effective substance abuse strategies for individuals with...
TRANSCRIPT
NADD 32nd Annual Conference & Exhibit Show
Equality, Recovery, Access: Integrating Treatment & Services for
Persons with IDD/MI
November 18-20, 2015
San Francisco, California
Effective Substance Abuse
Strategies for Individuals with IDDr. BJ Davis – Co-Executive Director & Clinical Director, Strategies for Change
John W. Decker, MSW – Community Placement Plan & Forensics Manager, Alta California Regional Center
1
Introduction
• This workshop will increase participants’
understanding of how to successfully deliver
substance abuse services to individuals with
developmental disabilities. Attendees will learn
about the impact of substance use disorder on this
population and how, through effective collaboration,
to tailor treatment paradigms to meet the specific
needs of this specialized population.
2
Learning Objectives
• Understand the relationship of developmental disabilities and
substance use with regard to prevalence and risk factors.
• Increase awareness of the key issues related to service utilization and
access to treatment and recovery by persons with an intellectual
disability. Be able to replicate a model of successful collaboration
across service systems.
• Increase knowledge of treatment competencies and strategies for
serving this population. Specifically, learn effective screening and
assessment tools and how traditional treatment can be modified to
address the learning needs of individuals with intellectual disabilities.
3
Agenda
• Background - Developing these Materials -
Collaboration and Cross Systems Cooperation
• Intellectual Disability and Substance Use
Disorder (Prevalence, Severity/Impact,
Special Considerations)
• How to Effectively Serve this Population
“What Works!”
4
Developing Collaboration &
Cross- System Cooperation• Alta California Regional Center Substance Abuse
Reduction Project 2011-2014
− Mental Health Services Act Grant administered by the
Department of Developmental Services
Project Deliverables:
− Community Steering Committee (MHSA Joint Taskforce)
− Training for alcohol/drug providers
− Training for regional center service coordinators
− Training for regional center vendors (developmental
disability professionals)
5
Project Deliverables cont.
• Outpatient Treatment-Strategies for Change- Expanded
funding for an existing Medi-Cal program. Added opportunities
for more sessions and home visits for ACRC clients. Provided
funding for additional training of staff and facility
improvements
• Peer Recovery Mentors – Mexican American Addiction
Program – ACRC funding for the training and oversight of our
clients that are in recovery to serve as mentors to those that in
need of substance use treatment.
6
Development of Web Based
Training
7
Collaborative Efforts
Getting Started• Participation in Sacramento County Alcohol and Drug
Executive Director’s Meeting - Spring 2012− Got buy in from Executive Director’s of local AOD agencies. The executive
directors shared their desire to implement a training program for their
staff relating to individuals with developmental disabilities receiving AOD
treatment. The executive directors overwhelmingly agreed to participate
in a needs assessment interview at their agency.
• In-person needs assessment interviews with 11 AOD
agencies – Summer 2012− Agency staff indicated they currently serve individuals with developmental
disabilities. They had little training about this population and were eager
to have their staff trained on working with clients with them. Individuals
with DD did not disclose, needed additional support, were challenging to
support in group settings
8
Collaborative Efforts cont.
• Development of a Joint Taskforce –
Summer 2012 -Ongoing
− Quarterly meetings held at Alta California Regional Center with
agenda items surrounding the development of the training
materials and discussing cross-disciplinary issues. Average
attendance at the Joint Taskforce is 17 professionals with nine
different non-regional center vendored community alcohol and
drug treatment agencies attending.
