Dealing with Substance Abuse and Employment of Homeless Veterans Sherry Dyche Ceperich, Ph.D. McGuire VAMC Richmond, VA

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1 Homeless Veterans Reintegration Program (HVRP) Technical Assistance Center HVRP Technical Assistance Center is funded by grant #HV with the US DOL. Dealing with Substance Abuse and Employment of Homeless Veterans Sherry Dyche Ceperich, Ph.D. McGuire VAMC Richmond, VA Agenda Overview of Substance Abuse Treatment Concept of readiness to change Strategies for helping someone change their substance abuse behaviors Agenda Strategies for helping someone stay abstinent Brief overview of VAs Compensated Work Therapy program Resources for accessing VA vocational and substance abuse services Substance Abuse/Addiction Drug/Alcohol addiction is a complex illness (brain disorder) Behavioral and social elements Intense, compulsive, craving and use despite very negative consequences Compulsion can take over one s life interfering with family, community, work Treatment works Addiction increases risk for other illnesses, both physical and mental Treatment is not simple Yet, research shows us there are several effectives approaches to treatment Treatments work! Similar efficacy as treatment for other chronic conditions 1

2 Principles of Drug Addiction Treatment (13 principles: Highlights) 1. No one treatment appropriate for all. 2. Effective treatment attends to multiple needs of the individual d l( (including vocational!) l). 3. Remaining in treatment for an adequate period of time is critical. 4. Counseling & other behavioral therapies are critical components. Principles continued 5. Medications are important part of treatment esp. when combined with counseling/behavioral therapies. 6. People with coexisting mental disorders should have both disorders treated in an integrated way. Principles continued 7. Medical detoxification is only the first stage of addiction treatment; by itself does little to change long term use. 8. Recovery from addiction can be a long term process and frequently requires multiple episodes of treatment. Sampling of Effective Treatment Cognitive Behavioral Therapy Motivational Enhancement Therapy Vouchers (Contingency Management) Medication based 12 Step Facilitation Relapse Prevention (CBT) Motivational Interviewing* A way to talk about behavior change *Prochaska & Diclemente, 1992 Miller & Rollnick,

3 The Righting Reflex Helpers, healers & teachers drawn to make things right Fix it Feeling of needing to tell someone what they should/need/must do for their own good. Comes from a good place. But, what happens when we do this? MI: Spirit Collaboration Partnerships, guide Evocation Listening i & Eliciting iti Autonomy The ability to make one s own choice 4 Principles of MI Express Empathy Roll with Resistance Support Self efficacy Develop Discrepancy Micro Skills ( OARS) Open Ended Questions Affirm The Person Reflect What the Person Says Summarize Ambivalence It s normal but uncomfortable. At each stage, helper intervenes differently based on veterans readiness (stage) to change. Feeling two ways about something. I want to and I don t want to. Don t want to change Continues throughout change process Want to Change *Prochaska & Diclemente,

4 Change Talk What you want to hear Self motivational statements in direction of change. Change Talk Types: DARN C D= desire statements I want to stop using A = ability statements I can give abstinence a try R= reasons statements Have to so I don t lose kids N= need statements If don t change, liver will fail. C = commitment language Change Talk Research shows it is important The more change talk, especially with high commitment, the more likelihood for change. So, reflect change talk! Say it back, ask more about it, encourage veteran to talk about it more. What about after treatment? Relapse Prevention Relapse Prevention*? A behavioral self control program to teach people who are trying to maintain behavioral changes (drinking, drug use, other) how to anticipate and cope with the potential for relapse. *Marlatt & Gordon, 1985 Why Talk About It? Behavior change is notoriously difficult Research shows pattern of relapsing to old behavior is similar across addictive behaviors. Average outcomes (depends on how measured and definition of relapse): 26% abstinent or improved at 12 months.* *Miller & Hester 1980 (500 alcohol outcome studies) 4

5 Conceptualization of Relapse In the stages of change model, relapse is viewed as a natural part of the process. When someone relapses, they do not go all the way back to the beginning of the process, they recycle, getting back on the wheel at stage that is as far along as possible. Slip v. Relapse SLIP An episode of use following a period of abstinence (a.k.a. a lapse) RELAPSE Return to uncontrolled use following a period of abstinence. SLIP does not equal (=) Relapse Relapse Prevention Goals 1. Prevent slips if possible 2. If slip occurs, prevent it from turning into a relapse 3. Slip is not a catastrophe Relapse Prevention Goals 4. Slip is a signal to re examine treatment (or aftercare) plan. 5. If relapse occurs, help person understand change process and the importance of trying again. High Risk Situations Relapse tends to be associated with high risk situations Three HR situations associated with 75% of relapses: negative emotional states interpersonal conflict social pressure Assessing High Risk Situations 1. Help veteran perform a self assessment of previous use patterns looking at triggers of use (antecedents) t (Could be done in context of employment issues) 2. Examine consequences and reinforcers of use 5

