PASA Lesson 3: Drug Treatment Principles PDF

**[Lesson III-Intervention]** **[International principles and standards]** **Manual 1, Key principles and standards for the treatment of drug use disorder:** -Principle 1 treatment should be available, accessible, attractive and appropriate -Principle 2 ensuring ethical standards of care in trea...

**[Lesson III-Intervention]** **[International principles and standards]** **Manual 1, Key principles and standards for the treatment of drug use disorder:** -Principle 1 treatment should be available, accessible, attractive and appropriate -Principle 2 ensuring ethical standards of care in treatment services (i.e. patient rights and dignity, evidence-based practices, transparency and accountability, cultural sensitivity and inclusivity) -Principle 3 Promoting treatment for drug use disorders through effective coordination between the criminal justice system and health and social services -Principle 4 Treatment should be based on scientific evidence and respond to the specific needs of individuals with drug use disorders. It should be based on scientific evidence because: - To ensure efficacy (i.e. the treatment effectively resolves the addiction problem) - Patient safety (minimising the risks of adverse effects) - Adherence to ethical and professional standards - To control therapist bias and subjectivity - To support continuous improvement -Principle 5 Responding to the special treatment and care needs of population groups (cultural sensitivity, age-specific interventions, trauma-informed care, socioeconomic factors/disadvantaged socioeconomic backgrounds, health conditions and disabilities) -Principle 6 Ensuring good clinical governance of treatment services and programmes for drug use disorders -Principle 7 Treatment services, policies and procedures should support an integrated treatment approach, and linkages to complementary services require constant monitoring and evaluation (Advantages of an integrated treatment approach includes: comprehensive patient care, improved coordination and continuity of care, greater treatment effectiveness, relapse prevention, resource optimisation) **Manual 2, Effective treatment principles:** 1-Addiction is a complex but treatable disease that affects brain function and behaviour 2-No single treatment is appropriate for everyone 3-Treatment needs to be readily available 4-Effective treatment attends to multiple needs of the individual, not just his or her drug abuse 5-Remaining in treatment for an adequate period of time is critical 6-Behavioural therapies including individual, family or group counselling, are the most used forms of drug abuse treatment 7-Medications are an important element of treatment for many patients, especially when combined with counselling and other behavioural therapies 8-An individual's treatment and service plan must be assessed continually and modified as necessary to ensure it meets his or her changing needs 9-Many drug-addicted individuals also have other mental disorders (depression, anxiety, bipolar, PTSD, personality disorders, OCD) 10-Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse 11-Treatment does not to be voluntary to be effective 12-Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13-Treatment programmes should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counselling, linking patients to treatment if necessary. **[Process of change and choice of treatment-Individualisation]** **Transtheoretical model of change. Prochaska and DiClemente (1992)** -One of the most used models to contextualise the treatment of addictive behaviours -Individuals can be classified into one of the following levels with respect to their intention to change. The task of treatment can be to encourage progress in the process, but we must respect and accompany what the patient wants -This model helps guide the patient and therapist in understanding where the person is in their recovery journey and what interventions are most appropriate at each stage -Phases of change: - Precontemplation No recognition of need or interest in change (think don't have a problem and people are overreacting - Contemplation Thinking about change/ambivalence (know drug use is causing problems, and they should probably do something, but not sure if ready to quit) - Preparation Willingness to implement, planning for change (I am ready to quit, I have looked at treatment options and am planning to start next week) - Action Implementing change, new habits (I have started attending support groups, I am sober for 2 months now and I'm working on improving my health and relationships) - Maintenance Sustained maintenance of change (sober for a year now, continuing with support group meetings and I am focused on my health. I have healthier coping strategies and have learned how to manage triggers without relapsing) - Relapse Is a return to the pattern of behaviour that existed before. A \'lapse' refers to a brief and single episode in which a person who is in recovery from an addiction consumes the substance again -Example on slide 23 of lesson 3 ppt. **[Care Resources]** -Outpatient Treatment Centres (OTC) - First step in the treatment of addictions - They offer outpatient consultations by appointment, where each patient is assessed and referred to appropriate services - The OTCs may be provincial, county or municipal, depending on their territorial scope of competence - The coordination of these centres is carried out by the provincial centres for drug addiction - They may be public or private - Some specialise in treatment of alcoholism, compulsive gambling etc. Some deal with addictions in general. -Hospital Detoxification Units - Integrated into hospitals and require the hospitalisation of the affected person - Units specialised in the care of people with addictions, integrated into the hospital environment - Accessed free of charge, through the OTCs, by means of corresponding Admission Protocol - Closed spaces, isolated from the rest of the hospital, but with necessary facilities to allow physical detoxification from any drug dependence, as well as the performance pf different activities and the development of appropriate interpersonal relationships between patients and the unit's technical teams. - Aim to carry out the complete, partial or selective detoxification of addictive substances, in those patients whose characteristics do not allow for outpatient detoxification. To carry out therapeutic interventions that require a medically supervised environment. To prepare the patient to guarantee the continuity of the process - Admission criteria patient with dependence on any type of substance, referred from an OTC, who meet one of the following criteria: - Drug addicts with a history of repeated failures