Lost: Providing a Compass for Families Jerri Avery, Ph.D. · Complex-PTSD Mourning for what has...

• Jerri Avery, Ph.D.Lost: Providing a Compass for Families

Jerri Avery, Ph.D.Consultant, Capstone Treatment Center

ASAM Disclosure of Relevant Financial Relationships

Date of Activity: June 2, 2017

Name Commercial

Interests

Relevant

Financial

Relationships:

What Was

Received

Relevant

Financial

Relationships:

For What Role

No Relevant

Financial

Relationships

with Any

Commercial

Interests

Jerri Avery, Ph.D. Capstone

Treatment

Center

Consulting Fee Speaking at the

West Coast

Symposium

n/a

Theme

Family therapy is not used to its greatest capacity in substance abuse treatment.

SAMHSA Consensus Panel

Combined Bepko & Kresten’s stages of treatment for families with Heath and Stanton’s stages of family therapy for substance abuse

treatment

Resulting levels of recovery are:

1. Attainment of sobriety

2. Adjustment to sobriety

3. Long-term maintenance of sobriety

While substance abuse counselors shouldn’t practice family therapy –they can:

(1) practice family-involved treatment

(2) examine policies and practices that promote family healing

What does the research say?

• Including family therapy in substance abuse tx works better than not

• Increases retention

• Increases engagement

• Reduces the individual’s substance use

• Improves both family and social functioning

• Discourages relapse

How Can Family Help with Outcomes?

• Support

• Pressure

• Direct Involvement

Label Yourself

JUST FRIENDSOR

FRIENDS WITH BENEFITS?

MARGINALLY INVOLVED VS. FAMILY INVOLVED

Individual ECO

How do you see it?

Four Levels of Counselor Involvement

Level 1: Little or no involvement

Level 2: Provides family with psychoeducation

Level 3: Addresses family members’ feelings and provides them with support

Level 4: If trained provides family therapy

Comparison of Basic Assumptions

Substance Abuse Tx

Focus: Individual needs; Self care

Neglects: Impact of changes on family systems

Impact: Individual not prepared for changes; unprepared to cope

Family Therapy

Focus: Changes in the family

Hope: Positive changes in family system improve family systemImpact: Tends to minimize the persistent, sometimes overpowering process of addiction

Assess

• Effectiveness of communication

• Supportiveness or Negativity

• Parenting skills

• Conflict management

• Understanding of addictive disease

• Child Abuse

• Violence

Integrated Treatment Models

• Structural/Strategic family therapy

• Multidimensional family therapy

• Multiple family therapy

• Multisystemic therapy

• Behavioral and cognitive-behavioral family therapy

• Network therapy

• Bowen family systems therapy

• Solution-focused brief therapy

Behavioral Couples Therapy for Alcoholism & Drug Abuse

• More abstinence

• Better relationships

• Decreased separation and divorce

• Reduced domestic violence

• Favorable cost/benefit ration compared to individual therapy

www. SAMHSA.gov.NREPP.

12 Sessions

Basics of Both: Barriers

Family motivation/influence

Balance of hierarchical power

Willingness to change

Cultural barriers

Erosion more than a Mudslide

Effects on the Family

Goals of FAMILY Therapy in SUD Tx

Helping families become aware of own needs and providing healing

Shifting power to parental figures & improving communication

Helping family make changes affecting individual in tx

Preventing abuse in the next generation

Families call when there is a: (1) Crisis OR (2) Opportunity

Lots to Learn; Lots of Jargon

Family are vulnerable. The system can be very confusing. The words are foreign.

• Accountability Vs. “Running Their Program”

• Go to Alanon – how?

• Boundaries?

• Peer Support Specialists In MS, can be immediate family members

Warn Them: Other People Will Condemn You

• For some, wrong for not kicking out

• For others, wrong for kicking out

• For others, should pay for treatment a fifth time

The concept of ALANON of "detach with love" is healthy but can be confusing. Parents are sometimes even made to feel guilty for continuing to seek help for their adult children who are caught in the grip of addiction, when intervention is required."

http://www.cnn.com/2017/04/02/opinions/stress-killing-us-keating-opinion/

Don’t Feel Don’t TrustDon’t Talk

DenialProtection of individual

Chronic angerStress

AnxietyHopelessness

Inappropriate sexual behaviorNeglected health

ShameStigma

Isolation

Relapse rates for addiction resemble those of other chronic diseases such as diabetes,

hypertension, and asthma.

Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). NIDA.

Gloom &

Doom

Recovery

emerges

from

HOPE

The FRAME of Recovery

Recovery is non-linear, characterized by continual growth and improved functioning that may involve setbacks.

Setbacks are a natural, though not inevitable, part of the recovery process. It is essential to foster resilience for all individuals and families.

Secular Recovery

Faith-based Recovery

Twelve Steps

Medication-Assisted Recovery

Natural Recovery

“The roads to recovery are many.” AA Cofounder Bill W., The AA Grapevine, Sept. 1944

Codependency (CoDA 1998) OR Fierce Lovers & Protective of their Families

(Heather Hayes)

• Controlling

• Low self-esteem

• Deny own feelings

• Excessively compliant

• Compromise own values and integrity to avoid rejection and anger

• Hypervigilant to disruption or trouble

• Remain loyal to people may not deserve it

Which of these cannot be applied to family members?

The Final Crisis Occurs

• Arrest• Maybe you charged them

• Overdose

• Eviction Notice

• Bills are late

• Act of violence

• Health condition

• Failed school

• Lost job

• Debt collection/law suits

• Outside relationships discovered

• Admit problem to unsuspecting family

• Child Protective Services intervention

• Car wreck

• What is a family?

• How many can visit?

• How to handle visits from family substance abusers? •

• What if is a parent is a substance abuser?• Can do family therapy with an individual.

• What if a parent or spouse can’t take off work for a week of family therapy?

Think about your policies…

Current Trends

Supporting a Better Tomorrow…Today

Source: Mineta, D. (2015 NASADAD Annual Meeting)

Toxicity Changes Everything

Where is the bottom?

What is ready? Not ready?

What does the data say? Commitment Laws

http://www.lifehack.org/482585/this-is-what-happens-when-someone-stops-using-heroin

• Reestablish normal brain functioning

• Reduce cravings

• Prevent relapse

NIDA. (September 2009). Infofacts: Treatment approaches for drug addiction.

MAT + Therapy

Medication Assisted Treatment (or Recovery)

Treats Two Categories of Substance Users

Source: Mineta, D. (2015, NASADA Annual Meeting)

Naloxone

Make sure prescriptions are provided

Consider training on administration for persons in treatment programs and other institutions

Trauma & Recovery by Judith Herman

• It is a psychological injury that results from protracted exposure to prolonged interpersonal trauma with "loss of feeling in control", "disempowerment", or "feeling trapped,”.

• The key difference between PTSD and C(Complex)-PTSD is the concept of "protracted exposure."

Emotional and psychological symptoms of trauma• Shock, denial,or disbelief

• Anger, irritability, mood swings

• Guilt, shame, self- blame

• Feeling sad or hopeless

• Confusion, difficulty concentrating

• Anxiety and fear

• Withdrawing from others

• Feeling disconnected or numb

Reactions to Trauma

• Exhaustion

• Confusion

• Sadness

• Anxiety

• Agitation

• Numbness

• Suicide ideation or attempts

• Dissociation

• Blunted Affect

• Persistant fatigue

• Sleep Disorders

• Nightmares

• Fear of recurrence

• Depression

Complex-PTSD

Removal of and protection from the source of the trauma and/or abuse.

Acknowledgement of the trauma as real, important and undeserved.

Acknowledge that the trauma came from something that was stronger than the victim and therefore could not be avoided.

Acknowledgement that recovery from the trauma is not trivial and will require significant time and effort.

Separation of residual problems into those that the victim can resolve (such as personal improvement goals) and those that the victim cannot resolve (such as the behavior of a disordered family member)

Complex-PTSD

Mourning for what has been lost and cannot be recovered.

Identification of what has been lost and can be recovered.

Program of recovery with focus on what can be improved in an individual's life that is under their own control.

Placement in a supportive environment where the victim can discover they are not alone and can receive validation for their successes and support through their struggles.

As necessary, personal therapy to promote self-discovery.

As required, prescription of antidepressant medications.

