Henry Schmidt III, Ph.D.Henry Schmidt III, Ph.D.Cory RedmanCory Redman

John Bolla, MA, CDPJohn Bolla, MA, CDP

Washington State Juvenile Rehabilitation Washington State Juvenile Rehabilitation AdministrationAdministration

CODIAC Co-occurring Disorders CODIAC Co-occurring Disorders

ConferenceConferenceYakima, WashingtonYakima, WashingtonOctober 1-2, 2007October 1-2, 2007

Treatment of Substance Treatment of Substance Abuse and Co-occurring Abuse and Co-occurring

Disorders Disorders in JRA’s in JRA’s

Integrated Treatment Integrated Treatment ModelModel

Substance Abuse Treatment Substance Abuse Treatment and JRA’sand JRA’s

Integrated Treatment Model Integrated Treatment Model (ITM)(ITM)

All youth receive treatment throughout JRA All youth receive treatment throughout JRA supervisionsupervision

Targets are identified based on treatment Targets are identified based on treatment modelmodel DBT for residentialDBT for residential FFPS for paroleFFPS for parole

Substance abuse treatment fits within the Substance abuse treatment fits within the broader ITM contextbroader ITM context Skill-building across multiple domainsSkill-building across multiple domains Improve family functioningImprove family functioning

Treatment in a NutshellTreatment in a Nutshell Clear behavioral targetingClear behavioral targeting Engage and motivate, elicit commitmentEngage and motivate, elicit commitment Assess controlling variables for client’s useAssess controlling variables for client’s use

ReinforcersReinforcers Cues/contexts of useCues/contexts of use Behavioral sequences (urges lead to plans…)Behavioral sequences (urges lead to plans…) Statistical risk factors (e.g., mental illness, Statistical risk factors (e.g., mental illness,

family use)family use) Modeling, Coaching and Reinforcing of Modeling, Coaching and Reinforcing of

skillsskills Contingency ManagementContingency Management Troubleshooting, Relapse PreventionTroubleshooting, Relapse Prevention

Treatment for Co-Occurring Treatment for Co-Occurring DisordersDisorders

Mental health diagnosis less important than Mental health diagnosis less important than symptomssymptoms

Psychiatric care as requiredPsychiatric care as required Increase client understanding of MH issues Increase client understanding of MH issues

and recognition as possible risk factors for and recognition as possible risk factors for target behaviorstarget behaviors

MH behavior may be a risk factor for a target MH behavior may be a risk factor for a target behaviorbehavior

‘‘Solutions’ for MH risk factors are selected, Solutions’ for MH risk factors are selected, learned and practicedlearned and practiced

Solutions are tailored to match client Solutions are tailored to match client interests, current skills, broad abilityinterests, current skills, broad ability

Program DevelopmentProgram Development

Assessment of client needsAssessment of client needs EBPs for adolescents, juv justice populationEBPs for adolescents, juv justice population Reviewed treatment expert Reviewed treatment expert

recommendationsrecommendations Fit with EBP treatment modalities currently Fit with EBP treatment modalities currently

in use (DBT; FFP; FIT)in use (DBT; FFP; FIT) Identification of treatment assumptions, Identification of treatment assumptions,

modesmodes Adaptation and creation of treatment Adaptation and creation of treatment

materialsmaterials

JRA Substance Abuse JRA Substance Abuse Treatment: Treatment:

Program Elements Program Elements Screening and AssessmentScreening and AssessmentPreventionPreventionPre-TreatmentPre-TreatmentTreatment Treatment AftercareAftercare

Substance Abuse Substance Abuse Screen/AssessmentScreen/Assessment

ScreensScreens Global Appraisal of Individual Needs (GAIN – Global Appraisal of Individual Needs (GAIN –

SS)SS) Substance Abuse Screen (SAS)Substance Abuse Screen (SAS) Client History Review (structured interview)Client History Review (structured interview)

AssessmentsAssessments Biopsychosocial Diagnostic ASAM AssessmentBiopsychosocial Diagnostic ASAM Assessment

Acute Intoxication and/or Withdrawal PotentialAcute Intoxication and/or Withdrawal Potential Biomedical Conditions and ComplicationsBiomedical Conditions and Complications Emotional/Behavioral Conditions and ComplicationsEmotional/Behavioral Conditions and Complications Treatment Acceptance/ResistanceTreatment Acceptance/Resistance Relapse/Continued Use PotentialRelapse/Continued Use Potential Recovery EnvironmentRecovery Environment