in outpatient or home detoxification - Patients with organic or psychopathological medical disorders that make detoxification in an outpatient setting unsafe - Drug addicts with psychosocial characteristics marked by: family and social uprooting making it impossible to control outpatient or home treatment, living in a high-risk social nucleus preventing the minimum isolation necessary for treatment, low socio-economic level that makes it impossible to obtain competency care to medical treatment, existence of drug users in the family nucleus -Meeting and Welcome Centres - Aimed at developing harm and risk reduction programmes for people with addiction problems who are unwilling or unable to give up consumption - Prioritising interventions that minimise harm caused by addictive behaviours - Provide info on consequences of consumption, the least harmful ways to consume, and access to social and healthcare services, as well as training and employment programmes -Treatment Support Housing (TSH) - Accommodation and cohabitation units located in buildings or areas of standardised housing, intended for the residence of people with addiction problems during their therapeutic process - Intended for the accommodation of people lacking systems of relationships and links with their environment, with the aim of enabling their social and family normalisation - Provide care in the first phase of treatment -Therapeutic Communities (TC) - Residential and socio-sanitary centres, aimed at providing attention to the demands derived from the consumption of drugs and other addictions, from an integrated care model adapted to the individual needs of people with addiction problems - Comprehensive treatment if offered, following a series of basic principles such as: free assistance, confidentiality, equality, participation. - The care they offer includes, detoxification and rehabilitation of addictive behaviours and the treatment of associated organic and psychiatric pathologies. Aim to advance towards normalisation and social incorporation, a wide variety of activities and actions of a socio-educational nature are carried out. - Attend men and women with any type of addiction, as well as those with special needs (minors, pregnant women, couples, people who are referred from Penitentiary Institutions - They have different activities that are adapted to individual needs - Admission is by referral from OTCs -Reintegration Support Housing - Same objectives as TSH but attend at a later stage, so they collaborate in the process of social incorporation and normalisation - Aim to improve levels of coexistence of people affected by drug dependence problems in a phase in which their treatment is stabilised, especially among patients without family or people close to them - Attend to people who have previously achieved stabilisation in their therapeutic process and need this resource for social incorporation and normalisation - Admission criteria: through TCs, OTCs, FILL in - Exclusion criteria Have an organic illness or psychological disorder in an acute phase making it impossible for them to integrate into the programme and relate to other users and teams. They have a physical disability that makes it impossible for them to be independent. Those users who are voluntarily discharged or discharged of disciplinary grounds in the TC from which the referral was made, would start the admission process again - General objective to promote and facilitate Social inclusion based on personal autonomy - Specific objectives Health, legal, family, labour/training, social relations, personal development, leisure and free time - Methodology 1.Design and monitoring of personalised itineraries of Social incorporation (flexibility),with the negotiation and participation of the user (active and participative), 2.Encouraging his/her autonomy, 3.Materialising in an incorporation agreement - Time stay variable, max 9 months - Types of medical discharge: +-----------------------------------+-----------------------------------+ | Therapeutic Discharge | When the objectives established | | | with the user have been fully or | | | partially achieved | +===================================+===================================+ | Derivative Discharge | -When the user is referred to | | | another device before the end of | | | treatment for family, health or | | | legal reasons beyond the control | | | of the user and the team. | | | | | | -In this case, when this | | | circumstance comes to an end, the | | | user will be able to continue | | | with his/her treatment and will | | | be re-admitted to the next vacant | | | place in the same Reintegration | | | Support Housing | +-----------------------------------+-----------------------------------+ | Voluntary Discharge | When the user requests discharge | | | without completing the | | | therapeutic process | +-----------------------------------+-----------------------------------+ | Disciplinary Discharge | When the user meets any of the | | | criteria specified for | | | disciplinary discharge | | | (non-compliance with rules, | | | repeated 'positives', violence, | | | introduction of prohibited | | | substances) | +-----------------------------------+-----------------------------------+ - Activities are carried out aimed at the acquisition of normalised living habits, timetables, distribution of free time, cultural, educational and work training activities/programmes, with the aim of favouring the social incorporation of people undergoing treatment - May be annexed to the OTCs and may share common services and treatments -Penitentiary Institutions Support Teams - Collaboration with the MOJ - Began in 1989 - Enabled implementation of the technical intervention teams in the penitentiary centres of Andalusia - These teams are attached to the Provincial Drug Dependency Centres (CPD) with the aim of improving the quality and coverage of health and social care provided in these institutions to people with problems deprived from drug use -Methadone Dispensing units - Specialised facilities where methadone is administered to individuals who are undergoing treatment for opioid dependence such as heroin or certain pain relievers - Methadone is a long-acting opioid medication used to reduce withdrawal symptoms and craving, facilitating the recovery proves - These units may be part of hospitals, mental health clinics, rehab centres or even OT programmes. Patients receive controlled doses of methadone under the supervision of medical professionals. - Goal is to stabilise the patient, reduce the use of illegal opioids, improve quality of life, enable them to lead a more stable life and control their addiction. - If use incorrectly, it can have harmful effects - Advantages of methadone prolonged and stable