− Products Created: Resource manual, modified 12-steps, screening
and brief intervention materials, case scenarios & an agency
alcohol/drug policy model
9
Community Providers Trained –
Approx. 360 Kaiser Hospital
Dignity Health
Sacramento County
Ombudsman’s Office
Sacramento County Public
Guardian’s Office
Sacramento County Adult
Protective Services
Sacramento County
Department of Human
Assistance
Substance Abuse Steering
Coalition of Yuba, Sutter
and Colusa Counties
Sutter Yuba Mental Health
Marysville Police
Department
Sutter County Office of
Education
Placer County Adult System
of Care
Placer County Children’s
System of Care
Bridges, Inc. (Inpatient,
Outpatient, & STARS Case
Management)
Mexican American
Addiction Program (MAAP)
Sutter Yuba Alcohol and
Drug Services
Sutter County Probation
Department
Yuba County Probation
Department
Golden Sierra Workforce
WestCare
Wellspace
Safety Center, Inc.
Tahoe Youth and Family
Services
Sierra County Health and
Human Services
4th & Hope (Walter House
Residential Drug Treatment
& outpatient)
CRC Health Group –
Treatment Associates
M.A.A.P.
Bi-Valley Medical Clinic
Strategies for Change
Pathways-Yuba City
10
Spreading the News
• ACRC was fortunate to have John de Miranda as a consultant on the
project and our collaboration was featured in articles published in
Addiction Professional and Alcoholism & Drug Abuse Weekly.
11
Spreading the News –
Testimonial
• “…Utilizing the training our staff received as well as the special
screening questionnaire, we are now able to identify these clients
from the start and make sure that their treatment plan is geared for
their success. Our staff was quickly receptive because now they had
tools with which to help these clients, rather than the frustration of
learning, perhaps too late, that they needed a slower pace and
simpler terms. We were also helped by the fact that several years ago
we adopted a treatment curriculum that was aimed at a 3rd-grade
reading level, so we were already attuned to the need to keep it
simpler.”
• -Tianna Roye - Deputy Director of Bridges Professional Treatment
Services in Sacramento
12
Staff Trainings – Developmental
Disability Professionals
Summer and Fall 2013 –Approx. 125 ACRC staff received training on
working with clients that have alcohol and drug issues. Staff were
provided with some assessment materials and were acquainted with
different treatment modalities.
Winter and Spring 2014 -Approx. 140 ACRC vendors(care home, day
program, supported living services, independent living services,
behaviorists and counselors) received training. These vendors received a
similar training to the ACRC staff but also discussed development of
agency policies related to serving clients with substance use issues.
13
Lessons Learned from the Substance
Abuse Reduction Project
• Cross system collaboration is not only possible but
welcome
• The incidence of co-occurring (SUD & ID) disorders is
a significant barrier to successful utilization of ID
Services
• Organizational champions are important
14
DSM-5 Diagnostic Criteria for
Intellectual Disability
Intellectual disability (intellectual developmental disorder) is a disorder with onset during the
developmental period that includes both intellectual and adaptive functioning deficits in
conceptual, social, and practical domains. The following three criteria must be met:
• Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract
thinking, judgment, academic learning, and learning from experience, confirmed by both
clinical assessment and individualized, standardized intelligence testing.
• Deficits in adaptive functioning that result in failure to meet developmental and socio-
cultural standards for personal independence and social responsibility. Without ongoing
support, the adaptive deficits limit functioning in one or more activities of daily life, such
as communication, social participation, and independent living, across multiple
environments, such as home, school, work, and community.
• Onset of intellectual and adaptive deficits during developmental period.
15
DSM-5 Determining Severity of
Intellectual Disability
• Based on adaptive functioning in 3 domains (NOT IQ SCORES)
• Age-relevant descriptors for different severity levels provided
for each domain (Mild, Moderate, Severe, Profound)
− Conceptual: ability to learn; information processing, approach to problem-
solving;
− Social: social interaction, communication, social cues, emotional
regulation, social judgement
− Practical: personal care, daily living tasks, ability to perform age-
appropriate roles
• Based on degree of needed assistance and support
16
California Statistics – ID
Diagnosis
17
California Statistics– ID
Diagnosis
18
Intellectual Disability cont.
Prevalence of Intellectual Disability
• 1 in 1000 individuals
Co-Occurring Conditions
• Mental Disorders, Cerebral Palsy & Epilepsy three to four times higher
than general population.