Behavior AnalysisBehavior Analysis

Intervention Decision Intervention Decision ProcessProcess

ScreenScreen AssessmentAssessment Assignment to Treatment LevelAssignment to Treatment Level Assignment to AftercareAssignment to Aftercare Transition to Parole ServicesTransition to Parole Services

PreventionPrevention

Goals of PreventionGoals of Prevention A comprehensive prevention curriculum for all A comprehensive prevention curriculum for all

youth not needing substance abuse treatment.youth not needing substance abuse treatment. Practice strategies for rejecting drugs and Practice strategies for rejecting drugs and

alcohol.alcohol. To emphasize that use of tobacco, alcohol, and To emphasize that use of tobacco, alcohol, and

drugs are not the norm among teenagers.drugs are not the norm among teenagers. Help youth to develop greater self-worth, self-Help youth to develop greater self-worth, self-

efficacy, and self-confidence.efficacy, and self-confidence. Enable youth to effectively cope with anxiety, Enable youth to effectively cope with anxiety,

depression, anger, shame, guilt, fear, etc. depression, anger, shame, guilt, fear, etc. Link prevention activities within the home, Link prevention activities within the home,

schools, and community. schools, and community.

Elements of PreventionElements of Prevention

Pschoeducation re:Pschoeducation re: Harmful effects of drugs and alcohol Harmful effects of drugs and alcohol

(including nicotine)(including nicotine) Peer norms for usePeer norms for use Risk factors for useRisk factors for use

Skill BuildingSkill Building Refusal skillsRefusal skills ‘‘Reasons to not use’ – strengthen Reasons to not use’ – strengthen

commitment and abstinence/moderation commitment and abstinence/moderation beliefs and expectanciesbeliefs and expectancies

Pre-TreatmentPre-Treatment

Goals of Pre-TreatmentGoals of Pre-Treatment

Prepare youth for substance abuse Prepare youth for substance abuse treatment.treatment.

Introduce preliminary education and Introduce preliminary education and information about substance abuse.information about substance abuse.

Identify individual’s risk and protective Identify individual’s risk and protective factors, triggers and cues, patterns of factors, triggers and cues, patterns of use, and functions and drivers.use, and functions and drivers.

Increase desire to engage in treatment.Increase desire to engage in treatment.

Elements of Pre-Elements of Pre-TreatmentTreatment

Orientation to treatmentOrientation to treatment Assess stage of changeAssess stage of change Increase motivation and engagement Increase motivation and engagement

toward participation in pre-toward participation in pre-treatment and treatmenttreatment and treatment

Obtain commitment to explore and Obtain commitment to explore and understand personal substance understand personal substance abuseabuse

TreatmentTreatment

Goals of TreatmentGoals of Treatment Decrease:Decrease:

substance abuse.substance abuse. physical discomfort from abstaining.physical discomfort from abstaining. urges and cravings to use drugs.urges and cravings to use drugs. apparently irrelevant behaviors.apparently irrelevant behaviors. keeping options to use drugs open.keeping options to use drugs open. capitulating to use drugs.capitulating to use drugs.

Increase community reinforcement of Increase community reinforcement of “clear mind” behaviors. “clear mind” behaviors.

Dialectical Behavior Dialectical Behavior TherapyTherapy(DBT)(DBT)

Developed by Marsha Linehan and Developed by Marsha Linehan and colleagues, forcolleagues, for

Chronically suicidal women meeting criteria Chronically suicidal women meeting criteria for Borderline Personality Disorderfor Borderline Personality Disorder

Manualized, one-year outpatient treatment Manualized, one-year outpatient treatment modelmodel

Successful in working with difficult-to-Successful in working with difficult-to-engage, difficult-to-treat populationsengage, difficult-to-treat populations

DBT AdaptationsDBT Adaptations Substance AbuseSubstance Abuse

Linehan et al. (1999)Linehan et al. (1999) AdolescentsAdolescents

Outpatient, Rathus & Miller (2002)Outpatient, Rathus & Miller (2002) Inpatient, Katz et al. (2004)Inpatient, Katz et al. (2004)

Residential settingsResidential settings Inpatient psychiatric, Swenson et al. (2001)Inpatient psychiatric, Swenson et al. (2001) Forensic inpatient - McAnn, Ball, Ivanoff Forensic inpatient - McAnn, Ball, Ivanoff

(2000)(2000) Washington State JRA – Trupin et al. (2002) Washington State JRA – Trupin et al. (2002)

Other Disorders: Batterers, couplesOther Disorders: Batterers, couples

Why DBT and Why DBT and Adolescent Substance Use?Adolescent Substance Use?

