THE ARISE MODEL

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THE ARISE MODEL Invitational Intervention
Theory and Outcome Research
James Garrett, LCSW, CAI, BRI II Linking Human
Systems LINC Foundation LinkingHumanSystems.com
garrett_at_linkinghumansystems.com 877-229-5462
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DEFINITION OF INTERVENTION

• Intervention is a desire by family, friends,
  employers, and other members of the support
  network actively to assist someone to change
  unacceptable behavior
• It is a pre-treatment engagement approach to
  assist the person struggling with addictive
  behavior to enter treatment or self-help

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TREATMENT ENGAGEMENT

• A VERY SMALL PROPORTION OF PEOPLE WITH DRUG
  DEPENDENCY OR ABUSE ARE ENGAGED IN TREATMENT OR
  SELF-HELP
• NATHAN (1990) ESTIMATED 5
• FRANCES ET AL. (1989) ESTIMATED 10
• KESSLER ET AL. (1994) ESTIMATED 8

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The Vast Majority (90-95) of Addicted
Individuals Are Never in Treatment Or Self-Help

• Untreated chemical dependency annually costs the
  USA 50,000 deaths and over 165 billion in
• Medical care
• Unemployment
• Criminal justice system involvement
• Addiction treatment
• (Brady, 95 Klaidman, 96 Rice, 94)
• Chemical dependency treatment saves 7.00 for
  every 1.00 invested (Berlant et al., 94
  Gerstein et al., 94 Langenbucher, 94, replicated
  2006)
• In Canada 40 billion in costs and treatment
  saves 11.00 for each 1.00
• CSAT (2005) 22 million Addicted Individuals
  needed treatment and only 3 million received
  treatment during the year 2005

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A Relational Intervention Sequence for Engagement
(ARISE)
A Three-Level, Graduated Continuum of
Intervention To Engage Addicted Individuals in
Treatment

• Goal Getting the Addicted Individual into
  treatment
• Principle Stop at the first level that works
• Process
• Applies the least amount of time and effort
• Responds to the love, fear, worry, and guilt of
  those living with the addiction
• Is designed to be cost and time effective

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• Level I The First Call
• Someone calls or contacts an agency concerned
  about a Addicted Individual
• The call is used to coach the caller on getting
  the Addicted Individual into treatment
• The First Caller (Concerned Other) is coached to
  mobilize members of the support system to get the
  Addicted Individual into treatment
• Level II Strength in Numbers
• Family, friends, and Concerned Others meet to
  plan bringing the Addicted Individual into
  treatment if Addicted Individual is not engaged
  after Stage I
• Level III The Formal ARISE Intervention
• If needed Network proceeds to a supportive,
  formal Intervention meeting

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ARISE

• Is a collaborative process. From the initial
  invitation extended, the process conveys respect
  and establishes the ground rules for openness and
  no secrecy from the very beginning
• Acknowledges that mistrust will be a major issue
  and assures the addicted individual that s/he can
  trust family/friends and does not have to trust
  the Interventionist

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ARISE

• Allows the Interventionist to say, We will all
  meet for the first time together, and Let the
  addicted person know s/he is only being asked to
  come to this one meeting to express his/her
  opinion
• Addresses the addicted individuals biggest
  complaint, fear, and source of defensivenessIm
  being tricked, Youre going behind my back, or
  Youre ambushing me and doing this as a
  surprise

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ARISE

• Views the First Caller/Concerned Other/Family
  Link as a valuable necessary resource in getting
  the AI into treatment, rather than viewing
  him/her as co-dependent or enabling
• Encourages the Intervention Network to make a
  solid commitment to the process, even if the AI
  refuses to come to the First Meeting

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ARISE

• Right from the 1st Call, acknowledges the power
  and destructiveness of addiction and recognizes
  how the addicted individual needs support
  encouragement to begin a process of recovery
• Breaks the isolation and private struggle of
  both AI and family preventing any further loss
• Sets the groundwork for the Intervention Network
  to be used as a Board of Directors for
  consensus decision making