Most Common Co-Occurring Mental and Nuerodevelopmental Disorders
• Attention-deficit/hyperactivity Disorder
• Depressive and Bipolar Disorders
• Anxiety Disorders
• Autism Spectrum Disorder
• Stereotypic Movement Disorder (with or without self-injurious
behavior)
• Impulse-control Disorders
• Major Neurocognitive Disorder 19
Prevalence – Co-Occurring ID and SUD
• Most research studies conclude:
− The effects of even low levels of substance use by persons with a developmental
disability tend to be more problematic because of already limited judgment and
impulse control.
− With increasing focus on independent or supported living for persons with a
developmental disability, alcohol and drug use rates and associated problems are
increasing.
− A significant percentage of people with minor to moderate developmental disabilities
are already in publicly-funded treatment programs but are not identified as persons
with special needs. These individuals tend to have poor outcomes.
McGillicuddy (2006)
20
Support and Prevalence
• Research indicates substance abuse
prevalence for persons with Intellectual
Disability depends partly on the level of
supervision provided by the caregivers.
21
Prevalence
• National Council on Alcohol and Drug Dependence
– “Alcohol and drugs are implicated in an estimated 80% of
offenses leading to incarceration in the United States such as
domestic violence, driving while intoxicated, property offenses,
drug offenses, and public-order offenses”.
• Alta California Regional Center Forensic Review
Team 2009-2015
− 332 ACRC Clients (DD not ID only) with criminal justice
involvement reviewed by interdisciplinary team
− 77 assessed as needing Substance Abuse Treatment as a
component of a diversion plan or competency training plan
− Approx. 23% of ACRC clients w/ CJ involvement – drug or alcohol
related22
Prevalence – Resident Type
2009 – 2015 Residential Status of ACRC Clients Criminally-Involved with AOD Issues
Living Independently Without Regional CenterFunded Support - 79%
Living Independently With Regional CenterFunded Independent Living Services - 10.5%
Living in Regional Center Funded ResidentialCare Home - 10.5%
23
California Statistics –
Residence Type by Age
24
Critical Risk Factors
• 2007 Study in Northern Ireland of Substance Abuse Counselors
yielded the following concerns regarding their patients with
intellectual disabilities:
− Vulnerability
− Aggression
− Psychological trauma
− Sexual and financial exploitation by non-disabled peers,
− Self-harming / overdosing
− Getting involved with the police
− Loss of structure in the person’s day
Mc Laughlin D, Taggart L, Quinn B and Milligan V (2007)
25
Critical Risk Factors
• Exposure to Substance Use in the Family
• Status Transitions
• Use with Medications
• Social Isolation and Influence of Friends
• Lack of Exposure to Prevention Messages
• Co-Occurring Substance Use and Mental Disorders
• Recognizing the Signs and Symptoms of Substance
Abuse
26
Lower Treatment Utilization
People with intellectual disabilities, substance use
(disorders), or serious mental illness appear to initiate
and engage in substance abuse treatment at lower
rates than their counterparts (persons who do not have
these conditions) and also may remain in treatment
for shorter periods of time while being more likely to
drop out of treatment.
Slayter (2010)
27
Slayter, E. (2010). Disparities in Access to Substance Abuse Treatment Among People with
Intellectual Disabilities and Serious Mental Illness. Health and Social Work, 35(1), 49-
60.
