paradigm developmental model of treatment: a motivational...
TRANSCRIPT
4/2/19
1
Paradigm Developmental Model of Treatment:
A Motivational, Cognitive Behavioral Approach, Utilizing the Collective Wisdom
of Recovery
Presented by L. Georgi DiStefano, LCSW
1
2
3
4/2/19
2
Paradigm
A set of assumptions, concepts, values, and
practices that constitutes a way of viewing
reality for the individual and the community
that shares them.
4
1940’s Mother’s Formula for Daughter’s Success
Marriage
5
Family
Homemaking
Today’s Formula for Daughter’s Success
Self-Reliance
6
EducationCareer
4/2/19
3
Step One: Problem Recognition“We admitted we were powerless over alcohol – that our lives had become
unmanageable.”Step Two: Looking Beyond Self
“Came to believe that a Power greater than ourselves could restore us to sanity.”Step Three: Letting Go
“Made a decision to turn our will and our lives over to the care of God as we understood Him”
Step Four: Self-Examination“Made a searching and fearless moral inventory of ourselves.”
Sept Five: Taking Responsibility“Admitted to God, to ourselves, and to another human being the exact nature of our
wrongs.”Step Six: Willingness to Change
“Were entirely ready to have God remove all these defects of character” Step Seven: Action to Change - Relinquish Control
“Humbly asked Him to remove our shortcomings.”
7
Step Eight: Accountability - Empathy“Made a list of all persons we had harmed, and became willing to make amends to
them all” Step Nine: Asking Forgiveness - Accepting Consequences
“Made direct amends to such people wherever possible, except to do so would injure them or others.”
Step Ten: Self Regulation“Continued to take personal inventory and when we were wrong promptly admitted
it” Step Eleven: Mindfulness
“Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to
carry that out.” Step Twelve: Giving Back - Transformation
“Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.
8
4/2/19
4
Clinical Themes 12 Steps
11
Step 1 Problem RecognitionStep 2 Looking Beyond SelfStep 3 Letting Go
Step 4 Self-Examination
Step 5 Taking ResponsibilityStep 6 Willingness to Change
Step 7 Action to Change
Step 8 Accountability / EmpathyStep 9 Asking Forgiveness - Accepting Consequences
Step 10 Self-RegulationStep 11 Mindfulness
Step 12 Giving Back / Transformation
L. Georgi DiStefano, LCSW
PARADIGM MODEL SYNTHESISParadigms I-II-III-IV provide the conceptual framework for clinical focus
Paradigm Stage
Provides:“Counseling Goals”
(Inherent in 12-Step Themes)
Counseling Goals
Problem RecognitionSelf-Examination
ResponsibilityAccountabilitySelf-RegulationTransformation
Paradigm 1: Problem Recognition, Looking Beyond Self, Letting go and Acceptance of HelpParadigm 2: Self Examination, Taking Responsibility, Willingness to change, Action, Accountability/EmpathyParadigm 3: Forgiveness/Consequences, Mindfulness, Self RegulationParadigm 4: Transformation
Note: The stages of change (Prochaska, DiClemente, Norcross) occur within each paradigm: Pre-Contemplation-Contemplation-Preparation-Action-Maintenance, and oftenwith multiple issues.
Assessment Tools(Chemical DependencyAssessment Instruments
and Paradigm Scale)
Provide:Client profile
Paradigm Scale
1. Disinterested 2. Contemplating/Open3. Accepting/Implementing4. Overconfident5. Consistent Action
Motivational InterviewingMiller/Rollnick
Provides:Spirit
OARSCommunication
Method
O-Open endedquestion
A-AffirmR-ReflectS-Summarize
Client Motivators
Provide:The lens
of the work
Language
MetaphorAnalogyImagery
Illustration
Cognitive, BehavioralStrategies/ Techniques
Provide:Counseling
Intervention & Exercises
Interventions
See Intervention List and
Exercises
12-Step Programs or other Self-help Groups
Provide:Client’s
support system
ProgramsAANA
Other self-help groups
* Individualized Nutrition, Physical exercise programs,
and Medical Management
Provide:Brain biochemistry support in recovery
InterventionsYoga
M editationExercise
Food PlansNutritional supplements
*This is not as yet evidence based
L. Georgi DiStefano, LCSW
12
4/2/19
5
Evidence-Based Practice Models
13
• Motivational Interviewing• Cognitive-Behavioral Therapy
Cognitive-Behavioral Therapy
14
Cognitive-behavioral therapy (CBT) is a short-term form of psychotherapy directed at present-time issues and based on the ideas that the way that an individual thinks and feels affects the way he or she behaves. Negative patterns of thought about the self and the world are challenged in order to alter unwanted or unproductive behavior.
