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• 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