8007 Test 2 week 4-7 Flashcards
Goals of tx for addiction
- Decrease frequency/intensity of use
- Sustain periods of remission
- Optimize functioning during remission
Addiction tx considerations
- Multidimensional
- Culture
- Gender
- Age
- Trauma history
- Co‐morbidity
Pros of AA
- Evidence for efficacy
- Cost‐effective
- Easily accessible
- Provides social support
- Increases self‐efficacy
- Instills hope
Barriers to 12 step
- Fluctuations in readiness and commitment to change
- High degree of spirituality or perceived religiosity, especially for individuals who are atheist or agnostic
- The need to surrender
- The sense of powerlessness
- Lack of compatibility between personal and treatment belief systems and philosophies
- Lack of comfort or perceived support in the group, due to membership in a special population (e.g., women, ethnic minorities, youth, dual disorders, sexual orientation)
Other self help groups for addiction
- Self‐Management and Recovery Training (SMART) Recovery.
- Women for Sobriety
- Secular Organizations for Sobriety (S.O.S.)
- Moderation Management
- Double Trouble in Recovery (DTR)
Self‐Management and Recovery Training (SMART) Recovery
CBT approach
Women for Sobriety
1st secular self help group
- Double Trouble in Recovery (DTR)
- Dual diagnosis
Psychotherapy models for addiction
- Motivational Interviewing
- CBT
- Integrated Family Therapy
- Many others…
Therapeutic framework considerations for addiction
- Be on lookout for transference/countertransference
- Make clear and reinforce expectations (pp. 587‐588)
- Can experience secondary trauma/burnout
- Use supervision/peer support
Contingency Management (CM)
- Successful treatment for range of substances/behaviors especially STIMULANTS
- Uses operant conditioning principles (SKINNER) in that they get an immediate reward for clean UA or staying clean etc (CHECK OFTEN 2-3x/WEEK)
- Stand‐alone or incorporated into other therapies (USUALLY 8-12 WEEKS)
- Not everyone is a fan…
EYE MOVEMENT DESENSITIZATION and REPROCESSING (EMDR)
An eight‐phase psychotherapy based on earlier life experience, present day stressor, thoughts for future
Can be part of treatment plan with other types of therapy
EMDR number of phases
8
Only evidence‐based modality that includes a somatic component for therapists to access all dimensions of memory
EMDR
EMDR used to tx conditions such as…
PTSD
Anxiety and panic attacks
Depression
Phobias
Sleep problems
Goal of EMDR according to wheeler
“…link dysfunctional memory networks with a larger, more adaptive network.”
How does EMDR work
Bilateral stimulation which is a rhythmic alternation of stimulation between the left and right hemisphere
the traumatic memory is isolated on one part of the brain and other parts cant access
tx triggers integration of affect with cognition, sensations, and emotions
Dual attention stimulation facilitates interhemispheric connection
8 phases of EMDR
History and Treatment Planning
Preparation
Assessment
Desensitization
Installation
Body Scan
Closure
Re‐evaluation
EMDR Phase 1 History and treatment planning
how it works, selection of therapy, how might best be used, getting to know each other
EMDR Phase 2 Preparation
explain more about the process and terms and sets expectations and client can ask questions and express concerns. Together work on coping strategies client can use if difficult emotions come up. How can they soothe themselves
some need a lot of time in phase 1-2
EMDR Phase 3 assessment
target identified
client asked to think about what those images are and the body sensations. Dont dwell on it but identify it. set baseline measurements.
subjective units of disturbance: scale of severity. goal to get to 1 (1-10)
validity of cognition scale: positive thoughts about the event, “I can get through this”. Do they have any of those starting out?
