Treatment Issues

1
Treatment Issues

• Theodore M. Godlaski
• College of Social Work
• University of Kentucky

2
Issues with Adolescents

• There is growing recognition that adolescents
  with substance misuse problems also, very
  frequently, have histories of traumatic abuse.
  
• There is now emerging data on adolescent response
  to treatment when victimization is an issue.

3
Adolescent Treatment Models, Cross site Analysis
(2002). Summary Report from June 27-28 Meeting.
Rockville, MD Northrop Grumman
Information Technology Health Solutions and
Service Division.
4
Funk, R., McDermeit, M., Godley, S.H., De Leon,
G. (2003). Maltreatment issues by level of
adolescent substance abuse treatment The extent
of the problem at intake and relationship to
early outcomes. Journal of Child Maltreatment, 8
(1) 36-45.
5
Clinical Considerations

• Screen adolescents with substance misuse for
  history of traumatic abuse.
  
• Treatment staff should be well trained in how to
  respond to victimization.
  
• Acute victimization should be considered in
  placement decisions.
  
• Recognize that dealing with victimization is
  complex.
  
• Recognize that the victim may also be a
  perpetrator.
  
• Track victimization for treatment planning and
  program development purposes.
  
• Address staff concerns about victimization.

6
Issues for Adults
7
A fundamental difference of opinion

• Proponents of classic family system theory
  maintain that violence is an outgrowth of a
  dysfunctional relational system.
  
• Feminist theorists maintain that violence is the
  result of the perpetrators dysfunction and that
  all concepts like codependency and enabling
  simply are attempts to excuse the perpetrators
  behavior by blaming the victim.

8
A fundamental difference of opinion

• Advocates of feminist approaches would contend
  that relationship counseling is almost never
  appropriate for the following reasons
  
• a.)The relationship has been altered by violence
  rather than violence being an outgrowth of the
  relationship.
  
• b.)Terrorized women cannot contribute freely and
  equally
  
• c.)Victims of abuse need a considerable time
  free of fear and coercion to viably participate
  in couples therapy.
  

9
A fundamental difference of opinion

• Classic family systems approach advocates contend
  that relationship counseling is the preferred
  mode of treatment so long as the following
  conditions can be met
• The threat of abuse must be greatly reduced over
  precounseling levels
  
• Violence must have been stopped for a period of
  time longer than any previous period in the
  relationship without violence
  
• After the first two conditions are met, both
  parties must agree that they wish to work for the
  repair of the relationship.

10
A fundamental difference of opinion

• Feminist theory calls for response on three
  levels
  
• Societal
• Passing and enforcement of laws proscribing
  violence and mandating referral of batterers to
  intervention.
  
• Providing women with access to all the resources
  men enjoy.
  

11
A fundamental difference of opinion

• Community
• Providing funding and support for shelters for
  battered women.
  
• Developing coordinated community response to
  domestic violence.
  
• Individual
• Appropriate interventions for women that empower
  them to leave their perpetrators.
  
• Educational programs for perpetrators that enable
  them to replace controlling and misogynistic
  attitudes with egalitarian attitudes.

12
General Concerns About Relationship Counseling

• Many counselors may limit their definition of the
  problem to the relationship and fail to recognize
  other critical issues.
  
• The interactive nature of relationship counseling
  limits attribution of responsibility for
  violent/abusive behavior.

13
General Concerns About Relationship Counseling

• Relationship counselors hold to strict therapist
  neutrality, viewing both parties as responsible
  for problems in the relationship.
  
• Relationship and family counselors tend to see
  violence as a symptom of family dysfunction and
  may minimize the need for specific intervention.

14
General Concerns About Relationship Counseling

• Violence may have altered the relationship beyond
  the ability of the partners to change it.
  
• Relationship counseling may cause women to stay
  in a violent relationship longer than they might
  otherwise.
  
• Perpetrators can learn the language of therapy
  and use treatment as another way to control their
  partners.

15
Intimate Justice Theory

• Applicable to relationship counseling where
  violence is involved.
  
• Based on establishing three basic conditions or
  principles
  
• Accountability
• Respect
• Freedom

16
Accountability

• Both partners can set limits on each others
  behavior.
  
• Both also provide corrective feedback about the
  other's behavior.
  
• Essential for establishing an environment of
  equality in the relationship.
  
• Its opposite is entitlement, which can often be
  at the root of intimate violence.

17
Respect

• According to this principle, counselors must
  confront the underlying attitudes of entitlement
  that contribute to control of women by fear.
  
• Respect is earned over time by the display of
  positive behavior (empathy, nurturance,
  intimacy).
  
