Developing and Implementing CBT Strategies for Co-Occurring Disordered Clients. Dr. Hal Baumchen

Transcription

1 Developing and Implementing CBT Strategies for Co-Occurring Disordered Clients Dr. Hal Baumchen

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3 Defining Co-Occurring Disorders Co-occurring disorders refers to an individual having one or more substance abuse disorders and one or more mental health disorders.

4 Identifying Co-Occurring Disorders

5 Identifying Co-Occurring Disorders

6 Identifying Co-Occurring Disorders

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8 Nick and Tim s Skit

9 Two Major Goals: 1. Reduce symptoms 2. Prevent relapse

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11 I was in and out of trouble since I was 14 years old. I couldn t sit still. I was rowdy and obnoxious. My mom took me to a doctor some kind of shrink. They told me I had ADHD and anxiety. I don t know about that I m not sure how bad it was you know, if I needed treatment or anything. But I know this, when I started using meth-it got worse. Like 10 times as bad. And it caused a boatload of problems job loss, wrecked relationships. It got out of control. I needed help for my drug abuse---and my mental health.

12 Which Came First? Some people have mental health problems and start abusing drugs and alcohol as a way to self medicate.

13 Which Came First? Others use alcohol and drugs long enough to develop mental illness symptoms or make existing mental illness symptoms worse.

14 Illnesses that frequently co-occur with substance use disorders include: Attention Deficit Hyperactivity Disorder (ADHD) Bipolar disorder Conduct disorders Personality disorders Anxiety disorders Depression Thought disorders (including schizophrenia, hallucinations, and delusions) Paranoia Post-Traumatic Stress Disorder (PTSD)

15 Co-Occurring Problems Mental health issues impact substance use disorders.

16 Co-Occurring Problems Substance use problems impact, launch or exacerbate mental health problems.

17 The Complexity of Co-Occurring Disorders

18 43,252,003,274,489,856,000 Different configurations of the Rubik s Cube

19 Cognitive processing is more difficult because of: Withdrawal effects Sleep-deprivation Chemical imbalance ADHD Anxiety Depression Trauma Thought disorders Brain injury Learning disabilities Nutritional Deficiencies Detoxification Complications Increased Stress Levels Infographic ordered

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21 CBT Specialized and Simplified Our secret to working with the complexities of co-occurring disorders was not to make the interventions more complex, but rather make the interventions simpler and more effective.

22 Good Treatment Requires Good Resources

23 We are not trying to direct a client s thinking, but instead, we are trying to accommodate the client s thinking difficulties.

24 Good Treatment Requires Good Resources

25 Making a Difference Sequential Treatments Parallel Treatment Fully Integrated Treatment Being different makes a difference.

26 I grew up in a medium size city in Michigan. My mom and dad divorced when I was about 10. I was in the fourth grade. I was then raised by my mom but I saw my dad every other weekend. I remember being anxious even when I was a little kid. I would get these awful stomach aches and I d worry about getting sick. I d especially worry about having to throw up. 26

27 I had more physical symptoms when I was in public. I would feel uncomfortable, blush, get all red in the face, feel sweaty all over. My heart would beat like crazy and I d feel like I was dizzy or going to pass out. Whenever that happened, I couldn t concentrate, couldn t focus on what I was doing. I didn t think about anything except getting out of there. Whenever those things would happen I d feel uncomfortable thought I was going crazy. I started to notice where these things were happening and then I would try to avoid whatever made me uncomfortable or panicky. 27

28 I started drinking when I was 12 maybe 13. At first it didn t affect me all that much, and I could keep doing my construction job. I d managed to go into work most days. Sometimes I would leave early, a couple of hours before the rest of the crew left. When I got home I d start drinking beer I could drink 6 to 12 beers a day I did this every day. I would sit in the chair get my beer, watch television and drink till it passed out. 28