EMDR Phase 4 desensitization
when they focus on the traumatic event and continues until SUD reduces to 1 (neutral)
new images might come up but goal is neutrality
EMDR Phase 5 installation
when they associate or strengthen positive beliefs associated with the event.
there is hope for me
do that until they feel like its true
EMDR Phase 6 body scan
hold in mind target event and positive belief and scan head to toe looking for discomfort in the body
EMDR Phase 7 closure
how you close every one of the reprocessing sessions
how you return the person to a state of calm
cant just let them go, they may still be upset
deep breathing/meditation
EMDR Phase 8 re-evaluation
how you begin each new session after you have gone through reprocessing successfully
are they still having positive feelings about the future
tx is continuing in the right direction
Motivational Interviewing
“Motivational Interviewing is a clinical approach that helps people with mental health and substance use disorders and other chronic conditions such as diabetes, cardiovascular conditions, and asthma make positive behavioral changes to support better health.” (SAMHSA)
“…a collaborative conversation style for strengthening a person’s own motivation and commitment to change.” (Miller & Rollnick, 2013)
its about ambivalence toward change
MI conversation styles
Directing
Guiding
Following
MI core skills
O: open ended questions
A: affirmations
R: Reflective listening
S: Summarizing
DBT has been studied for many thing including
Suicide attempts
self harm
SUD
PTSD
mood do
eating do
anxiety
Stages of change
- Pre‐contemplation (get hx and values)
- Contemplation (get pros and cons)
- Preparation (make a plan, anticipate, ask about confidence)
- Action (support/barriers)
- Maintenance (check ins/triggers)
Dialectical Behavior Therapy (DBT)
developed by?
1st line tx for?
Marsha Linehan in the 70s
1st line for BPD (borderline personality disorder)
DBT theoretically based on…
dialectics
which is a synthesis of simultaneous yet opposing truths (and not but) (balance acceptance and change)
DBT tx strategies are a combo of
CBT
humanism
Zen Buddhism
Goal of DBT
life is worth living
standard DBT structure
1 yr+
pre tx + 4 stages
Modes: Individual, group, inter session contact, peer consultation team meeting
therapist available 24 hrs
note sometimes modified
individual DBT
weekly, one hour
homework–diary card on skill develpment/mood etc
Behavioral chain analysis (CBT principles: precipitating event, thought about it, resulting emotions, and behaviors)
targets (according to a heirarchy)
formal assessments
group skills training DBT
weekly 1.5-2.5 hrs
psychoeducation groups
4 modules:
2 acceptance skills: Mindfulness and distress tolerance
2 change skills: Interpersonal effectiveness and emotional regulation
intersession contact DBT
any communication outside therapy session
dont have to be in crisis
peer consultation team meetings DBT
weekly
case supervision
peer support
learn about self
discuss and apply DBT
pretreatment DBT
2-3 sessions
compatibility
terms of therapy
commit to 1 yr
no suicide or self injury
Stages and targets of DBT
4 and non linear
Heirarchy of behaviors to target:
1.Life threatening
2. Therapy interfering
3. Quality of life interfering
4. Skills acquisition
Stage 1 of DBT
most clients start here
control severe behavior dysfunction
target: life threat, life interfere, quality of life interfere
Stage 2 DBT
process trauma
behaviors like emotional avoidance, numbness, sx of PTSD
must have stage 1 issues under control
Need high level DBT skill development
Goal is to go from quiet desperation to emotional experiencing”
Stage 3 and 4 of DBT
most research is on stage 1 and 2
3: move from problems in everyday living to ordinary happiness and unhappiness. Work on individual goals
4: move from incompleteness to capacity for sustained joy. Deeper meaning in life including spirituality and transcendence
Trauma elements
Stressful event/situation
Overwhelms ability to cope
Highjacks neural pathways linked to memory processing
Sympathetic/parasympathetic response
Trauma vs PTSD prevalence
- ~6 of every 10 men and ~ 5 of every 10 women experience at least one trauma in their lives.
- ~ 6 out of every 100 people (6%) will have PTSD at some point in their lives.
- ~ 15 million adults have PTSD during a given year.
- Twice as many women (8%) develop PTSD sometime in their lives as men (4%).