• Once established, respect becomes the foundation
  of relationship.

18
Freedom

• Freedom implies the ability of individuals to
  speak openly, unrestricted, and unconstrained by
  fear of their partners.
  
• Is necessary for establishing negotiation.
• Counselors explore the experiences of empowerment
  and disempowerment for both partners, confronting
  stereotypes and attitudes that tend toward
  coercion and control.

19
Important Distinction

• Common Couples Violence (reactive violence) vs.
  Patriarchal Terrorism (instrumental violence)
  
• This may be a critical distinction in considering
  whether relationship counseling is appropriate.
  
• In cases of common couples violence, where the
  conditions for relationship counseling have been
  met, relationship counseling may be appropriate.
  
• In cases of patriarchal terrorism, relationship
  counseling is unlikely to ever be appropriate.

20
Common Couples Violence

• When the violence is sporadic, mild, and to some
  degree mutual
  
• When the perpetrator lacks or has only to a small
  degree characteristics indicative of psychopathy,
  hostile depression, or perfectionistic over
  control
• When the victim experiences little fear of the
  perpetrator and considers relationship problems
  primary.

21
Patriarchal Terrorism

• When the violence is persistent, severe, and
  without any real provocation
  
• When the perpetrator exhibits to a marked degree
  characteristics indicative of psychopathy,
  hostile depression, or perfectionistic over
  control
• When the victim fears further violence whether or
  not she considers relationship problems primary.
  

22
General Consideration About Treatment of Dual
Problems

• We would probably do well not to get too
  preoccupied with theoretical considerations until
  we have better theories.
  
• We would do well to use the guidelines already
  provided.
  
• We would do well to better understand the needs
  and desires of our clients.
  
• We would do well to understand that this problem
  requires a concerted and coordinated effort of a
  number of resources.

23
Brief Overview of Motivational Interviewing

• Theodore M. Godlaski
• College of Social Work
• University of Kentucky

24
Motivation is . . .

• a process that leads to a behavioral
  probability.
  
• The probability that a person will enter into,
  continue, and adhere to a specific change
  strategy.
  
• It is the function of counseling to facilitate
  the process leading to this probability.

25
change
relief
26

• In general, the more the counselor
• insists on change

• the more the client is obliged to resist

27
Some Basic Insights about Change

• Change occurs naturally
• What happens during and after formal intervention
  mirrors natural change
  
• The likelihood that change will happen is
  influenced by interpersonal interaction
  
• When change occurs during treatment, it tend to
  happen in the first few sessions
  
• The clinician is a significant variable in
  determining outcome dropout, retention, and
  adherence

28
Some Basic Insights about Change

• Empathic counseling style seems to facilitate
  change, its absence tends to deter change
  
• People who believe that they are likely to
  change, do so.
  
• What people say about change is important.
• What people say about change can be influenced

29
So What is Motivational Interviewing?

• It is a treatment approach in which the client
  supplies the content and the counselor supplies
  the methods.
  
• It is a client centered, directive, approach
  that is designed to assist individuals in
  resolving their ambivalence about change.
  
• The methods are primarily active empathy and
  summarizing feedback to assist the client to move
  forward in a process of change.

30
Strengths of Motivational Interviewing

• Non-confrontational empathic style
• Supported by research, proven effectiveness with
  a variety of human problems.
  
• Successful with different high risk populations
• Successful in brief sessions
• You dont have to be specialized in chemical
  dependency counseling to use it

31
Qualities of a Motivational Counselor

• Respect for individual differences
• Tolerance for disagreement and ambivalence
• Patience with gradual approximations
• Realistic humility about his/her expertise
• Genuine concern and interest in clients as
  individuals

32
exiting
relapsing
sustaining
not thinking
thinking
changing
planning
adapted from Miller, W. Rollnick, S. (1991)
Motivational interviewing Preparing
people to change addictive behavior. The Guilford
Press, NY, p. 15.
33
Adapted from Prochaska, J.O. DiClemente, C.C.
(1982). Transtheoretical therapy
Toward a more integrative model of change.
Psychotherapy Theory, Research, Practice,
19, 276-288.
34
Basic Principles of Motivational Interviewing

• Express Empathy
• Develop Discrepancy
• Avoid Argumentation
• Roll with Resistance
• Support Self-Efficacy

35
Express Empathy

• Acceptance facilitates change
• Skillful reflective listening is fundamental
• Ambivalence is normal
• We are more likely to be successful if we begin
  change from a position of self-acceptance than of
  self-loathing.