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ARISE

• Establishes roles and clarification of the
  process and asserts the initial rule that the
  group is going to meet regardless of whether the
  addicted individual attends meetings
• Empowers the family, builds on family competence,
  resilience and strengths, offering hope and
  reducing blame, shame and guilt
• Acknowledges boundaries for the family, the
  Intervention Network, and the AI
• Sets the scene for the initial and future
  meetingsthe Invitational Intervention Continuum

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ARISE

• Acknowledges the importance of choice at every
  step in the Intervention
• Offers the AI options, and thereby avoids the
  rebellious/defiant response set up by telling
  him/her what to do
• Removes the power of the addictive disease from
  controlling and defining the family

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Addicted Individuals Have frequent contact With
their families of origin

• 26 of 28 reports indicate drug addicts are in
  regular contact with one or more parent (Stanton
  and Shadish, 97)
• 90 of 22 year-old New York narcotic addicts
  returning from treatment lived with mother, if
  alive (Vaillant, 66)
• 86 of 25-30 year old opioid addicts saw one or
  both parents face-to-face at least weekly
  (Stanton, 82)

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Percentage of Subjects in Daily Telephone Contact
With One or More Parent
Addicts
Heroin
Addicts
Polydrug
Non- addictss
(Purzel and Lamon, 79)
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DRUG ABUSERS LIVING WITH PARENTS
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Relationship of Addiction toLoss and Trauma
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Loss and Addiction

• Onset of addiction is almost always connected to
• death of a parent, grandparent, spouse or
  significant friend,
• natural or human-made disaster,
  immigration/refugee experience, or war
• Substance use
• numbs the sadness, loss, anger, guilt and
  loneliness
• distracts from grief in other members of the
  family

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Effects of Trauma and Loss

• Oklahoma City
• For every one person directly impacted by the
  Oklahoma City Bombing, 10 years later five showed
  symptoms of stress or PTSD
• US War Veterans
• Demonstrate very similar statistics

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Effects of Trauma and Loss contd.

• Taiwan
• A series of major earthquakes and floods after
  1999 resulted in a 60 increase in rates of
  depression and suicide
• New York City
• 1 year after 9/11, 30 increase in abuse of drugs
  and alcohol
• Katrina
• 1 year after the disaster, 63 increase in abuse
  of drugs and alcohol

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More Vietnam veterans have died from addiction
and/or suicide than were lost during the Vietnam
conflict

• Deaths of Vietnam veterans
• during Vietnam conflict 58,000
• since Vietnam conflict from addiction/suicide
  62,000

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Trauma and AddictionHistorical Trauma

• Trail of Tears (1830s)
• 18,000 Cherokee and Muskogee Indians forced to
  move (4,000 deaths)
• Long Walk (1863)
• 8,000 Apache and Dine incarcerated at Ft. Sumner,
  NM resulting in over 2,000 deaths

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Trauma and AddictionHistorical Trauma contd.

• Holocaust (1938-1945)
• Approximately 6 million Jews killed in the
  Holocaust
• Armenian Genocide (1900-1923)
• 3.5 to 4.5 million Armenians, Greeks, Nastorians
  and other Christians killed by various Turkish
  regimes

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Trauma and AddictionIndividual Trauma

• 60 of the women in AA report a history of
  sexual abuse
• 30 of the men in AA report a history of sexual
  abuse

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Family Resilience
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Transitional Family Therapy
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Philosophy of Transitional Family Therapy

• Families are intrinsically healthy and competent
• People and environments are constantly in
  transition
• Individuals, families and communities will find
  and utilize their competence
• Competence is unavailable when individuals and
  families are cut off from their extended families
  and natural support systems
• To access competence, mobilize and extend natural
  support system
• Eliminate the we/they dichotomy and maintain
  connection to family and culture of origin

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Principles of Transitional Family Therapy

• Empower family and natural support system
• Remove the blame, reduce shame and guilt
• Help the elders (parents and grandparents) take
  charge
• Identify natural resources
• Identify patterns across generations

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Principles of Transitional Family Therapy

