Working with Addicted Youth: as if it s not complicated already!

Transcription

1 Working with Addicted Youth: as if it s not complicated already! Training, Boundaries, & Risk Management Nadyia Abbas, MA CAGS LADC LMHC Bonnie Byer, MA Devereux Massachusetts

2 Section 1: Program Training

3 Training Methods Train and Hope training a skill and hoping that generalization will occur. Train To Generalize Training to generalize involves providing specific reinforcement for instances of skill generalization. Reinforcement On the floor competency training Maintenance strategies Train-the-Trainer Knowledge assessment

4 Other Considerations Keep it simple! Less is more! Operational Definitions Observable skills!

5 Essential Training Topics Substance Use, Abuse, and Dependence Signs and symptoms of intoxication Adolescent development and the impact of substance use on this development Co-Occurring Disorders The Change Process Relapse warning signs Treatment: Harm Reduction, Motivational Interviewing, 12-Step Approaches Families.

6 Substance Use, Abuse, & Dependence Substance USE Developmentally appropriate experimentation of substances Appropriate use of substances that is related to one s culture Use of prescription medication according to physician s instructions Substance ABUSE Recurrent substance use results in Negative Life Consequences (i.e. work, school, social, legal) Substance DEPENDENCE Substance use becomes a Lifestyle (i.e. the cycle of getting, using, and withdrawing from substances)

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9 The Developing Brain Specific Regions Nucleus Accumbens Amygdala Prefrontal Cortex Back to Front Maturation Bottom Up VS Top Down Process The Pruning Process

10 Adolescent + Substance Abuse = Arrested Development Brain Structure Volume 10% smaller volume of hippocampus region White Matter Quality Less white matter = dissipation of myelincoated axons = slower connections Delays in Cognitive Task Memory, attention, information processing, spatial tasks, and executive functioning (Squeglia et al., 2009)

11 Arrested Development Adolescents are less sensitive to the sedative effects of alcohol = stay awake to drink more = making them more vulnerable to alcohol-induced neurotoxicity. Parts of the brain undergoing the greatest changes in adolescents are most sensitive to alcohol neurotoxicity in adolescents (Crews & Boettiger, 2009) Morbidity/Mortality rates increase by % between middle childhood and late adolescents Children reaching puberty earlier... despite brain continued slow development = fast car with no breaks (Dahl).

12 Co-Occurring Disorders

13 Co-Occurring Disorders Co-occurring disorders means that any psychiatric or medical disorder coexists with the addictive disorder. Each of these disorders has a life of its own and is not dependent on the other for its cause or continuation. Substance abuse often leads to worsening of a person s mental illness, and more severe mental health symptoms sometimes lead to greater substance abuse % of adolescents receiving inpatient substance abuse treatment have a coexisting mental health disorder. So why do we continue to treat these separately?????

14 Co-occurring Problems Are the Norm and Increase with Level of Care Co-occurring Problems by Level of Care Conduct Disorder ADHD Major Depressive Disorder Generalized Anxiety Disorder Traumatic Stress Disorder Any Co- Occuring Disorder Outpatient Long Term Residential Short Term Residential Source: CSAT & Cannabis Youth Treatment (CYT), Adolescent Treatment Model(ATM), and Persistent Effects of Treatment Study of Adolescents (PETS-A) Studies

15 Treatment

16 Critical Treatment Components Integrated Treatment Clients receive simultaneous treatment of both disorders in a setting designed to accommodate both problems Relational Connection Allows the adult to serve as a Point of Reference for the adolescent. Structure Routine and Consistency Critical for Behavioral Restructuring Provides External structure to clients with internal disregulation. Skills Training Social Skills, Coping Skills, Self-Care Skills and Independent Living Skills, DBT Family Therapy Multisystemic Family Therapy

17 Harm Reduction Harm Reduction refers to measures aimed at reducing the harm associated with drug use without necessarily requiring a reduction in consumption

18 Criticisms of Harm Reduction Assumption that Harm Reduction leads to more use Continued use leads to arrested development Substance use in adolescents is negatively correlated with school performance lower mean wages and higher rates of institutionalization It seems to be counter-intuitive!!!