36
Develop Discrepancy

• Awareness of consequences is important
• Discrepancy between present behaviors and
  important and valued goals motivates toward
  change
  
• Have the client present the reasons for change

37
Avoid Argumentation

• Resistance is a signal to change strategies
• Labeling is unnecessary and unhelpful
• Arguing is generally counterproductive
• A clients attitudes are shaped by their words,
  not yours

38
Roll With Resistance

• Use momentum to your advantage
• Shift perceptions
• Invite new perspectives, dont impose them
• The client is the most valuable resource in
  finding solutions to his/her problems

39
Support Self-Efficacy

• Belief that change is possible is a critical
  motivator
  
• It is the client who is responsible for choosing
  and carrying out actions to change
  
• There is hope in the range of alternative
  approaches available

40
Building Motivation Opening Strategies

• Ask open ended questions
• Listen reflectively
• Affirm
• Summarize
• Work toward self-motivating statements

41
Opened Ended Questions

• You can gain more information with an open ended
  question than with a series of closed questions.
  
• Open ended questions invite the client to explore
  an area of function and lead to the client
  talking more than the counselor.
  
• Open ended questions also allow the client to
  express values and attitudes that might otherwise
  remain unnoticed.

42

• Open Ended Questions
• What was it like growing up in your family?
• What kind of person was your mother?
• What kind of person was your father?
• What was it like for you in grade school?

• Closed Questions
• Where were you born?
• How many brothers and
• sisters did you have?
• Where were you in the birth
• order?
• Who raised you?
• Where did you go to school?
• Did you have problems
• learning to read or write?

43
Reflective Listening

• All communication begins as thoughts or images in
  the head of one person that become spoken words
  and gestures. This process is encoding. These
  sounds and sights must be decoded by the listener
  back into ideas or images.
• The process of encoding and decoding is effected
  by the life experiences of each individual and
  the cultures from which they come.
  
• Reflective listening attempts to clarify that the
  idea or image in the listeners head is the same
  as that in the speakers head.

44
Affirm

• It is important that the counselor appreciate the
  vulnerable and anxious situation of the client
  during a session.
  
• Affirming the clients willingness to talk, to
  begin to recognize problems, to think about
  taking action, etc. is a powerful means of
  establishing a relationship.
• Most importantly, it opens the door to the
  clients sense of self-efficacy.

45
Summarize

• Offering the client feedback in the form of
  summaries is one of the most powerful strategies
  in early motivational interviewing.
  
• Clients have seldom, if ever, reviewed chunks of
  their lives.
  
• Summarizing can assist the client in beginning to
  make motivating connections between specific
  behaviors and unwanted experiences and sensations.

46
Self-Motivational Statements

• Recognizing the problem
• Maybe I have been taking foolish risks.
• Expressing concern
• How could this happen to me.
• Stating the intention to change
• I dont know how Im going to do it, but I have
  to make some changes.
  
• Optimism about change
• Somehow, Im going to overcome this problem.

47
Some Ways to Elicit Self-Motivating Statements

• Evocative Questions
• Using Decisional Balance Worksheet
• Elaboration
• Using Extremes
• Looking Back
• Looking Forward
• Exploring Goals
• Paradox

48
Basic Methods of Reflexive Listening

• Repeating what the client has said.
• Rephrasing using synonyms.
• Paraphrasing using inferred meaning.
• Reflection of the affect behind the statement.

49
Counseling in Not Thinking About Change Stage

• Raise doubts in the client about their current
  patterns of behavior.
  
• Increase the clients sense of the risks and
  problems with current patterns of behavior.

50
Carlo DiClement and Mary Valasques comment that
precontemplators fall into four broad groupings

• reluctant precontemplators who may lack
  information about the effects of problem
  behaviors or are comfortable with the problem
  behaviors and need empathic feedback
• rebellious precontemplators who have strong
  investment in making their own decisions and need
  a menu of options for incremental change
  
• resigned precontemplators who have lost hope in
  their ability to change and need affirmation and
  increase in self-efficacy
  
• rationalizing precontemplators who project
  responsibility for problem behavior onto others
  and need decisional balance assessment to accept
  personal responsibility for change.

51
Counseling in the Thinking About Change Stage

• Tip the balance in favor of change.
• Evoke reasons for change, point out the risks of
  not changing.
  
• Strengthen the clients self-efficacy for
  behavioral change.

52
Things to Keep in Mind

• Thinking about changing and being ready to change
  are not the same things.
  
• This is a stage of intense ambivalence.
• It is important to explore the pros and cons of
  changing and of staying the same.

53
Counseling in the Planning Change Stage

• Assist the client in finding the best, acceptable
  course of action for bringing about the desired
  change.
  