Behavioral DyscontrolBehavioral Dyscontrol Truancy, criminality, substance use, self-injury Truancy, criminality, substance use, self-injury

Emotional DyscontrolEmotional Dyscontrol Low-skilled in identifying and regulating Low-skilled in identifying and regulating

emotionsemotions Cognitive Rigidity Cognitive Rigidity (developmental)(developmental)

b/w thinking, oppositional, rule-governed b/w thinking, oppositional, rule-governed morals morals

Interpersonal IssuesInterpersonal Issues Socially isolated or shifting groups, deviant Socially isolated or shifting groups, deviant

peers, etc.peers, etc. Issues of Self Issues of Self (developmental)(developmental)

Unstable sense of self, low self-esteemUnstable sense of self, low self-esteem

Basics of DBTBasics of DBT

JRA’s Residential Treatment

DBT Modes of TreatmentDBT Modes of Treatment

Individual TherapyIndividual Therapy Group Skills TrainingGroup Skills Training Telephone ContactTelephone Contact Therapist Consultation GroupTherapist Consultation Group Pharmacotherapy (as needed)Pharmacotherapy (as needed)

Functions of Functions of Comprehensive CBTComprehensive CBT

Enhance Client MotivationEnhance Client Motivation Acquire SkillsAcquire Skills Generalize SkillsGeneralize Skills Structure Environment for Structure Environment for

TreatmentTreatment Enhance Therapist Motivation and Enhance Therapist Motivation and

SkillsSkills

Important ElementsImportant Elements

DIALECTICS - Balance of Acceptance v. DIALECTICS - Balance of Acceptance v. ChangeChange

BEHAVIORAL ASSUMPTIONSBEHAVIORAL ASSUMPTIONS Clients are doing the best that they canClients are doing the best that they can Maladaptive behavior occurs becauseMaladaptive behavior occurs because

Lack of skills to do otherwiseLack of skills to do otherwise History of it being reinforcedHistory of it being reinforced Strong contextual risk factorsStrong contextual risk factors

Thus, the behavior makes sense in Thus, the behavior makes sense in contextcontext

DBT Treatment DBT Treatment HierarchyHierarchy

DECREASEDECREASE Suicidal, Self-Injurious BehaviorSuicidal, Self-Injurious Behavior Treatment-Interfering BehaviorTreatment-Interfering Behavior Quality-of-Life Interfering BehaviorQuality-of-Life Interfering Behavior

Behaviors are targeted Behaviors are targeted sequentiallysequentially

Only one or two targets at a Only one or two targets at a timetime

DBT-SDBT-S Substance use is top quality-of-life Substance use is top quality-of-life

interfering targetinterfering target

New Concepts for DBT-New Concepts for DBT-SUDSUD

‘‘Dialectical Abstinence’Dialectical Abstinence’

DBT-SUD Path to Clear DBT-SUD Path to Clear MindMindDecrease Substance AbuseDecrease Substance Abuse

Decrease Urges and Cravings to use DrugsDecrease Urges and Cravings to use Drugs

Decrease Apparently Unimportant BehaviorsDecrease Apparently Unimportant Behaviors

Decrease ‘Keeping Options to Use Drugs Decrease ‘Keeping Options to Use Drugs Open’Open’

Decrease Capitulating to Use DrugsDecrease Capitulating to Use Drugs

Increase Community Reinforcement & Increase Community Reinforcement & ‘‘Clear Mind’ BehaviorsClear Mind’ Behaviors

CLEAR MINDCLEAR MIND

Strong Emphasis on Strong Emphasis on Attachment Strategies for Attachment Strategies for

ClientsClients DBT already successful at retaining difficult-DBT already successful at retaining difficult-

to-treat clients (BPD)to-treat clients (BPD) Increased emphasis on engaging clients Increased emphasis on engaging clients