Dx reaction to trauma
- PTSD
- Acute Stress Disorder
- Psychosomatic Disorders
- Dissociative Disorders
- Complex PTSD
Dissociation
a disconnection between a person’s thoughts, memories, feelings, actions or sense of who he or she is
Dissociation as disorder
- Depersonalization/derealization d/o
- Dissociative amnesia/fugue
- Dissociative identity d/o
Goals of tx for PTSD/Trauma
- Reduce symptoms
- Prevent/treat comorbidities
- Improve adaptive functioning
- Decrease chances of relapse
- Increase sense of security and safety
Evidenced‐based therapies for PTSD
- CBT
Including Prolonged exposure therapy (PE) and Cognitive processing therapy (CPT) - EMDR
Stage 1 Trauma tx: Symptom Stabilization and safety
- Safety first
- Identify strengths and support systems
- Address physical needs and environment
- Building trust
- Self‐soothing strategies
- Psychoeducation
Framework for tx of trauma in 3 stages
- Stage 1: Symptom stabilization and safety
- Stage 2: Memory processing
- Stage 3: Continued growth, rehabilitation, reintegration
Prolonged exposure therapy for trauma CI
DID
Complex PTSD
Process trauma with patients only after the patient is ___
stabilized
also note i must have the expertise.
Be aware of secondary trauma
Takes months or years
Humanistic Existential therapy is based on these 3 philosophies
Humanism
Existentialism
Phenomenology
Humanistic Existentialism
- Movement started in mid-20th century by psychologists Carl Rogers, Abraham Maslow, Rollo May, and others
- “Third-force” of psychotherapy
- Diverse approaches grounded in philosophies of humanism, existentialism, phenomenology
Person Centered Therapy believes
- People are inherently good
- Remove impediments to growth through therapeutic relationship
Person Centered Therapy was started by
Carl Rodgers
Person Centered Therapy has 3 pillars
- Unconditional positive regard
- Genuineness
- Empathetic understanding
Person Centered Therapy techniques
- Congruence
- Nondirectivenss
- Reflecting feelings
- Open questions
Gestalt
- “…a physical, biological, or symbolic configuration or pattern of element so unified as a whole that its properties cannot be identified from a simple summation of its parts.”
Gestalt Therapy goal
the only goal is awareness… Awareness takes place now. Prior events may be the object of present awareness, but the awareness process [e.g., remembering] is now
Other aspects of Gestalt Therapy
- I-Thou Relationship (Buber) (based on reciprocity and mutuality)`
- Creative experimentation
therapist is active participant
patients learn how they are seen and how awareness is limited by the relationship
Examples of gestalt experiments
- Staying with the Feeling
- I Take Responsibility For. . .
- Empty Chair Technique
- The Exaggeration Experiment
Existential therapy
roots in 1950s
Frankl (Man search for meaning)
Wide range of methods depending on client
more of a mindset and can be woven in with other types
goal of authenticity
Givens of Human existence by Yalom
- Death
- Freedom
- Isolation
- Meaning
What does the therapist do in existential therapy
not one of seeking to impose a directive change or to ameliorate the lived inter-relational world of the client, but, rather, to attempt to clarify it
explicitly remind their clients that, ultimately, the task remains up to them – the clients – to find their own meanings and truths, and, hence, to realize their role and responsibility in the choices they have made and will continue to make throughout their lives
The most gratifying task of the existential counsellor is to assist people in their struggle to live such a worthwhile life…both counsellor and client will constantly be reminded that earth is a place somewhere between heaven and hell, where much pain and much joy is to be had and where some degree of wisdom can make all the difference
Solution Focused Therapy
- SFT or SFBT (B=brief)
- Developed in early 1980’s
- Postmodern therapy
deconstruct problems and construct solutions
SFT techniques
Goal Goal-setting
Look Look for previous solutions
Look Look for exceptions
Do Do more of what is working
Compliments
Miracle question
Scaling questions
Coping questions
Older adults and mental health in stats
- 15% of older adults impacted by a behavioral health problem
- 4.8% have SMI
- .2% bipolar disorder
- .2‐.8% schizophrenia
- 3‐4.5% depression
- Account for 17.9% of suicide deaths
Factors to consider in tx of older adults
- Cohort
- Changes in metabolism
- Many losses experienced
- Acute and chronic medical conditions
- Cognitive impairments
- Functional and sensory impairments
- Less likely to seek treatment
- More likely to seek religious support over treatment
- Growing ethnic/racial diversity
Individual psychotherapy models for older adults
CBT
Interpersonal Therapy
Reminiscence