Shared Provider Challenges
• Limited expertise in each other’s field
• Small numbers needing AOD service
• Lack of training and treatment
• Funding restrictions
• System not set up to address shared population
• Mental illness co-morbidity may be 50% and rehab
sophistication and needs increase exponentially
28
ID/ Provider Challenges
• No clear policies/practices
• Staff AOD issues
• Client choice issues
29
AOD Provider Challenges
• System not set up to address ID
• Increasing service standardization
• Attitudinal
• Discriminatory policies/practices (medication)
• Architectural issues
30
Risk Factors for Substance Abuse for
Persons with Developmental Disabilities
• Poverty (public disability income) limits options for
pro-social recreational activities
• Social stigmatization ( being viewed as “retarded”)
decreases healthy social inclusion with people doing
healthy activities
• Vulnerability to high stress, post-trauma sequelae (e.g.
abuse and neglect) increases vulnerability to “quick
fix” relief of emotional pain
• Undertreated physical pain increases vulnerability to
obtain and abuse alcohol and street drugs
31
Risk Factors Continued
• Judgement
− Difficulty accurately judging others can be caused by exposure to high-turnover care providers who are strangers
− Desire for friends, who are easily met in pubs, bars, or playgrounds where drug crowds gather
− Desire for healthy sexual experimentation and experience is often thwarted or discouraged by family members and other caregivers • This can lead to secret sexual behavior including
exchanging sex for drugs or drinks
32
Risk Factors Continued
• Interpersonal relationships− Fear of socializing, dating, and sexuality can
be eased by intoxication
− Prescription psychiatric medications may cause disinhibition, dulled judgment, and may intensify effects of drinks and drugs
− The natural desire to rebel and self-assert may be punished by caregivers but rewarded by users
− Drug users like to share, so poverty may not be a barrier
33
Risk Factors Continued
• Manipulation− People with intellectual disabilities may be
more vulnerable to manipulation by others
− People with intellectual disabilities are occasionally used to carry and deliver drugs
− People with disabilities may have a learned ability to manipulate others to get things and attention for free
− Some people are desensitized to, or seek feeling drugged, due to a history of being medicated for behavior problems
34
Persons with Developmental
Disabilities May Experience…
• “Learned helplessness”
− Has been taught to many children
and adults who have received
•Custodial care
•Overprotection
•Poor education in self-responsibility
35
Barriers to Treatment
• Ableism
• Discriminatory Policies, Practices, Procedures
• Communication Barriers
• Architectural Barriers
Annand (2002)
36
Discriminatory Policies,
Practices, & Procedures
• Examples of common discrimination within the
developmental disabilities treatment community
− Refuse to serve clients who are taking medications
− Clients must be ambulatory
− Clients must have minimum reading participation
− Clients are required to actively participate in group for minimum duration of time (ex. 1 hour)
− Clients must provide their own interpreters
− Fire regulations require everyone to evacuate the building on their own, without assistance
− Animals/pets are not allowed
37
Example of the Problem
• A treatment program has three discussion
groups during daytime hours. A person with
cerebral palsy asks to be excused from the
third discussion group because of fatigue.
− Denial Response: I'm sorry you're tired, but everyone has to attend all three meetings.
− Enabling Response: If it's a problem, you don't have to go.
− Accommodation: Why don't you take a rest period in late afternoon, and attend a third meeting, or alternative treatment activity, in the evening?
Annand (2002)
38
• Most people with developmental disabilities
are supported by public benefit programs,
regardless of substance use behaviors
• Prevented by the system from “hitting
bottom”
− May be less likely to be motivated to make changes in substance using behaviors
− Example• Every time Bill walked downtown and got too drunk to
find his way back to his supported apartment, a staff person would come and pick him up.
An Enabling System
Annand (2002)
39
How To Know if You Are Enabling:
Are you...• Doing something for someone else that you haven't
been asked to do?
• Doing something for someone else you don't really
want to do?
• Doing something for someone else because you feel
sorry for that person?
• Doing something for someone else that would be
healthier or more consistent with societal norms for
the person to do for him or herself?
• Doing something for someone else in a way that
keeps you from taking care of your own needs?