Increase positive contact outside of sessionIncrease positive contact outside of session Post cards, birthday and special occasion cardsPost cards, birthday and special occasion cards Increasing non-demanding contact during first 3 Increasing non-demanding contact during first 3

monthsmonths Daily telephone check-in, exchange of messagesDaily telephone check-in, exchange of messages

Conducting therapy ‘in vivo’Conducting therapy ‘in vivo’ Altering session length (non mood-dependent)Altering session length (non mood-dependent) Supportive friends and family network meetingsSupportive friends and family network meetings

Attachment strategies for Attachment strategies for patientspatients

Finding ‘lost’ clients Finding ‘lost’ clients Clients are ‘dropping off’ until formally out Clients are ‘dropping off’ until formally out

of treatmentof treatment Often drop off when lapsing, relapsingOften drop off when lapsing, relapsing

Therapist task is to ‘find’ client who is not Therapist task is to ‘find’ client who is not responding to phone callsresponding to phone calls

Social network mapping – all relevant Social network mapping – all relevant networksnetworks Where gone in the past? What places does s/he Where gone in the past? What places does s/he

frequent?frequent? Orient clients to ‘getting found’ ahead of Orient clients to ‘getting found’ ahead of

timetime

Working with Mandated Working with Mandated ClientsClients

Also requires a large emphasis on Also requires a large emphasis on Engaging and MotivatingEngaging and Motivating

Cannot expect client to show up Cannot expect client to show up wanting to changewanting to change

Many clients ignore negative impact of Many clients ignore negative impact of lifestylelifestyle

Confrontation not effectiveConfrontation not effective Caution against settling for compliance Caution against settling for compliance

over participationover participation

JRA’s Residential DBT-SUD JRA’s Residential DBT-SUD ModelModel

Individual sessions with case managerIndividual sessions with case manager Skill acquisition groupsSkill acquisition groups Skill generalization groupsSkill generalization groups Milieu interventionMilieu intervention Family skills groupsFamily skills groups Staff meetingsStaff meetings Psychopharmacology (for MH, not Psychopharmacology (for MH, not

SUD)SUD)

JRA Residential Tx. JRA Residential Tx. HierarchyHierarchy

Engage and Motivate – ALWAYS!Engage and Motivate – ALWAYS! Suicidal/Self-injurious BehaviorSuicidal/Self-injurious Behavior Aggressive BehaviorAggressive Behavior Escape BehaviorEscape Behavior Treatment-interfering BehaviorTreatment-interfering Behavior Quality-of-life-interfering BehaviorQuality-of-life-interfering Behavior

Substance Abuse, DependenceSubstance Abuse, Dependence Criminal Behavior, Gang Involvement, Criminal Behavior, Gang Involvement,

Truancy, etc.Truancy, etc.

Know your client’s goals, strengthsKnow your client’s goals, strengths Explore pro-social, community- or Explore pro-social, community- or

family-oriented valuesfamily-oriented values Nonjudgmental exploration of issues Nonjudgmental exploration of issues

around substance usearound substance use Orient to program – this is what we Orient to program – this is what we

have to offerhave to offer Commit to work full-time to help Commit to work full-time to help

client reach own goals (partnership, client reach own goals (partnership, coach)coach)

Engage and Motivate Engage and Motivate ClientsClients

Engage and Motivate Engage and Motivate ClientsClients Distinguish between education and treatmentDistinguish between education and treatment

Elicit a commitment to treatment before Elicit a commitment to treatment before beginning change strategies (Linehan; Miller beginning change strategies (Linehan; Miller & Rollnick)& Rollnick)

Soft commitment is acceptable; ‘foot in the Soft commitment is acceptable; ‘foot in the door’door’

Problem-solve client wanting to quit Problem-solve client wanting to quit What would s/he find helpful? What would s/he find helpful? What has worked in the past?What has worked in the past?