• Engage the entire system
• Be sensitive to issues of culture, gender and
  spirituality
• Expose and resolve secrets
• Consider medical problems
• Reconnect the transitional pathway
• Assure continuity of family values, mission and
  heritage

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Principles of Transitional Family Therapy

•        Determine why now?
• Understand impact of the time compression/life
  cycle reversal
• Deal with unresolved transitions, grief, loss and
  abuse
• Identify strengths, themes and resources across
  generations

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Principles of Transitional Family Therapy

• Establish a balance of agency and communion
• Achieve co-operation across all systems and the
  network
• Refer and collaborate whenever necessary
• Delegate
• Reconnection, continuity and recalibration

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Impact of Stressors/Change on Family Functioning
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SUMMARY OF ARISE PRINCIPLES (based on
Transitional Family Theory)

• Families are intrinsically healthy and when
  things go wrong have the drive to heal
• Families are resilient and can be guided to
  access strengths that have allowed them to
  flourish in the past and successfully address
  problems and achieve goal
• Families are more powerful than professionals
• The end is in the beginning (addiction is related
  to trauma and unresolved loss and stops when
  families heal and resolve the trauma and loss)
• Respect the symptomsymptomatic behavior it is
  adaptive and initially designed to solve a
  problem (symptoms are manifestations of a healing
  process)

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Invitational Intervention

• Why an Invitation?

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Why an Invitation?

• Studies in 1980s showed that 8 of every 10
  families calling for a Johnson Intervention
  refused to follow through (Garrett et al.)
• 100 of women in Australian study refused to do a
  Johnson Intervention when offered (Barber
  Gilbertson)

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ARISE

• Views families as being intrinsically healthy
• Empowers the family, builds on family competence,
  resilience and strengths, offers hope and
  reduction of blame, shame and guilt
• Is a collaborative process from the initial
  invitation

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ARISE

• Conveys respect and establishes the ground rules
  for openness and no secrecy from the very
  beginning
• Views the First Caller/Concerned Other as a
  valuable necessary resource in getting the AI
  into treatment, rather than as co-dependent or
  enabling
• Helps Intervention Network understand the power
  and destructiveness of addiction and the need for
  support and encouragement for the AI to begin the
  recovery process

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ARISE

• Breaks the isolation and private struggle of
  both AI and family
• Sets the groundwork for the Intervention Network
  to be used as a Board of Directors for
  consensus decision making
• Identifies and builds on the motivation within
  the family to heal from unresolved grief and/or
  trauma

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ARISE

• Acknowledges the importance of choice at every
  step in the Intervention
• Acknowledges the importance of choice at every
  step in the Intervention
• Offers the AI options, and thereby avoids the
  rebellious/defiant response set up by telling
  him/her what to do
• Removes the power of the addictive disease from
  controlling and defining the family

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Family Motivation to Change
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Family Motivation to Change is the combined
forces operating within a family guiding it
toward maintaining survival and healthy
functioning in the face of serious threat, and
toward healing when that threat is removed.
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FAMILY MOTIVATION TO CHANGE THE PROCESS IN
ACTION

• First Protecting and then Healing the Family
• Completing the Transitional Task for Peace of
  Mind.
• Getting a Loved One Back
• Preventing Further Loss

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FAMILY MOTIVATION TO CHANGE

• Recovery Messages
• Breaking the Inter-Generational Cycle of
  Alcoholism
• The Power of Wanting to Get a Loved One Back
• Preventing More Loss

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Using ARISE for Other Problems

• Compulsive Gambling
• Eating Disorders
• Psychiatric Disorders
• Sexual Addiction
• Internet Addiction
• Compulsive Spending
• Medical Problems (treatment and medication
  compliance)

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THE FIRST CALL
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FIRST CALL WORKSHEET

• Callers phone number____________Relationship to
  SA___________
• Presenting Problem (Join Address Callers
  Initial Concerns Identify Presenting Problem)
• Get Permission to Ask More Personal Questions 
• Construct a Preliminary Genogram (use back of
  this page or separate page) 
• Construct list of support network members to
  invite to First Meeting
• Get Substance Abuse History
• Get Brief Treatment History (include self help,
  use of sponsor and treatment)
• 7. Identify Past Family Efforts (join around SA
  manipulation and breaking one-on-one isolation) 

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FIRST CALL WORKSHEET (cont.)