40
• Clients may experience− Difficulty with insight
− Slow to learn and understand
− Memory recall is difficult
− Cause and effect is not understood
− Social skills may be poor
• Change from achieving understanding, insight, and acceptance to
developing a routine of living that supports long-term recovery
− Shift must be from cognition to behavior—“acting to change
thinking”
Recognizing Cognitive
Limitations
41
Recognizing Language
Deficits• Communication disorders
• Difficulty making one's needs understood
• Lack of basic information and vocabulary
− “...impairments in cognitive and verbal skills make it difficult for many developmentally disabled individuals to articulate abstract or global concepts such as a depressed mood.”(Silka, 1997)
− Examples• Kevin, a thirty eight year old man with mild mental retardation and
lacking effective expressive language skills went to a support group for alcoholics where his attempt at telling his story was met with snickers of derision. He never went back.
• Ed, a twenty nine year old man with mild mental retardation was told by the worker at the social services department that he would need "documentation of income to qualify for low income housing." Ed had no idea of what she was talking about and continued to be homeless.
Annand (2002)
42
• Difficulty comprehending abstractions
• Extreme difficulty understanding “cause and
effect” relationships
• Rarely benefits from analogous situations
− Examples• Howie had been going to AA for twelve years and could
quote all of the slogans, although he had no idea what any of them meant. He was attending because someone told him it would “help my drinking.” He had not been sober during that entire period.
• Sam enjoyed hearing the stories of people in an AA meeting. He could not however apply them to his own situation. To Sam, it was pure entertainment.
Recognizing Concrete Thinking
Annand (2002)
43
• Easily Angered
• Very little ability to defer gratification
• Often not persistent about achieving
goals
− Lack of self-efficacy
• May not understand the goals and steps
necessary to achieve them
Recognizing Low Frustration
Tolerance
44
• Unrealistic ideas of what "normal" means
• Unrealistic goals that often are set up for
failure (being placed into G.E.D. classes or
unsuitable job-training programs )
• Wanting to “fit in” by going to bars and
buying drinks for everyone− Example
• Susan is in a supported work program where she makes just enough money to supplement her public benefits. She cannot understand why she doesn't own a house, a car, and work in a “fancy office like they have on T.V.”
Recognizing the Desire to be
Seen as “Normal”
Annand (2002)45
• Difficulty understanding “cause and effect”
relationships for judgment making
• Tendency to be impulsive
• Difficulty learning from life experience− Especially relevant for specific diagnoses, such as
Fetal Alcohol Syndrome
• Example
− A forty five year old woman with intellectual disability opened her apartment door to a perfect stranger at two o'clock in the morning. She was raped. Why did she open the door? “He sounded like he would be mad at me.”
Recognizing Deficits in Sound
Judgment
Annand (2002)
46
• Well-meaning workers in all service providing agencies
tend to be unaware of the developmentally disabled
person's limitations and have ascribed to the notion that
anything a normal person can do, so can a person with
intellectual disability - only slower
• This can be a “set-up for failure”
• Example
− Stewart, a 37 year old man with mild intellectual disability and traumatic brain injury as the result of a pedestrian-car accident, told a young worker that he wanted to study to become a psychologist. She enrolled him in a G.E.D. program which was so far beyond his ability, that the G.E.D. program referred him to a job training program for people with intellectual disabilities. Stewart is currently bagging groceries. He feels like a failure and has become increasingly dysphoric. His drinking has increased.
Recognizing Unrealistic
Expectations
Annand (2002)47
Seeing
□ Braille
□ Taped
written
materials
□ Large print
□ 14 point,
san serif
materials
□ Room
lighting
Hearing
Sign language interpreters
Assistive listening devices
Loop system
Hand-written notes
Quiet environment
Identify speaker in groups (raise hand)
Speak clearly facing client or coworker
Speaking
Provide
alternatives—
writing, letter board,
iPad
Ask client or
coworker about
communication
preferences
Remember, the
person has years of
experience finding
ways to
communicate
Accommodations for….
48
Thinking
□ Written materials
at 2nd grade level
or less
□ Expectations
clear and easy to
understand
□ Repeat and check
understanding
□ Check literacy
including learning
disabilities
Feeling
Clear
instructions,
expectation, and
requirements
Reduce
ambiguity
Recognize stigma
Moving
Survey
environment for
barriers
Develop plan for
alternatives
and/or removal
Accommodations for….