Label ‘not being motivated’ as normative, Label ‘not being motivated’ as normative, cyclical, problem to be solved – not moral cyclical, problem to be solved – not moral failingfailing

Structure Supports Structure Supports EngagementEngagement Token economyToken economy

Level system tied to commitment, Level system tied to commitment, treatment participation and progresstreatment participation and progress

Compelling reinforcers for clients to Compelling reinforcers for clients to earnearn

Non-contingent staff warmth and Non-contingent staff warmth and encouragementencouragement

Peers are bought into the programPeers are bought into the program Low support for drug using, war stories Low support for drug using, war stories

(seen as unskillful, not goal-oriented)(seen as unskillful, not goal-oriented) Public recognition for accomplishing Public recognition for accomplishing

treatment goalstreatment goals

Relevant Assessment of Relevant Assessment of Drug and Alcohol HistoryDrug and Alcohol History

Statistical v. Idiographic Risk FactorsStatistical v. Idiographic Risk Factors ASAM Biopsychosocial Assessment, ASAM Biopsychosocial Assessment,

Researched risk factors, Chain AnalysisResearched risk factors, Chain Analysis

Psychological Constructs v. Behavioral Psychological Constructs v. Behavioral DescriptionsDescriptions

Understand in which situations the Understand in which situations the client used (topography – complete client used (topography – complete picture)picture)

The Chain AnalysisThe Chain Analysis Pick specific instances of different Pick specific instances of different

situationssituations Moment-by-moment narrative of eventsMoment-by-moment narrative of events Identify the controlling variables for use Identify the controlling variables for use

– – What problems did using solve?What problems did using solve? What were prompts for using? What got the What were prompts for using? What got the

ball rolling?ball rolling? What were vulnerabilities for using – made it What were vulnerabilities for using – made it

more likely the youth would use? (External more likely the youth would use? (External or internal contexts.)or internal contexts.)

Client and therapist both understand Client and therapist both understand what drove substance usewhat drove substance use

Assess for Relapse – Plan Assess for Relapse – Plan for Successfor Success

Problem-solve future use – what is Problem-solve future use – what is present in community environment present in community environment that could lead to relapse?that could lead to relapse? What skills will be needed to address this?What skills will be needed to address this?

What changes in environmental What changes in environmental structure could be made to support structure could be made to support treatment and long-term goal treatment and long-term goal attainment? (‘Burning bridges’)attainment? (‘Burning bridges’)

Skill AcquisitionSkill Acquisition Broad palette of skillsBroad palette of skills Skills are behaviorally specific.Skills are behaviorally specific. Particular skills are focus for individualized Particular skills are focus for individualized

treatment, needed to address specific elements treatment, needed to address specific elements of client’s risk for use.of client’s risk for use.

Groups and individual work incorporate Groups and individual work incorporate principles of learningprinciples of learning ModelingModeling ShapingShaping ReinforcementReinforcement

Arbitrary vs. NaturalArbitrary vs. Natural

Staff speak the same language throughout Staff speak the same language throughout programprogram

Skill GeneralizationSkill Generalization Milieu program – all interactions are Milieu program – all interactions are

opportunities to drag out and strengthen opportunities to drag out and strengthen skillful behavior, diminish unskillful behaviorskillful behavior, diminish unskillful behavior

Remind clients to take skills into all contextsRemind clients to take skills into all contexts SchoolSchool Family meetingFamily meeting Interactions with peersInteractions with peers Recreation and work activitiesRecreation and work activities Interactions with staff, etc.Interactions with staff, etc.

Highlight positive outcomes of skill use (staff Highlight positive outcomes of skill use (staff help youth to notice)help youth to notice)

Encourage client self-reinforcementEncourage client self-reinforcement

Structuring the Structuring the EnvironmentEnvironment Visual cues to remind youth and staff of the Visual cues to remind youth and staff of the

treatment environmenttreatment environment Invite youth’s parents/significant others to Invite youth’s parents/significant others to

participateparticipate Youth report on progress in program (new Youth report on progress in program (new

skills, chains for use, relapse prevention plan)skills, chains for use, relapse prevention plan) Family meetings focus on what has been Family meetings focus on what has been

effective in eliciting commitment, maintaining effective in eliciting commitment, maintaining motivation; what has ‘tripped up’ youthmotivation; what has ‘tripped up’ youth

Youth are taught to begin to structure their Youth are taught to begin to structure their own environment, begin to display those skillsown environment, begin to display those skills

Community resources are identified, Community resources are identified, contacted and agree to participate with youth contacted and agree to participate with youth (mentors, programs, treatment)(mentors, programs, treatment)

Motivating StaffMotivating Staff Knowledge that leaders are developing/have Knowledge that leaders are developing/have

vision for complete programvision for complete program Confidence in skill level and knowledge of Confidence in skill level and knowledge of

treatment director (or identified program treatment director (or identified program specialist)specialist)

High-quality training, when needed (paced, High-quality training, when needed (paced, relevant to expanding demands of job, etc.)relevant to expanding demands of job, etc.)