29 At first the alcohol helped me calm down. After a while it just didn t seem to work the same way. I was still getting super anxious. I went to a doctor who is sympathetic with my panic attacks. She prescribed an anti-anxiety medication called a benzo. I noticed almost instant relief from the medication. After a few refills I was drinking and overusing the medication. I d get a 30-day prescription and it would only last me a week. I used the pills along with alcohol for 10 years. Whenever the doctor started to catch on-i would go to a different doctor or buy medications on the street. When the medications and alcohol still didn t work, I d drink even more. I m not proud of it and I needed help. That s why I m here. 29

30 Intervention #1: Illustrate How CBT Works I have a thought and a belief that there is a ferocious dog on the other side of the door.

31 Intervention #1: Illustrate How CBT Works I have strong, corresponding feelings such as fear, worry, apprehension, and irritability.

32 Intervention #1: Illustrate How CBT Works I have corresponding actions and behaviors that fit what I think and believe such as I m going to stay put or I m going to have someone remove the dog.

33 Intervention #1: Illustrate How CBT Works Turns out, there is no dog.

34 Intervention #1: Illustrate How CBT Works My behavior and my strong feelings perfectly fit what it not true.

35 Intervention #1: Illustrate How CBT Works Anxiety, depression, and substance abuse are filled with thoughts that are not true.

36 Intervention #1: Illustrate How CBT Works If you want to change the way you behave, you have to change the way you think.

37 Most people with chemical dependency problems want help Intervention #1: Illustrate CBT But those same people can become resistant to change Rather than change they justify reasons to stay the same Old thinking leads to the same old problems

38 Intervention #2: Outline how long lasting change occurs. The Ten Principles of Self Change

39 Intervention #2: The Ten Principles of Self Change: 1. Change is possible. Out of respect for yourself and others, you can change yourself.

40 Intervention #2: The Ten Principles of Self Change: 2. The foundation of change is in your thinking.

41 Intervention #2: The Ten Principles of Self Change: 3. Change is made possible through simple but systematic efforts, in a single direction, over time.

42 Intervention #2: The Ten Principles of Self Change: The goal of treatment is not how fast you can get out. The goal of treatment is to get as strong as you can before you leave.

43 Intervention #2: The Ten Principles of Self Change: 4. The will to change can be developed.

44 Intervention #2: The Ten Principles of Self Change: 5. The ability to change can be strengthened.

45 Intervention #2: The Ten Principles of Self Change: 6. The enemies of change can be identified and minimized.

46 Intervention #2: The Ten Principles of Self Change: 7. It is critical to understand the interaction between the environment, circumstances, and your thinking.

47 Intervention #2: The Ten Principles of Self Change: 8. Thoughts rule. Perceptions, attitudes, and feelings are influential, but they should not be the decision-makers in life.

48 Intervention #2: The Ten Principles of Self Change: 9. Healing for psychological pain of the past, requires changing how you think in the present.

49 Intervention #2: The Ten Principles of Self Change: 10. Successful change is inspirational. Motivational momentum can be maximized.

50 Intervention number 3: Teach Positive Self-Talk to Change Your Thinking

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52 People used to try to tell me I was pretty. I could never believe that. I d be like what do you want? Get out of my face! And drop, dead why don t you! I used to call myself worthless and you're a loser. You ugly, worthless, screw up! In treatment I began to catch myself doing that. I couldn t believe how often it would happen. My counselor told me to argue with that lie. I told the lie to shut up. I began accepting myself, believing I could make changes and that I could amount to something. I m feeling better about myself and my recovery. Now, I got it going on And if you don t think so-then drop dead, why don t you."

53 Intervention #4: Teach character goals. 10 Essential Traits

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55 I was making excuses like everybody, I guess. But most of my excuses were just bold faced lies. If I was late for work, I d say I was stuck in traffic, but the truth was, I was too hung over to get out of bed on time. If I got home late, I d say that the game went into extra innings. But the truth was I was having 3 or four more beers before I went home. My excuses for drinking were made up lies-designed to cover my tracks. Honesty didn t determine what I said, alcohol did.

