including SUDs) that have more than 16 beds. ~ Right now, states entirely responsible for Medicaid-eligible patients in inpatient treatment facilities, including patients undergoing withdrawal management in addiction treatment facilities rather than hospitals. ~ This will immediately open treatment to thousands of Americans in existing facilities in all 50 states…Or will it? ~ Require extensive provider enrollment procedures ~ Requires extensive staff training ~ Requires extensive modifications to the HER and P&P

Training—Wish List (Basic Medicaid Training Requirements can be found here: https://allceus.com/member/cart/index/product/id/765/c/ ) ~ Require all persons from technicians to clinicians and managers to receive specialty training in Addiction Counseling ~ In FL a bachelors level practitioner with specialized training in treatment of behavioral health disorders, human growth and development, evaluations, assessments, treatment planning, basic counseling and behavior management interventions, case management, clinical record documentation, psychopharmacology, abuse regulations, and recipient rights ~ Biopsychosocial evaluations ~ Group therapy services ~ Certified recovery peer specialist • Certified recovery support specialist • Certified behavioral health technicians can also provide ~ Group counseling in Day Treatment Programs ~ Community support and Rehabilitative services ~ Clubhouse services ~ Therapeutic behavioral on-site support services with persons under 21 Prescriber Education ~ Fewer than 20% of the over one million prescribers licensed to prescribe controlled substances to patients have training on ~ How to prescribe opioids safely. ~ How to screen for addiction ~ What to do if a patient has become dependent on substances or presents with an SUD ~ Mandate prescriber education initiatives with the assistance of medical and dental schools ~ Require all Drug Enforcement Administration (DEA) registrants to take a course in proper treatment of pain. ~ Work with partners to ensure additional training opportunities, including continuing education courses for professionals. ~ Promote expanded implementation of the CDC Guideline for Prescribing Opioids for Chronic Pain ~ 4 of 5 new heroin users begin with nonmedical use of prescription opioids ~ Not necessarily their own…. Medication Assisted Treatment ~ MAT has proven to reduce overdose deaths, retain persons in treatment, decrease use of heroin, reduce relapse, and prevent spread of infectious disease. ~ Only 10 percent of conventional drug treatment facilities provide MAT for opioid use disorder. ~ There are only 12 methadone clinics in TN. ~ Office based prescribers of MAT are not required to provide the counseling and support which is REQUIRED of methadone clinics. ~ Veterans and Medicare recipients have even more limited access to affordable MAT from qualified professionals ~ Recommendation: Immediately enhance access to Medication Assisted Treatment (MAT). ~ Require that all modes of MAT are offered at every licensed MAT facility ~ Partner with the National Institutes of Health (NIH) and the industry to facilitate testing and development of new MAT treatments. Naloxone ~ Provide model legislation for states to ~ Allow naloxone dispensing via standing orders ~ Requiring the prescribing of naloxone with high-risk opioid prescriptions ~ Equip all law enforcement in the United States with naloxone to save lives. Enforcement ~ Prioritize funding and manpower to ~ Department of Homeland Security’s (DHS) Customs and Border Protection ~ DOJ Federal Bureau of Investigation (FBI) ~ DEA to quickly develop fentanyl detection sensors and disseminate them to federal, state, local, and tribal law enforcement agencies. ~ Support federal legislation to staunch the flow of deadly synthetic opioids through the U.S. Postal Service (USPS). Data Sharing / Doctor Shopping ~ Provide federal funding and technical support to states to ~ Enhance interstate data sharing among state-based prescription drug monitoring programs (PDMPs) to better track patient-specific prescription data and support regional law enforcement in cases of controlled substance diversion. ~ Ensure federal health care systems, including Veteran’s Hospitals, participate in state-based data sharing. HIPAA ~ Better align patient privacy laws specific to addiction with the Health Insurance Portability and Accountability Act (HIPAA) to ensure that information about SUDs be made available to medical professionals treating and prescribing medication to someone with a SUD. ~ This could be done through the bipartisan Overdose Prevention and Patient Safety Act/Jessie’s Law. ~ CFR 42 part 2?? Parity ~ Enforce the Mental Health Parity and Addiction Equity Act (MHPAEA) to ensure health plans cannot impose less favorable benefits for mental health and substance use diagnoses verses physical health diagnoses. ~ What about the uninsured? (i.e. single men and persons with felony convictions) ~ What about high copays and deductibles ~ Most Americans cannot scrape together $2000 for an emergency ~ MAT costs on average $3500-$6000 per year WITHOUT counseling ~ Most people’s deductibles are over $1,000 per year Prevention Programs ~ Evidence-based prevention programs for schools ~ Make it a priority, like the state testing ~ Tools for teachers and parents to: ~ Enhance youth knowledge of the dangers of drug use, ~ Provide early intervention strategies for children with environmental and individual risk factors (trauma, foster care, adverse childhood experiences (ACEs), and developmental disorders). ~ Physical abuse ~ Sexual abuse ~ Emotional or physical abuse or neglect ~ Intimate partner violence (dating or parental DV) ~ Substance misuse within household ~ Household mental illness (Nearly 35% of Americans) ~ Parental separation or divorce ~ Incarcerated household member