• 8. Assess for Safety
• Is the AI threatening to hurt him/herself or
  anyone else? (Are there weapons involved?)
• Has someone needed to call the police recently?
  (Explore details)
• Has the AI been involved in any serious accidents
  lately? (Explore details)
• Has there been any history of trauma, Domestic
  violence or abuse (Explore details)
• 9. Finalize who to invite to form the
  Intervention Network--Get commitment to attend
  regardless of whether AI attends
• 10. Finalize time and place to hold the First
  Meeting
• 11. Develop Recovery Message and strategy to
  invite the AI
• 12. Complete financial arrangements and any other
  details regarding referral to treatment (I.e.,
  insurance verification, pre-certification, bed
  availability, etc.). Cover all potential levels
  of care pending decision at First Meeting.

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ARISE NIDA Study Findings
Data From National Institute of Drug Abuse Study
(RO1 DA09402 )
Landau, Stanton, et al., 2004
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PRIMARY SUBSTANCE ABUSED

• Substance of Choice was not a Predictor
• Cocaine 73 (66.4)
• Alcohol 26 (23.6)
• Other 11 (10.0)
• (Cannabis 6)
• (Opioid 4)
• (LSD 1)

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RELATIONSHIP OF CONCERNED OTHERTO THE Addicted
Individual

• 94.7 OF ALL CONCERNED OTHERS WERE FAMILY MEMBERS
• PARENTS 38 40.3
• SPOUSES/PARTNERS 29 30.9
• OFFSPRING 4 4.3
• OTHER RELATIVES 18 19.2
• NON-RELATIVES 5 5.3
• The majority was female 68.8
• Their mean age was 46.6 (range 15-78)

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PRIMARY CONCLUSIONS

• Included all consecutive cases with no exclusion
  criteria (i.e., all Concerned Others who called
  the agencies)
• Of 110 cases, 82.7 (n 91) became engaged in
  treatment (n 86) or self-help (n 5)
• Over half (55) became engaged during Level I
  (First Call or Contact)
• Mean amount of time required (telephone and
  face-to-face) per case was 88 minutes (median
  75 minutes)
• 50 were engaged within 1 week 76 within 2
  weeks 83 within 3 weeks

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PRIMARY CONCLUSIONS cont.

• Greater number of network members involved
  predicted greater success of engagement and
  less time and effort by Interventionist
• Less time spent by Interventionist on phone, or
  fewer calls, predicted better outcome
• Parental involvement significantly enhanced rate
  of success, regardless of age of parent or
  Addicted Individual
• Preferred substance of abuse did not predict
  success, neither did severity of abuse nor
  psychiatric problems

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MOST SIGNIFICANT PREDICTOR VARIABLE

• The greater the number of significant others
  involved in the network, the more likely was the
  Addicted Individual to get engaged in treatment
  or self-help (plt.0001)
• Successful cases averaged 3.3 members (including
  Concerned Others). Unsuccessful cases averaged
  1.3 members
• The point biserial correlation between engagement
  success (yes/no) and the number of network
  members involved was .39 (plt.001)

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Percent Engaged in Treatment
Stage of Engagement
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Engagement Outcome By Level of Care
60.00
52.70
50.00
Inpatient
Intensive OPD
40.00
27.50
SA OPD
30.00
Self-Help
20.00
13.20
10.00
5.50
0.00
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PERTINENT NULL FINDINGS

• Preferred substance of abuse did not predict
  success, nor did severity of substance abuse or
  psychiatric problems
• Interventionist difference (years of experience
  degree age gender) did not affect engagement
  outcome
• There was no difference across the two sites
• Race, Gender, role of Concerned Other were not
  significant factors in engagement outcome

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Real World Test of ARISE at SSTAR
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Real World Test of ARISE at Asian-American
Outreach Program in New York City
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