49
Overall
Flexibility
Alter how goals
are achieved,
not the goals
themselves
Maintain
expectations
Program
Access
Everything
doesn’t need to
be accessible
Goal is equal
participation in
programs
Level the playing
field
Accommodations for….
50
Models of Treatment and
Support• Preventing Substance Abuse and Mentoring Sober Living
• Stresses the absolute importance of creating “sober
community”
• Accessing assessment, treatment, and recovery services• AA and Social Model
• Requires ability/capacity for− Cognition
− Reflection & Insight
− Reading
− Writing
− Identification
• Harm Reduction
• A set of practical strategies that reduce negative consequences
of drug use, incorporating a spectrum of strategies from safer
use, to managed use to abstinence
• Meet substance users “where they’re at,” addressing conditions
of use along with the use itself51
Harm Reduction• Recovery = Any Positive Change
− Values the development and maintenance of a non-judgmental partnership enabling the client to make well-informed, empowered choices
− Recovery is envisioned as a process; the client sets the pace and parameters of that process and any steps forward are valued
• Harm Reduction & Abstinence− Harm reduction and abstinence are highly congruent
goals− Harm reduction expands the therapeutic conversation,
allowing providers to intervene with active users who are not yet contemplating abstinence
− Harm reduction strategies can be used at any phase in the change process
52
Strategies for Change Substance Abuse
Treatment Programs for Persons with
Developmental Disabilities
• Programs: Alta Regional (ACRC) & Cognitively Impaired/Co-Occurring
(CI/CO)
• Program duration: 6-12 months, depending on the needs of the client
• Clinical approach
• Life Skills Development, Core (Choice Theory & AOD
Psychoeducation), Life Laws, Memory/Minds Strengthening,
Social Skills, & Relapse Prevention
• All curriculum done at slower pace to enhance understanding of
material• Tracks
• 3-day: 1 group/day, 3 days/week
• 3 groups/week for 3 months, reduces to 2 groups/week for 3 months,
followed by 1 group/week (aftercare), as needed
• All reductions per clinical judgement
• 2-day: 1 group/day, 2 days/week
• 2 groups/ week for 6 months, followed by 1 groups/week (aftercare),
as needed
53
What Triggers Referral?
• The objective of the program is to provide
substance abuse treatment for individuals served
by Alta California Regional Center (ACRC), as well
as all individuals identified with developmental
disabilities and substance use problems − Referrals also come from other community providers
and patient self-referral
A determination of outpatient or intensive outpatient schedule will be based on assessment by either the referral source or by the assessing counselor for the program
54
Referral Continued• Importantly, regardless of referral reason and or presenting
problem, SFC will complete an assessment of the client at
intake and recommend a level of care consistent with the
findings
− Cognitive Functioning Screening Form
• Each track is 3-6 months based on client need
− The program will consist of an intake, additional assessments for determining substance use/abuse/dependence, individual service plans coordinated by both agencies, psycho-educational groups, discharge planning, and discharge
• The agency’s programs are based on flexibility and can be
customized on a case-by-case basis
55
How Does the Intake Work?