• Encourage fall back plans in case primary plans
  fail.

54
Things to Keep in Mind

• The willingness to change does not imply the
  knowledge of how to change.
  
• The more complete and systematic the plan the
  better.
  
• Ambivalence is still quite strong at this stage.

55
Counseling in the Changing Stage

• Assist the client to take concrete steps toward
  change.
  
• Recognize even partial success.
• Suggest additional steps.
• Encourage the clients sense of self-efficacy

56
Things to Keep in Mind

• Taking action to change is not yet change.
• Clients need encouragement and praise for their
  efforts.
  
• Supporting self-efficacy is critical.

57
Counseling in the Sustaining Change Stage

• Shift strategies to those emphasizing relapse
  prevention.
  
• Move from substitutive strategies to more global
  issues.
  
• Build recognition of the benefits of sustained
  change.

58
Things to Keep in Mind

• Sustaining change is not static.
• Individuals need to be reminded of their
  progress.
  
• Unrealistic expectations need to be corrected.

59
Counseling in the Relapsing Stage

• Initiate a new cycle of thinking about, planning,
  and sustaining change.
  
• Support the client to minimize a sense of being
  stuck and demoralized.

60
Things to Keep in Mind

• Loss of self-efficacy is the greatest risk.
• Reframing relapse as an opportunity rather than a
  tragedy is an important skill.

61
A Final Word

• Motivational Interviewing is a method of
  communication rather than a set of techniques. It
  is not a bag of tricks for getting people to do
  what they dont want to do. It is not something
  that one does to people rather, it is
  fundamentally a way of being with and for people
  a facilitative approach to communication that
  evokes natural change
• Rolnick, S., Miller, W. (1995) What is
  motivational interviewing?. Behavioral and
  Cognitive Psychotherapy, 23 (4) 325-334.

62
Time for a 10 Minute Paper

• Pretend that you are part of a clinical research
  team that has developed and tested a treatment
  approach that is actually very effective in
  changing the behavior of substance misusing
  individuals who are also involved in intimate
  violence. Over a 24 month follow-up, 64 of
  families had no incidents of substance misuse or
  intimate violence and 24 had significantly
  reduced incidents compared with pre-treatment
  levels. The treatment protocol has very specific
  thresholds of intensity and duration and must be
  done with specific frequency over a long enough
  time to be effective.
• However, the intervention is very time and labor
  intensive, costing an average of 32,000 per
  family treated.
  
• Think about your chances of convincing an
  insurance company or a state legislature to cover
  the cost.

63
Future Directions

• It must be admitted that much of the work done to
  date is descriptive.
  
• Information about the overlap of substance
  misuse, violence, and mental health problems is
  largely a byproduct of other investigation.
  
• Many of the theories and models explaining the
  linkage are speculative, untested, and lack
  specificity.

64

• Better theory building and theory testing will be
  a critical component of future research.
  
• Theories and models that focus on contextual
  stress, stress response, and the effects of the
  immediate social environment.
  
• Social Learning Theory, especially with emphasis
  on the mediating and moderating role of substance
  use and expectations about the outcome of
  substance use and violence.
• Theories and models that center on executive
  function.
  
• Theories and models that use developmental
  pathology as a pathway connecting violence,
  substance misuse, and emotional problems.
  
• Approaches that clarify the mediating and
  moderating role of substance use and emotional
  state in increasing the likelihood of violence.

65
Clinical 1 Identifying, Recognizing, and
Referring

• Development of better methods -- using
  sociodemographic, ethnic, historical, and
  personal factors to identify at risk
  populations.
• Development of methods of identifying homogeneous
  subgroups within violent populations to
  facilitate client-intervention matching.

66
Clinical 2 Understanding and Overcoming
Barriers to Treatment

• Understanding the factors that effect readiness
  to recognize and address the problems of
  substance misuse and violence.
  
• Better understanding of the role of the general
  and familial culture.
  
• Better understanding the the culture specific
  conditions that facilitate help-seeking.
  
• Better understanding of the role of payer
  mechanisms and agency culture in effecting who
  receives help and what help they receive.
  
• Better understanding of the factors in
  multi-agency involvement that inhibit or
  facilitate appropriate intervention.

67
Clinical 3 Evidence Based Interventions

• Put simply, we need to understand whether what we
  are doing is of any value.
  
• Can evidenced based interventions for substance
  misuse be adapted to include intimate violence?
  
• What, if any, current approaches to treatment of
  intimate violence actually change behavior in
  significant and lasting ways?
  
• What are the appropriate measures for success of
  interventions targeting substance misuse and
  intimate violence?