Pain Scaling ~ Examination of the need for satisfaction with pain level as a satisfaction criteria through which health care providers are evaluated by HHS. ~ Too many people expect to be pain free nearly always

Treatment Program Improvement ~ Improvements in treatment programs, based on adherence to principles of: ~ Evidence Based Treatment ~ EBPs are expensive and challenging to implement “to fidelity.” ~ Continuum of care ~ Outcome measures ~ Patient education on quality treatment Other Areas for Evaluation ~ Targeted data collection and analytics needed to identify most effective prevention and treatment strategies, quality treatment access programs, reimbursements, and aid to law enforcement activities. ~ Develop a behavioral health surveillance system run through CDC that tracks prevalence rates, treatment modalities, and comorbidities with other illnesses in real-time.

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Tips for Responding After a Disaster Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director: AllCEUs Counseling CEUs and Specialty Certificates Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery

The Counseling CEU course for this presentation can be found at: https://allceus.com/member/cart/index/search?q=disaster+Response

Objectives ~ Review common reactions to disaster and interventions ~ Identify common stressors in shelters ~ Identify common issues when sheltering in place ~ Explore how to help reduce stress and anxiety through ~ Facilitated and independent activities ~ Facilitated groups Disaster Response ~ Acute stress is a NORMAL reaction to an ABNORMAL event ~ The majority of people will recover with no long-term effects Sheltering in Place ~ Common Stressors ~ Anxiety about the situation and your safety ~ Concern about loved ones who are elsewhere ~ Feelings of isolation, loneliness, sadness or boredom ~ Guilt about not being able to perform normal duties or help out ~ Fear over loss of income/cost of repairs ~ Changes to sleeping and eating patterns Disaster Response: Shelters ~ People who are in shelters ~ Have suffered a trauma (loss of control/sense of helplessness) ~ May experience significant losses (possessions, pets) ~ May not know where some of their loved ones are Additional Stressors in Shelters ~ Environment that is ~ crowded/noisy/overstimulating ~ less secure than home ~ Poor sleep: Routine, Safety, Ergonomics ~ Pain ~ Nutritional changes ~ Additional caffeine and nicotine ~ Ambiguity about what lies ahead ~ Boredom/time to dwell Common Responses in Adults & Adolescents ~ Difficulty communicating thoughts ~ Difficulty sleeping ~ Difficulty with balance in life ~ Low threshold of frustration ~ Increased use of drugs/alcohol ~ Limited attention span & poor work performance ~ Headaches/stomach problems ~ Colds or flu-like symptoms ~ Disorientation or confusion ~ Difficulty concentrating ~ Reluctance to leave home ~ Depression, sadness, hopelessness ~ Mood-swings ~ Overwhelming guilt ~ Fear of crowds, strangers, or being alone ~ Argumentativeness / refusing to follow rules / being overly controlling

Common Responses in Children ~ Birth through 2 years. ~ Irritability ~ Crying more than usual ~ Wanting to be held and cuddled ~ Regression to an earlier age (crawling, mama-dada) ~ The biggest influence on children of this age is how their parents cope. Common Responses in Children ~ Preschool - 3 through 6 years. ~ Preschool children often feel helpless and powerless in the face of an overwhelming event. Because of their age and small size, they lack the ability to protect themselves or others. As a result, they feel intense fear and insecurity about being separated from caregivers. ~ Preschoolers cannot grasp the concept of permanent loss. ~ In the weeks following a traumatic event, preschoolers’ play activities may reenact the incident or the disaster over and over again. Common Responses in Preschool cont… ~ Crying/Depression ~ Inability to concentrate ~ Bedwetting ~ Withdrawal and isolation ~ Thumbsucking ~ Not wanting to attend school ~ Nightmares ~ Headaches

~ Clinging/fear of being left alone ~ Changes in eating and sleeping habits ~ Regression to previous behaviors ~ Excessive fear of darkness or storms ~ Fighting ~ Increase in physical complaints Common Responses in School Children ~ School age - 7 through 10 years. ~ The school-age child can understand the permanence of loss ~ Some children become intensely preoccupied with the details of a traumatic event and want to talk about it continually ~ This preoccupation ~ Can interfere with the child’s concentration at school ~ Prompt irritability from adults ~ Children may hear inaccurate information from peers/media