6 Assessing High Risk Situations 3. Explore how employment has been affected by use 4. Pay special attention to: 1. Negative feelings 2. Interpersonal conflict 3. Social pressure 4. Positive feelings from events such as celebrations Managing High Risk Situations Positive Coping Strategies: Help veteran understand that relapse is a process and a slip/lapse does not have to equal a relapse Help veteran avoid people, places, and things that are high risk. Practice/think through leaving a high risk situation Managing High Risk Situations Positive Coping Strategies: Help veteran to think positively: Practice positive self talk: I did not use yesterday y& I don t need to use today. I have non using friends I can call for support. Help veteran avoid negative emotional states Remember HALT Avoid getting too Hungry, Angry, Lonely or Tired. Managing High Risk Situations Help challenge irrational or negative thoughts Help veteran create a worksheet: Relapserelated thought Statements that disputes the thought New, rational thought Managing High Risk Situations Challenging negative thoughts Relapserelated thought I didn t get that job. The boss thought I was a loser. I m worthless. Might as well get loaded. Statements that disputes the thought Didn t get job because I don t have the skill needed. Did not have anything to do with boss or anyone else thinking I m worthless. New, rational thought I can learn new skills and apply for other jobs. Do not need to use. Coping with Urges & Cravings 1. Self talk: I know what is happening &this intense feeling will pass if I can distract myself for a few minutes. 2. If I use now, I blow 6 months of sobriety &feel terrible about myself. If I don t use, I ll feel strong & proud of myself. 3. Call sponsor or counselor or attend a 12 step meeting 4. Involve self in strenuous or pleasant activity that distracts from craving 6

7 Lifestyle Changes Leisure Time: what to do instead of use? Hobbies, develop new interests, Get a job Social/Communication Skills: may need training in listening skills, interviewing skills, how to ask for time off, how to resolve disagreements with coworkers. Self Care: may need caring advice on nutrition, hygiene and dress Lifestyle Changes Financial Planning: help managing money, saving, setting up bank account, paying off debt Relationships: may not have experienced drug free relationships, help in making decisions in face of intense emotions of relationship If a Slip Occurs What is veteran thinking & feeling? To what does veteran attribute the slip? (IMPORTANT) Help veteran re evaluate and develop positive coping strategies. Preventing Slips from Escalating Help limit guilt and shame so veteran is more likely to talk about slip with key people. Use a relapse contract that includes an agreement to time out if a slip occurs Reminder cards: Veteran can carry cards that contain specific steps in plan, people to call Remain hopeful slip not a relapse Relapse Prevention Plan 1. Goal: To remain abstinent 2. The most important reasons why I chose this goal: 3. The steps to my goal are: 1.create detailed list of high risk situations & triggers 2.create list of positive coping strategies 3.create worksheet for challenging negative thoughts Relapse Prevention Plan 4. The ways people can help me are: Person Possible ways to help (be specific, what you want people to do now and what htto do if you slip, relapse) 5. If I slip, I will: 7

8 VA Homeless Programs Homeless veteran coordinator Key person to assist with housing and substance abuse services Chaleng Stand Downs Grant and Per Diem Programs Compensated Work Therapy VA program that gives veterans a supportive, structured environment to address voc goals Provides vocational rehabilitation: Situational assessment, job placement, exploration, resume writing, help with applications, interviewing skills, help with documentation, basic work skills Compensated Work Therapy Goal = help veterans return to competitive employment. Located within VA medical centers Frequently utilized by homeless veterans CWT Services Vocational rehabilitation Assessment of job history, transferable skills, strengths, interests, short & long term goals. Job matching and employment supports Case Management CWT Services Work site and job analysis Accommodations necessary to maintain employment Provide diverse work environments for on the job training and on the job supports. Work Examples IT, office management, clerical, retail, manufacturing & production, warehousing, manual labor, food service On and off site assembly On and off site custom packaging Reclaiming and recycling services Inspection, grading and sorting 8

9 Transitional Work Program Pre employment program up to 9 mos Veteran screened, assessed and matched to job. Supervised by work site staff Same job expectations as others Transitional Work Program Case managed by a VA vocational specialist works on substance abuse issues, how to ask for time off, interacting with coworkers, arriving on time, etc. Must be referred by VAMC provider May be homeless or with SA or PTSD Individual Service Plan Supported Employment Competitive FT / PT employment for veterans with SMI Also some services for SCI and TBI Workplace accommodation and supports provided Work with employer to tailor needs to veterans specific needs Benefits VA benefits including service connected compensation, and non service connected pensions cannot be reduced, denied, or discontinued based on participation in CWT. No time limit on participation Summary Substance Abuse is a problem for many homeless vets & can cause or compound employment issues. A variety of substance abuse treatments work. But, not overnight. The stages of change model conceptualizes change as a process that includes recycling through the stages again after a relapse, which is not uncommon. Summary Relapse prevention involves strategizing with veterans to try to prevent slips and relapses. If they occur, refer to the Stages of Change model and encourage veteran to try again. 9

10 Summary MI emphasizes collaboration, empathy, and microskills related to good listening and strategic responding to change talk. VA offers vocational services for homeless veterans. An excellent VA contact is the Homeless Coordinator. Resources Substance Abuse NIDA Principles of Effective Drug Treatment Motivational Interviewing website National Clearinghouse for Alcohol and Drug Information (NCADI) Resources Substance Abuse National Institute on Alcohol Abuse and Alcoholism (NIAAA) National Institute on Drug Abuse (NIDA) Substance Abuse and Mental Health Administration (SAMHSA) Resources Substance Abuse Alcohol Use and Alcohol Related Risk Behaviors among Veterans, NSDUH Report: The NSDUH Report: Substance Use, Dependence, And Treatment among Veterans: Addiction Technology Transfer Center Network Resources Homeless & Employment Veterans Affairs Homeless Veterans: NATIONAL COALITION for HOMELESS VETERANS fact sheet Thank you VA Compensated Work Therapy Program 10