56
Curriculum• SFC has developed a standardized manual-based curriculum for working with
individuals with developmental disabilities by modifying its current CORE
curriculum and adding several evidenced based interventions
• The CORE was created by integrating curriculum obtained from the principals
of Choice Theory as developed by Dr. William Glasser and Manual 4 from the
National Institute on Drug Addiction (NIDA) publication of Therapy Manuals
• The NIDA manual takes a Cognitive-Behavioral/psycho educational approach
to addiction treatment
• Developed based on extensive clinical experience conducting addiction
recovery groups and on a review of the relevant literature and has been used
with significant effectiveness with our current cognitively impaired group
since 2007
• Manual chapters include:
− Stages of Change, The Process of Recovery: Part I & II, Managing Cravings:
People, Places, and Things, Self-Help Groups, Establishing a Support
System, Managing Feelings in Recovery, Coping With Guilt and Shame,
Warning Signs of Relapse, Coping With High-Risk Situations, and
Maintaining Recovery
57
Curriculum Continued• Groups such as Parenting, Anger Management,
and Domestic Violence are adjunct and can be
add-on modules in addition to the core
curriculum − These groups are not stand alone groups and can be added at
any point and are based on assessment of client’s substance use and abuseo Each group is 12 sessions
• The program will be defined by the size of each
group rather than the staff ratio− Each group will be limited to a maximum of 10 clients
− Group size will also be based on the level of developmental disability of each client
58
Regular Reassessment
• Reassessment each six weeks
− Alcohol Use Disorders Identification Test
(AUDIT)
− Drug Abuse Screening Test (DAST)
− Schwartz Outcome Scale (SOS-10)
− Case-by-case use of additional assessments
• University of Rhode Island Change Assessment
(URICA)
• Quality of Life Inventory (QOLI)
• Brief Symptom Inventory (BSI)59
• 24-hour behavioral plans
• Identification of behaviors, places, and people that threaten
recovery
• Preventive behavioral responses to those threats
• Patient and persistent repetition of basic concepts
• Token economy: ALTA bucks
• Hands-on, creative and artistic projects
• Intensive case management
• Multidisciplinary team participation
Tools
60
• Similar to mainstream treatment programs
• A significant amount of group time must be
spent teaching group skills, not just in early
group development, but every day
• One important aspect of group work is to
develop a true peer support group
• Objective is to train the client to live a
sustainable routine that supports on-going,
long-term recovery
Modalities
61
62
Phases of Treatment• Phase One. The Core Curriculum has 24 group sessions to be taught during Phase One.
(Attached is the list of the 24 groups.) Before each group session ends a review of the
material is completed called “roundup.”
• Phase Two. Phase Two continues to focus on the 24 group sessions and discusses how
each client is practicing and applying the material in their everyday lives.− Client shares how their refusal skills, coping skills and new thoughts and behaviors have been
applied to a current situation or it might have been done differently. Inclusive of the Core Curriculum would be the “24 hour plan.”
• Phase Three. Phase Three is a transition phase. An effective intervention is home
visitation to determine the environment the client is residing in. A home visit will be
conducted by the counselor during the first 30 days of treatment to assess the
environment that the client lives and then throughout the aftercare phase to work
with the client in their environment and assess and role played their new learned
refusal and coping skills in their own living situation. Caregivers or significant persons
in the client’s life may be present at this time. − This phase is unique and tailored for the client’s individual needs. Group will be conducted
weekly to discuss application and review. Completion of each Phase could take 3-6 months based on attendance, understanding of refusal skills and application of interventions learned.