Common Responses in School Children ~ School age - 7 through 10 years. ~ They may display a wide range of reactions — ~ Sadness ~ Generalized fear, or specific fears of the disaster happening again ~ Guilt over action or inaction during the disaster ~ Anger that the event was not prevented ~ Fantasies of playing rescuer ~ Regression to earlier behaviors ~ Irritability ~ Oppositional behavior to distract or get secure limits Interventions ~ Prepare a go-bag with essentials ~ Remember medication, razors, brush/comb, toothbrush/toothpaste, cell phone/charger, pillow, security items for kids ~ Stop media overload leading up to, during and after the incident ~ Keep routines as stable as possible ~ Practice mindfulness each day ---personally and as a family ~ When communicating, validate each other’s feelings and identify a tangible solution ~ Try to replace “buts” with “ands” Other Interventions for Children ~ Personal contact is reassuring. ~ Calmly provide factual information about the recent disaster and current plans for insuring their safety along with recovery plans. ~ Encourage your children to talk about and own their feelings. ~ Spend extra time with your children such as at bedtime. ~ Involve your children by giving them specific chores to help them feel they are helping to restore family and community life. ~ Praise and recognize responsible behavior.

Other Interventions for Children ~ Understand that children have a range of reactions to disasters. ~ Reassure the child frequently that you are safe and together. ~ Allow children to grieve about their lost treasures; a toy, a blanket, a lost home. ~ Try to spend extra time together in family activities to begin replacing fears with pleasant memories. ~ If your child is having problems at school, talk to the teacher so that you can work together to help your child. ~ Talk with your child about what you will do if another disaster strikes. Let your child help in preparing and planning for future disasters. Turn shouldas into next times.

Sheltering Games ~ Go Fish / Card Games ~ Solitaire ~ Tic-Tac-Toe ~ Hang Man ~ Charades ~ I spy ~ Mobile device games: Checkers, scrabble, chess, Angry Birds… ~ Tell jokes (knock-knock apps) ~ Coloring books / Coloring ~ Word-finds / Crosswords / Sudoku

Encourage Routine ~ Lights up and out at the same time each night ~ Start the day with mindfulness and planning ~ Meals at the same time ~ In large shelters divide the groups into A-B-C Each group gets to go first for one meal each day ~ Physical activity: Walking, calisthenics, stretching… ~ Kids: Duck-Duck-Goose, put on kids music and encourage dancing, have them do a performance for the shelter ~ Chores each day in your “zone”

Environmental ~ Have “quiet spaces” – Visual and auditory ~ Ear plugs / headphones ~ Encourage awareness of space ~ Keep it smelling good

Groups ~ Goal Identification and Radical Acceptance ~ Goal Identification ~ What things, people and experiences are most meaningful to you? ~ What values are most important to you? ~ Radical Acceptance ~ What has happened cannot be changed ~ How you feel right now is how you feel ~ What can you do to improve the next moment and move closer to your goals and embodying the values you hold dear? Groups: Distress Tolerance

~ Imagery ~ Meaning ~ Prayer ~ Relaxation ~ One thing in the moment ~ Vacation ~ Encouragement

~ Activities ~ Contribute ~ Compare ~ Emotions (Happy) ~ Pushing Away ~ Thoughts (Happy) ~ Sensations

Groups ~ Hardiness ~ Commitment ~ What things in your life make it worth living? ~ What are you committed to? ~ Control ~ What parts of your life/this situation do you have control over ~ Challenge ~ How have you dealt with problems in the past? ~ What challenges do you now face and how can you approach them? Groups ~ Understanding Anger and Irritability ~ Natural response to threats and stress ~ “Fight or Flee” ~ Anger pushes people away or gives you power over them and may reduce stimulation ~ When you get angry ~ Are you angry at the person, the situation or yourself? ~ Anger tells you to do something. How can you improve the next moment? ~ When someone gets angry at you, reflect on whether it is because of you, the situation or their stuff.

7-Habits in Shelters ~ Be proactive seeing alternatives and opportunities not roadblocks (Anger is often a sign of a feeling of powerlessness) ~ Being with the end in mind, defining a win-win with practical and realistic outcomes. ~ Put first things first recognizing that some things are not worth the energy or effort and other things like your health and family are more important 7-Habits in Shelters ~ Seek first to understand the other persons point of view and the whole situation then to be understood ~ Synergize to use each person’s strengths ~ Sharpen the saw---Encourage each person to take time for relaxation and recreation each day and practice positive health behaviors to prevent vulnerabilities Summary ~ After a disaster people will experience distress ~ There are certain things that can be done to reduce stress whether sheltering in place or at a public shelter ~ Maintenance of routines is vital ~ Prevention of vulnerabilities through proper nutrition, sleep and activity can help reduce stress ~ Radical acceptance and goal directed activity can help people choose responses that will better assist them in reducing their distress

Addiction Counselor Exam Review: Recent Episodes

Dr. Dawn-Elise Snipes