19 What's wrong with abstinence-only approach with adolescents??? Developmentally Incongruent (Psychologically, Socially, and Neurodevelopmentally) = Adolescents see SU as normative Adolescents usually don't identify themselves as addicts, given the length of time of their use and the fairly limited negative consequences that they experienced Adolescents can not see the relevance in life long commitment to abstinence Adolescents have difficulty with accepting such concepts as 'powerlessness' and belief in 'higher power' Typically, those adolescents going into treatment are in the precontemplation stage; therefore their investment in deception is far greater than accepting change and being honest

20 Goals of Harm Reduction Promote Honesty Informed choice education Focus on reducing harmful effects Free of labeling, stigmatization, and judgment about the morality of one's behavior

21 Goals of Harm Reduction Increasing self-efficacy and self-confidence Abstinence = ultimate risk-reduction goal. (Wasterman & Kelly, 2003)

22 Putting it into practice Harm Reduction Strategies need to be age appropriate and must incorporate the social context of the adolescent (Bonomo & Bowes, 2001) Program expectations surrounding substance use during time of treatment Accepting the gray

23 Putting it into practice Open conversation with all parties about program's use of Harm Reduction upon student's evaluation and admission Open conversation with potential staff at time of interview Harm Reduction is part of the training curriculum and is also discussed at all meetings with staff (i.e. staff meetings, milieu meeting, and supervision) Educating Probation and Parole Officers on Harm Reduction and negotiating 'consequences' with them for positive drug screens Relapse Prevention plans written and shared with families

24 Client Video

25 Boundaries Section 2:

26 The balancing act of self disclosure: Sharing too little or sharing too much

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28 Supervisory Tool of Boundaries Which client/clients are you the closest to (spend the most time with, have the best relationships with, can talk with the easiest)? How do you manage boundary issues with this client (spending time alone, sharing personal information, physical touch)? How do you process touch with the clients ( i.e. what does your touching the clients mean to them, what is your comfort level around them touching you)? What mannerisms/attire issues do you personally need to be mindful of in working with these clients?

29 Supervisory Tool of Boundaries cont d How would you handle a situation when a client has a "crush" on you? Which clients are you not close with and why? What needs do you get met in your job? What policies/procedures/rules contradict you own personal values/beliefs? How do you handle this? What are the warning signs of an inappropriate staff/client relationship?

30 Questions to ask yourself before selfdisclosing: What do I hope this will accomplish? To what extent am I attempting to meet my own needs? How might the client personalize or perceive what I share about myself? Is there another way to make the same point? How can I put the focus back on the client? What do I risk by sharing or not sharing?

31 Countertransference Special guidance must be provided to staff who are in recovery and wish to disclose their recovery process It worked for you but it may not work for them!

32 Client Video

33 Section 3: Risk Management

34 ONE Thing on Their Minds!!!!

35 Risk Management Continuum Least Intrusive to Most Intrusive l l l l l l l l l No Eyeball Ask Dog Pocket Dog Johnny Johnny Cavity Search Them Them Search Search Search Search Search Search of of -No -Visual Env. Person Visual

36 Managing High Risk in the Milieu Drug Screens Frequent and random Based on suspicion of use or intoxication Returning from community/home visit Comprehensive Searches Room/Environment search Body search Mental Status Exam Suicidal ideations Homicidal ideations Self Injurious Behaviors Elopement Watching for any sudden changes in behavior and attitude

37 Contraband. Clients who bring contraband into a treatment facility are not doing this to be difficult, defiant, or bad, they are doing this because they are addicted! By nature, addiction is the state of being enslaved to a habit or practice or to something that is psychologically or physically habit-forming to such an extent that its cessation causes severe trauma. --- Dictionary.com

38 Contraband Clients who are found with contraband should: Revisit and rewrite their relapse prevention plan Consider restrictions on home-passes Be drug screened immediately Receive extra support in their treatment Determine if this is just possession or was there intent to distribute Be assessed for a possible higher level of supervision and/or care placement Encourage the client to report this to their families and outside agencies.

39 Relapse Prevention Plan

40 Positive Drug Screen Since relapse is often part of recovery, it is common for clients with addictions to test positive for substances during their treatment. Clients who test positive: Should revisit and rewrite their relapse prevention plan May have restricted off campus passes or activities, until they have processed through and addressed their relapse May require additional support in their treatment (i.e. extra groups, AA/NA meetings) Should be assessed for a possible higher level of supervision and/or care placement Encourage the client to report their relapse to their families and outside agencies.

41 Managing Cross-Addiction Over-exercising Over or under eating or purging Gambling with dice, cards, or trading items Sexual acting out Obsessive cleaning

42 Mental Status Many people who are new in their recovery are susceptible to depression, anxiety, and increased irritability. These emotions can act as triggers for substance use in our clients. When substances are not available to them as coping skills, they may resort to other options as a way to relieve themselves of these negative emotions. They may engage in self injurious behaviors (which can cause a high through an adrenalin rush), attempt suicide or to elope (as a way to escape the negative feelings or to use substances), or act out aggressively towards others (in order to get the feelings out ).

43 Creative Interventions to Address Cravings Sensory Rooms Walking Plans Use of Caffeine Candy Knitting CARE Plans Replacement Skills

44 Risk Management and Preparation for Discharge Home Visits Reduction of Searches Reduction of Drug Screens Increase in Independence

45 Home Visit Contract

46 Client Video

47 Contact Information Devereux Foundation Integrated Treatment Program 60 Miles Road, PO Box 219 Rutland MA (508)