Children of Substance Abusers

Surrogate spousesElaborate systems

of denial

Engage in behaviors that are

not age-appropriate

Feel guilty or responsible

Struggle with trustAlso can develop

tools for responding

Report Child Abuse

Why Families don’t set boundaries

Suicide threats

Fear of never seeing the addict again

Fear of addicted family member living on the streets

Fear of addict turning to illegal behavior

Parents punishing themselves

Avoiding own problems and life’s goals

Blaming it on bad genes

Stuck in remembering the tender times

Pleasing the addict

Trauma-specific Interventions

•Addiction and Trauma Recovery Integration Model (ATRIUM)

•Essence of Being Real

•Risking Connection®

•Sanctuary Model®

•Seeking Safety

•Trauma, Addiction, Mental Health, and Recovery (TAMAR)

•Trauma Affect Regulation: Guide for Education and Therapy (TARGET)

•Trauma Recovery and Empowerment Model (TREM and M-TREM)

See SAMHSA.GOV

Trauma-Informed Care

• Quiet and nurturing environment

• Less rigid rules

• Incorporation of spirituality

• Techniques such as mindfulness and meditation, yoga…

• Increased use of peer support

• Relationships matter (parents vs. spouses)

Peer Support

Yoga

Meditation

Case Management

Mindfulness

Technology

Whole Health

When is enough enough?

• Violence

• Stress

• Destroying property

• Stolen property

• Addict is a bad influence

• Facing financial disaster

• Done with lies

• Refuses help

Have boundaries that are either too rigid or non-existent.

Creates isolation or enmeshment of family members.

Engage in behaviors that eliminate individualization and promote continued use of chemicals. Encourages oppression and enables using behaviors.

Rigid resistance to outside influences, multi-generational addiction, and firm adherence to homeostasis. Family members have difficulty expressing emotions, processing troubles, and achieving intimacy.

The basic emotions experienced, but rarely expressed are; anger, shame, guilt and depression The emotions become the person’s regular response to any situation they encounter or experience.

AdvocacyAdvocacy

Addiction is a disease. It’s not a moral failing. Seek help.

Jeffrey and Jim Moore

Policy Implications

• Purposeful Integration

• Decision-makers hold themselves accountable

• Commitments of time and funding

• Identify point person(s)

Sharp, Cheryl. (2015, January 9). Waiting to be asked. Thenationalcouncil.org.

POLICY IMPLICATIONS

Increased inclusion of family members

Making room for funding for recovery organizations

Consider family members as partners in advocacy

Purposeful acknowledgment and participation

Connections (i.e. Collegiate Recovery Programs)

Identification of point person(s)

Recovery-Oriented Strategies, Pilot Projects,Transformational Recovery-Oriented Culture• Utilize family members on leadership/Advisory Councils

• Sponsor storytelling training

• Include family members in monitoring processes

• Family members participate in RFP reviews; policies and procedures; strategic plans

• Family members help develop the vision for transforming atmosphere

• Integrate Family members in crisis response teams & interventions

• Hire family members with lived experience in leadership positions

Achara Consultin, inc.

Recovery Schools

Brown University

Augsburg College

Texas Tech University

MS State University

University of MS

Scholarships for students in recovery

Sober housing

On-campus support groups

Recovery coaching

Academic mentoring

Community service projects roups

Sober social activities

Study groups

ReferencesSAMHSA. Substance Abuse Treatment and Family Therapy. Treatment Improvement Protocol (TIP): 39

www.thenationalcouncil.org/blog/2015/09/strengthening-specialty-addictions-sector/, Meghan. 27 April 2016. “Is Anonymity Still Required in Addiction Recovery?”. Addiction Treatment Articles.

https://www.recoveryranch.com/articles/anonymity-still-required-addiction-recovery/.

Nahttp://collegiaterecovery.org/programs/tional Institute on Drug Abuse (NIDA). (2011). Research Report Series: Cannabis Abuse. Accessed November 2011 at http://www.drugabuse.gov/ResearchReports/Cannabis/cannabis4.html

https://lifering.org/wp-content/uploads/06%20Presenting_20p_Web.pdf

References, cont’d

http://www.varta-consumer.com/~/media/images/global/products/professional-special-batteries/hearing-aid/explore/1-in-6-people.ashx?mw=265&h=170&la=en&w=265&hash=A05F8FC03CA60A23A7913D940F673C5866920AD7

http://proofofalien.com/wp-content/uploads/2016/02/10-Tips-Of-How-To-Get-Abducted-By-Aliens.jpgleft

https://www.simplypsychology.org/maslow.html