Life Review Therapy
others in lit
CBT for older adults
- Most commonly studied for depression and anxiety
- Middle phase/working can be most difficult
- Family involvement may be helpful
Interpersonal Therapy for older adults
- For depression and anxiety
- Opportunity for reflecting and resolving relationship transitions
- Not suitable for every patient
- Better suited for therapists experienced treating older adults
Reminiscence for older adults
- Less structured
- May be done in group or individual
- Focus on past event, pleasurable memory
- Cognitively intact to moderately impaired
Life Review Therapy for older adults
- Structured
- 1:1
- Over course of life, good and bad events
- Analytical, evaluative
- Cognitively intact to mildly impaired
Mental health stats for youth
- 1 in 5 ages 13‐18
- ADHD, behavior problems, anxiety disorders, depression most prevalent
- 9.4% (6.1 million) ages 2‐17 have ADHD diagnosis
- 7.4% (4.5 million) ages 3‐17 have behavior problem diagnosis
- 7.1% (4.4 million) ages 3‐17 have anxiety diagnosis
- 3.2% (1.9 million) ages 3‐17 have depression diagnosis
- Suicide 2nd leading cause of death for ages 10‐14
Underlying assumptions of child therapy
- Developmental considerations (Erikson, Piaget)
- Family involvement (Involve family even if seeing child for individual therapy)
- Systems involvement (family, school, community)
- Resiliency (Strength‐based, promoting protective factors)
Therapy with younger children
play therapy
* Have variety of toys, games, art supplies across age groups
* Structured or unstructured
* Therapist maintains calm; gives words to behaviors and expression of emotions
* Family involvement
therapy with adolescents
- Art supplies, blocks/Legos, games
- Establish trust
- Treat with respect, equal
- Follow their lead
- Structured session and rationale
Trauma‐Focused CBT (TF‐CBT) for kids Goals
Goals:
1. Enhanced sense of safety
2. Re‐regulate “domains of impact,” e.g., affect, behavioral, biological, social
Trauma‐Focused CBT (TF‐CBT) for kids Components
- Components (PRACTICE) and phases (stabilization, trauma narrative, and integrative/consolidation)
Trauma‐Focused CBT (TF‐CBT) for kids consideration and length of tx
- Parents/caregivers must be part of therapy, individual sessions and conjoint
- 12‐15 sessions; longer for complex
Common elements therapy for kids
- Transdiagnostic
- Discrete clinical interventions (e.g., relaxation, exposure)
- Typically modular, can be delivered independently
- Flexible
- Allows for co‐morbidity
Examples
* CBT+: CBT and parent management training (PMT)
* FIRST
Other evidenced based tx for kids
PMT
MI
IPT
CBT
EMDR
CBT for kids
8+ but maybe variable
Guided by Piaget level of cognitive developement
-concrete operational (7-11) (can imagine what will happen using logic or reasoning)
-Formal operational (12+)
Catch it, check it, change it– basic structure
COPE: Creating Opportunities for Personal Empowerment
EMDR for kids
CI is risk for dissociation
8 phases like adult
may need parent/caregiver present and that caregiver may be trauamatized
Telemental health for kids: considerations
Setting ‐Room
* Accommodate child and 2‐3 adults
* Child can move freely but not too freely (hyperactive child)
* Child can play on floor while conversing with parent
Privacy
* Who can be present and who cannot
Establish ground rules
* Discuss with parent and youth at outset, may have to remind periodically
* “Proper” attire and body language
* No distractions (TV, cell phones)
Telemental health for kids: The session
Establish routine to start and end session
* Starting out: turning off phones, devices, getting comfortable in therapy chair
* Ending: doing a pleasurable activity between youth and provider, i.e., relaxation exercise, coloring
Take frequent breaks, such as with PowerPoint games or YouTube videos
Utilize physical things in child’s environment: Use dolls and toys that the patient has or mail items such as stress balls or fidget toys that child can use.
Tailor activities to each child’s interests to enhance engagement
Adapt worksheets and activities for digital use
Picture in picture
* Older children and adolescents love seeing themselves
* May distract younger children and children with developmental disabilities so better not to use with them
Written materials for younger children should have minimal text (that is displayed in large font) and medium‐to‐large images
Incorporate a combination of worksheets and experiential exercises for adolescents and older children
Engaging adolescents
- Engage in online site like YouTube or Facebook
- Aren’t always comfortable “just talking,” so they may be more engaged sharing favorite art pieces, poetry, journal writings, or music
- If reluctant to verbalize, use chat feature
- Apps – be sure to vet them