Cognitive-Behavioral TherapyThe goal of CBT is to change a client’s thought patterns in order to change their responses to difficult situations.
Beck Institute of CBT, accessed Feb 3, 2017, Psychology Today
14
4/2/19
6
⦿ Validate ambivalence
⦿ Increase cognitive dissonance by reframing
⦿ Don’t argue
⦿ Don’t label
⦿ Roll with resistance: reframe
⦿ Enhance self-esteem by optimism and by collaborative problem-solving
Miller & Rollnick, 1991
Motivational Interviewing
16
Collective Wisdom
Client stories, “Case Histories” that teach,
clarify, or reinforce recovery concepts in
each paradigm, theme, or stage.
16
18
The Process
Determine ParadigmClinical Themes and Stage of Change
Counselor Client Analyze Data
MI StyleMotivators Interventions
• Elicit follow-up• Elicit/New• Provide• Elicit• Summarize
• Keeping license 1. Assessment feedback• Staying out of jail 2. Motivators/Goals• Keeping family/spouse 3. Decisional balance• Health 4. Personal value card sort• Keeping job 5. Personal ruler• Feel better 6. Mutual support group• Not killing someone 7. Medication compliance • Healthy finances 8. Other cognitive behavioral
interventions
Assessment Instruments
Theoretical Models Cognitive Behavioral 12 Step FacilitationMotivational Interviewing
The
Par
adig
m D
evel
opm
enta
l Mod
el o
f Tre
atm
ent
L. Georgi DiStefano, LCSWMelinda Hohman, Ph.D
4/2/19
7
Typical Client Motivators•Keeping license
•Staying out of jail
•Keeping family/spouse
•Health
•Keeping job
•Not killing someone
•Finances
19
Collective Wisdom
• Target the Collective Wisdom (CW) to the appropriate motivator.
19
Paradigm Developmental Model of Treatment ScaleL. Georgi DiStefano, LCSW and Melinda Hohman, Ph.D.
1=Strongly Disagree 2= Disagree 3= Not sure 4=Agree 5=Strongly Agree
21
Please answer each question as it applies to you right now, using the following scale:
1. When I drink/use drugs, I frequently am unable to manage my use 1 2 3 4 5
2. I now believe I have a problem with alcohol/drugs 1 2 3 4 5
3. I realize I need help with my alcohol/drug problem 1 2 3 4 5
4. I now believe that I am an alcoholic/drug addict 1 2 3 4 5
5. I have decided to quit drinking or doing drugs 1 2 3 4 5
6. I am currently attempting abstinence 1 2 3 4 5
7. I understand the characteristics about myself that get me in trouble 1 2 3 4 5
8. I know what my high risk behaviors are 1 2 3 4 5
9. I know what my strengths are that support recovery 1 2 3 4 5
10. I monitor my thoughts and feelings on a daily basis 1 2 3 4 5
11. I manage my self-defeating behaviors regularly 1 2 3 4 5
12. I take a personal inventory regularly and admit mistakes/promptly 1 2 3 4 5
13. I am a totally different person now from when I was drinking/using 1 2 3 4 5
14. I have incorporated healthy and productive behaviors into my life 1 2 3 4 5
15. I go to self-help meetings such as AA 1 2 3 4 5
Client’s name: Date:
Paradigm: Scale Category:
4/2/19
8
Paradigm I: Disinterested
Client is disinterested in addressing alcohol and other drug issues with behavioral change
Paradigm I: Contemplating/OpenClient is not sure there is a significant alcohol and drug problem but is open toward exploration of theissue.
Paradigm II: Accepting/ImplementingClient accepts they have an alcohol and drug problem and is preparing to make behavioral changesor has initiated some behavioral change. Must be abstinent from alcohol and other drugs.
Paradigm II: OverconfidentClient has initiated abstinence from alcohol and drug use but is overconfident or unrealistic about therecovery process or is self-managing abstinence.
Paradigm III: Consistent ActionClient is engaged in a recovery process and action is taken on a consistent basis to manage alcoholand drug issues.
Paradigm IV: TransformationClient has fully integrated their recovery process over a significant period of time.
PARADIGM SCALE CATEGORIES
L. Georgi DiStefano, LCSW 22
23
Paradigm 1Problem Recognition and Acceptance of HelpClinical Goals■Determine client motivators■Realistic evaluation of AOD issues■Identification high risk behaviors■Identification of co-occurring disorders■High-Risk Behavior prevention planning■Harm reduction plan/Initiation of abstinence■Willingness to accept formal AOD treatment
Para
digm
Dev
elop
men
tal M
odel
L. Georgi DiStefano, LCSW 24
4/2/19
9
Paradigm 1Problem Recognition and Acceptance of HelpINTERVENTIONS:1. Providing Assessment Feedback2. Motivators and Goals3. Assessment: Loss/Grief/Anger/Resentment Family/Friends: Attitude/Support4. Assessment: Identification of High-Risk Behaviors
Selecting Interventions5. General MI Discussions. MI Discussion Using Change -Talk Questionnaire.