63
• Train everyone in system to ID need for AOD
assessment− Assessment: Cognitive Functioning Screening Form,
Montreal Cognitive Assessment (MoCA), Cognistat
• Train AOD recovery staff to ID clients who are
likely to “fail” because of cognitive disabilities
• Motivate clients to accept assessment− Explain purpose and benefit
• Convey welcoming environment and instill hope
from the first and through every contact
Stages of Treatment—
Pre-treatment
64
• Collect information to show cause and
effect of substance use
• Assist client to acknowledge need for
help
• Facilitate client's acceptance of
treatment
• Gather information about the bad
things that happen
Phase One
65
Addressing Anger
• Investigate what the client thinks you are saying
when they get angry
• It is important to remember addiction causes the
problem, not the client, thus avoiding blame
• It is important to expand their vocabulary, which
will increase their ability to verbalize frustrations
• Ongoing recovery requires immediate identification
and reinforcement of cause-and-effect
66
• One hour group sessions
• Introduce 24 hour plan and “bad
things” forms
• Track abstinent and using days
Phase Two
67
The 24-Hour PlanImportant to praise the client for doing the 24-hour plan
•Client should be praised for doing what they can do – the things that are on their plan – not for staying sober
When clients are not praised for following their plan
•Tend to do nothing, as long as they do not drink or use
•Think that doing something to stay sober is only necessary when they want to use
•Fail to respond to the desire to use by doing abstinent supportive behaviors
•Use again
68
• Extensive support to develop a
routine
• Introduction and use of forms
• Attend three meetings a week
• Internalize cause and effect
relationships
• Identify triggers
Phase Three
69
• Maintaining peer group of others with
developmental disabilities
• Calling each other
• Going to meetings together
• Volunteering to help others with similar
challenges
• Pro-social leisure activities
• Educational pursuits
Transition to Meetings &
Aftercare
70
Determination of Progress• Transitioning a client from Phase I to Phase II
will be based upon progress demonstrating that
the client will be able to maintain his/her
progress with less weekly contact
− Examples of sufficient progress would include:• Regular attendance to treatment; accomplishment of
short-term treatment goals determined collaboratively by client and counselor
• Improved medication compliance, self-care, and/or emotional regulation
• Application of effective coping skills
• Improvement of social support network
• Client report of maintaining recovery/preventing relapse
• Improved ability to communicate and utilize community resources etc.
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Discharge Criteria• Discharge from the program can indicate positive or negative
outcomes
• Clients will be successfully discharged when they have
completed the SFC program requirements, including their case
management and treatment goals
− Reduced use
− Worked toward sobriety
− Identified triggers
− Have identified refusal skills that work for the client
− Home visit by primary counselor has been conducted by the counselor during the discharge planning phase of treatment to continue to assess the environment that the client lives in
− Client and counselor will role play their refusal and coping skills in their own living environment
− Discharge plan will be developed with the client when the client completes treatment
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Goals & Outcome
Expectations• Shift from understanding and insight to developing a routine
• Use aphorisms as the tools
• Relapse must really be accepted as a learning tool and no
reason for discharge
• Progress must be measured by change in the ratio of using
abstinent days and by reduction of harm
− Emphasis on progress, while not replacing the goal of abstinence, must be valued by both staff and client.
• Quality of life may not change much because the enabling
environment in which the client lives, however life
satisfaction will improve
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Staff Members Must• Develop patience with clients and tolerance for
frustrating behaviors
• Be persistent (persevere in the face of seemingly
overwhelming odds against recovery)
• Respond immediately to both abstinence–producing
and abstinence–destructive behaviors
• Develop a tolerance for the need to repeat, repeat,
repeat processes and information
• Don’t lie to, for, or about the client
• First remember the old adage − “If you give a man of fish you feed him for a day. If you
teach a man to fish you feed him for a lifetime"
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“Can’t think your way into a new
way of acting, have to act your
way into a new way of thinking.”
Action Is the Best Teacher
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Thank you!
• For more information visit :
www.altaregional.org/mhsa-grant
www.strategies4change.org
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References
Annand, J. (2002). More than Accommodation: Overcoming Barriers to Effective Treatment of
Persons with Both Cognitive Disabilities and Chemical Dependency. Beaverton, Oregon:
Nightwind Pub.
McGillicuddy, N. (2006). A Review of Substance Use Research among Those with Mental
Retardation. Mental Retardation and Developmental Disabilities Research Reviews, 12(1),
41-47. doi:10.1002/mrdd.20092.
McLaughlin, D., Taggart, L., Quinn, B., & Milligan, V. (2007). The Experiences of Professionals
Who Care For People With Intellectual Disability Who Have Substance‐Related Problems.
Journal of Substance Use, 12(2), 133-143. doi:10.1080/14659890701237041.
Slayter, E. (2010). Disparities in Access to Substance Abuse Treatment among People with
Intellectual Disabilities and Serious Mental Illness. Health and Social Work, 35(1), 49-60.
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