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57 Whenever I would get around my friends I would just give in. I didn t want to ruin their good time by not using. What would they say if I turned them down? They d pour me something or pass me something and I d be like, all right then, I m in! Serve it up.

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66 Intervention number 5. Identify and reduce selfishness.

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68 I always wanted my way. I didn t really get mean or anything. I wasn t a bully, I was more of a baby. If I didn t get what I wanted, I d complain and get upset. I d throw a fit. I let everybody who knew me, and half the people who didn t, know that I d gotten screwed over-and I was not happy. I saw myself as a victim or a martyr. I d get really offended if someone was late, or I got overlooked, or misunderstood. It was like I was mad about something all the time. Then, like a lightning bolt, I began to see how I exaggerated my importance and slighted everyone around me. It wasn t easy but I had a serious reality check.

69 Intervention number 6. Develop A Can Do Attitude. Placeholders

70 Intervention number 7. Cultivate Acceptance. Common Exceptions I don t drink anything, except beer I only drink on the weekend She offered me a drink This is a special occasion I couldn t pass up free beer

71 I couldn t accept responsibility for my own problems. I blamed anything and everyone. When I got my second DWI ticket I blamed the bartender who served me, the cop who arrested me, my attorney for not helping me, my girlfriend for not supporting me, and my dad for not bailing me out.

72 Intervention number 7. Cultivate Acceptance. Common Excuses One drink won t hurt Hey, we re all going to die of something No one is going to tell me how to live my life Everybody drinks sometimes You drink, why can t I?

73 I can t handle this. I must have said that a million times. I don t even know who I was saying it to. I guess anybody who d listen. I grew up in a home with a lot of problems. My dad was a drunk. He was always drunk and he d come home and yell at my mom. Or he would just be at home drinking and something would upset him and he d start cussing out my brother or calling names. Just screaming at us. He was always asking, why the dishes weren t done, who was supposed to do them? And he d always be upset about it. It made us kids really defensive. We d lie, or make up excuses. I got good at shifting blame saying I didn t do it, it wasn t me. One time I left my bike in the driveway, he ran over the bike accidentally, my dad that is. He came into the house like he was going to kill somebody. I told him I didn t know how it got there made up some kind of story. When I started drinking, it was the same thing for me. I rationalized my use. I started out just drinking once in a while. Maybe on the weekends or some kind of special occasion like a wedding. I drank when I was on vacation or on the holidays, or when the guys would come over to watch the game. When I had business in Detroit the franchise owners that I made calls on, would always supply dinner and drinks. How could I pass up a free meal, and free booze? The more I drank the more stressed out I got. My wife at that time, we re divorced now, she told me I was drinking too much. I justified my drinking by saying I m really stressed out, I can t take this anymore. That s when I started saying I just can t handle this. I excused my drinking, started to believe it myself. When I went to treatment, the other guys could see through my bogus excuses. They pushed me to face the truth. The truth was I could solve my problems without alcohol, I could manage my stress without drinking. I can reach out for help when I am feeling overwhelmed. When I make mistakes, I m not beating myself up anymore. And I m not using those old excuses to start drinking again I m done with that.

74 Intervention number 8. Develop Frustration Tolerance. Placeholder

75 I m learning how to tolerate frustration even when things don t go my way. I know now, that in every situation I actually have a choice. I can be frustrated or I can let it go. And I m getting better at tolerating those silly things that happen in everyday life. I m really trying to change the way I think about these things. And it s helping me manage my distress and frustration. And every time I make a positive choice it seems like I m getting stronger. I may now have the same old problems-but I actually have a brand-new perspective.

76 Intervention number 9. Teach the Power of Gratitude.

77 Intervention number 10. Instill Hope. 30 Ways to Increase Hope: Hope is the belief that there are good things and better days ahead.

78 Any questions?