Additional Change -Talk questionnaire.6. Consequence History / Looking Forward7. Decisional Balance8. Personal Values Card Sort9. Discussion of Drinking Change - Personal Ruler
10. Mutual Support Group and AA - Reactions to AA11. Identifying Craving/Urges and Triggers: Playgrounds, Playmates and Playthings12. Determining UnmanageabilityPa
radi
gm D
evel
opm
enta
l Mod
el
25L. Georgi DiStefano, LCSW
Collective Wisdom
• Target the CW to the consequences that concern the client.
30
Collective Wisdom
• Target the CW to the client’s projections of the future.
32
4/2/19
10
Paradigm 2 Taking ResponsibilityClinical Goals■Revisit goals and motivators■Identification self-sabotaging behaviors■Identification Strengths / Resiliencies■Managing co-occurring disorders■Relapse prevention plans ■Practice alternative behaviors
Para
digm
Dev
elop
men
tal M
odel
28L. Georgi DiStefano, LCSW
Paradigm 2Taking ResponsibilityINTERVENTIONS:1. Self-Examination and What is my Communication Style?2. Change Plan Worksheet3. What gets in the Way?4. Revisiting my Goal and Motivators5. My Cultural Influences6. Trigger Response Plan7. Urge Monitoring Card8. Social Pressure Situations and Coping Responses. Exercise 1 & 29. Learning from Collective Wisdom
10. Old/New Behaviors11. What is in my Control?12. Monitoring Both Sides of the StreetPa
radi
gm D
evel
opm
enta
l Mod
el
29L. Georgi DiStefano, LCSW
Collective Wisdom
• Target the CW to the successes of the client. Support client optimism.
38
4/2/19
11
Collective Wisdom
• Tie the CW to needed behavioral changes.
41
Paradigm 3Self-RegulationClinical Goals■ Embracing change■ Exploration of ACA/family of origin issues■ Ability to self-regulate/self-correct■ Engage in new health practices■ Integrate alternative behaviors■ Develop consistency of recovery behaviors■ Relapse prevention
Para
digm
Dev
elop
men
tal M
odel
32L. Georgi DiStefano, LCSW
The Three R’s
• Rituals
• Routines
• Resources
43
4/2/19
12
Collective Wisdom
• Use CW to identify, teach, and reinforce specific rituals, routines, and resources.
44
Paradigm 3Self-RegulationINTERVENTIONS:1. How I have changed2. Examination of Growth Zones - Part 1 and Part 23. Self-Regulation Planning4. Amends5. ACA (Old ) Behaviors Today6. Building My Future
Para
digm
Dev
elop
men
tal M
odel
35L. Georgi DiStefano, LCSW
•Medication non-compliance•Missed appointments•Referral non-compliance•Resumed drinking •Thinking about a referral
36
AT ANY STAGE
4/2/19
13
Collective Wisdom
• Address non-compliance issues in a motivational, “non-confrontational” manner with CW.
52
38
Paradigm 4TransformationClinical Goals■ Giving back■ Mindfulness■ Self-Actualization■ Resolve Family of Origin issues
Para
digm
Dev
elop
men
tal M
odel
39
L. Georgi Distefano, LCSW
4/2/19
14
References
40
DiStefano, L.G. (2017). Paradigm Change: The Collective Wisdom of Recovery. San Diego, Montezuma Publishing.
DiStefano, L.G. (2012). The Paradigm Developmental Model of Treatment Group Topics. San Diego, Montezuma Publishing.
DiStefano, L. G. & Hohman, M. (2010) Paradigm Developmental Model Of Treatment. A Clinical Guide For Counselors Working With Substance Abusers And The Chemically Dependent. San Diego, Montezuma Publishing.
Hohman, M. & DiStefano, L.G. (2009). Preliminary Validation of the Paradigm Developmental Model of Treatment. Alcoholism Treatment Quarterly, 27 (1), 82-83.
DiStefano, L. G. & Hohman, M. (2007). The Paradigm DevelopmentalModel of Treatment: A Framework for Treating Multiple DUI
Offenders. Alcoholism Treatment Quarterly, 25 (3), 133-148.
DiStefano, L. G. & Hohman, M. (2006). The Paradigm Developmental Model of Treatment. The Counselor, 7 (6), 49-55.