Examples of high-quality work (paperwork, Examples of high-quality work (paperwork, video or live demonstration of clinical tasks)video or live demonstration of clinical tasks)

Weekly staff consultation meeting focused Weekly staff consultation meeting focused on describing treatment, de-polarizing staff on describing treatment, de-polarizing staff (and increasing flexibility)(and increasing flexibility)

Motivating Staff (2)Motivating Staff (2) Advancement based on demonstration of skillsAdvancement based on demonstration of skills Managers are provided training to manage Managers are provided training to manage

wellwell Focus on systematic skill developmentFocus on systematic skill development

Link learning skills to individual staff goalsLink learning skills to individual staff goals

Staff see results of their own treatment effortsStaff see results of their own treatment efforts More skillful youthMore skillful youth

Committed to long-term goalsCommitted to long-term goals Accomplishing important tasksAccomplishing important tasks Understanding what drives own behaviorUnderstanding what drives own behavior Building a support networkBuilding a support network Preparing for success (relapse prevention plans)Preparing for success (relapse prevention plans)

JRA Community JRA Community AftercareAftercare

Functional Family ParoleFunctional Family Parole Families’ needs are identified and Families’ needs are identified and

discussed prior to the youth being discussed prior to the youth being released to the community on parole.released to the community on parole.

Youth and family with special needs Youth and family with special needs (mental health, substance abuse, etc.) are (mental health, substance abuse, etc.) are assisted by the Parole Counselor in being assisted by the Parole Counselor in being linked to community based resources.linked to community based resources.

Families are contacted regularly and Families are contacted regularly and youth with substance abuse issues are youth with substance abuse issues are monitored by random urinalysis. monitored by random urinalysis.

Family Integrated Family Integrated Transitions (FIT)Transitions (FIT)

EBP to transition juvenile offenders with the co-EBP to transition juvenile offenders with the co-occurring disorders back into their communityoccurring disorders back into their community

Designed and implemented by Eric Trupin, Designed and implemented by Eric Trupin, Ph.D. and David Stewart, Ph.D., from the Ph.D. and David Stewart, Ph.D., from the University of Washington.University of Washington.

To meet the needs of these high risk youth, To meet the needs of these high risk youth, several evidence-based programs were several evidence-based programs were combined. Those are:combined. Those are:

o Multi-Systemic Therapy (MST) as the core Multi-Systemic Therapy (MST) as the core treatment model, plus:treatment model, plus:

o Dialectical Behavior Therapy (DBT)Dialectical Behavior Therapy (DBT)o Motivational Enhancement Therapy (MET)Motivational Enhancement Therapy (MET)o Relapse Prevention/Community Relapse Prevention/Community

ReinforcementReinforcement

FIT Target PopulationFIT Target Population

Ages 11 to 17.5, with a substance Ages 11 to 17.5, with a substance abuse/dependency and mental health abuse/dependency and mental health needneed

At least 2 months left on sentenceAt least 2 months left on sentence Residing in Snohomish, King, Thurston Residing in Snohomish, King, Thurston

or Mason counties (JRA Regions 3, 4, or Mason counties (JRA Regions 3, 4, and 6) with a family or stable placementand 6) with a family or stable placement

Sex offenders are NOT excluded from Sex offenders are NOT excluded from the target populationthe target population

FIT Demonstrated FIT Demonstrated OutcomesOutcomes

33% reduction in felony recidivism33% reduction in felony recidivism FIT reduces recidivism from 40.6% to FIT reduces recidivism from 40.6% to

27.0%. 27.0%. Cost of Program: $8, 968 spent per Cost of Program: $8, 968 spent per

youth youth Benefit-cost ratio related to the Benefit-cost ratio related to the

reduction in crime is a savings of $3.15 reduction in crime is a savings of $3.15 for every dollar spent – or total of $19, for every dollar spent – or total of $19, 247 per youth in the FIT program247 per youth in the FIT program