effect, reducing withdrawals and cravings, does not produce same euphoria as opioids, allow people to function normally, administered in a controlled manner which reduces risk of overdose, helps with gradual transition away from opioids. **[Motivational Interview]** -We have different models of change: traditional and motivational approach 1.Traditional approach for change: - Information + consequences = change. Believed that having the necessary info and understanding the consequences is enough for change to happen. - Although having info and understanding is usually enough for change to occur, 2 mechanisms can be activated that may block this change: -Denial defence mechanism where individuals minimise, ignore or reject the reality of their substance use or its negative consequences (refuse to acknowledge the problem, minimisation of the issue, rationalisation, projection) -Resistance refers to behaviour or attitudes that oppose or obstruct change, even when a person might consciously or unconsciously know that change is necessary. In addiction treatment, resistance can be an expression of the persons fear of the unknown, unwillingness to give up the addiction, or ambivalence about the change process - If we include certain variables such as expert advice and confrontation, change can occur: -Expert advice involves the therapist or counsellor taking on the role of the expert, providing clear and directive guidance on how to address addiction -Confrontation direct method and more forceful. Aims to disrupt the persons defence mechanisms and compel them to face the truth about their addiction (have you tried, if you don't, don't you see) 2.Motivational approach for change - Transtheoretical Model stages - Use motivational interviews collaborative conversation style. Designed to strengthen person motivation and commitment to a specific goal by eliciting and exploring the person's own reasons for change within an atmosphere of acceptance and compassion. Need to have: - Partnership/collaboration - Acceptance/Autonomy uses person's experience to teach rather than directly advising, focus on persons autonomy, resourcefulness and ability to choose, communicated worth, empathy, affirmation. - Evocation eliciting persons own perspectives and motivations - Compassion -Have open-ended questions, affirmations, reflections, summaries (OARS): - Open ended questions closed ones are where the response would be one word. It keeps the conversation going, facilitates exploration, offers diverse options and possibilities to respond, gives a chance to expand. Don't want to use too many questions as don't want to be interrogative. +-----------------------------------+-----------------------------------+ | **Closed questions** | **Open questions** | +===================================+===================================+ | How many times have you been in | What has your experience with | | treatment before? | treatment been like in the past? | | | | | | How do you feel to be in | | | treatment again? | +-----------------------------------+-----------------------------------+ | Are there good things about using | What are the positive aspects you | | drugs? | or others may associate with | | | drugs? | | | | | | What are the good things about | | | using drugs? | +-----------------------------------+-----------------------------------+ | Do you like your brother? | What is your relationship like | | | with your brother? | | | | | | What do you like about your | | | brother? | +-----------------------------------+-----------------------------------+ | Are you sad about your father's | How does your father's death make | | death? | you feel? | | | | | | How do you feel about your | | | father's death? | +-----------------------------------+-----------------------------------+ | Are you worried about your | Do you have any concerns | | children? | regarding your children? | | | | | | What most concerns you about your | | | children? | +-----------------------------------+-----------------------------------+ - Affirmations Statement and gestures that recognise/appreciate strengths and behaviours that lead in the direction of positive change, no matter how small. They are not compliments, they are observations of ability, decision, or realisation. They build confidence in one's ability to change. They must be genuine and congruent. Such as "thanks for coming today in spite of", "I appreciate that you are willing to talk to me about", "You are obviously a resourceful person to have coped with those difficulties", "that's a good idea", "it is hard to talk about BLANK, I appreciate you continuing with this" - Reflections: Example "since my mother passed away I'm not sure i can make it without her": -Repetition (repeat a key word or phrase). "You "are not sure you can make it without her\| -Simple reflection (rephrase in new words, add meaning to what was said). "Sounds like it is difficult for you to manage without her" -Complex reflection (States content and emotion that the person seems to be feeling). "It seems you are feeling hopeless since your mother passed" -Reflective listening a statement intended to mirror meaning of preceding persons speech. Seeks to understand the persons subjective experience, offering reflections as guesses about the persons meaning. Checking rather than assuming that you know what you meant. Listening not only to what they say, but what they mean. Check out whether you really understood. Highlight the persons own motivation for change. Steer the client towards a greater recognition of her or his problems and concerns. You do not need to agree, just understand and accompany. Reinforces statements. -How to do reflective listening? Avoid judging, criticising or blaming. Letting person know you are interested (verbal and non-verbal), creating environment of unconditional acceptance, listening to the words and being aware of non-verbal communication. -What blocks reflective listening? - Ordering or threatening: Controlling the conversation by giving commands or issuing threats, which can induce resistance - Providing advice or solutions: Offering unsolicited suggestions or solutions, which can undermine the individual's autonomy in problem-solving - Persuading with logic or arguing: Attempting to convince through reasoning or arguments, often leading to defensiveness rather than engagement - Moralising or preaching: Imposing moral judgements or telling the individual what they "should" do, which can create feelings of guilt or inadequacy - Judging or criticising: Engaging in criticism, blame or disagreement, which fosters resistance and inhibits openness - Distracting or changing subject: Shifting the conversation away from important issues, preventing deeper exploration of the individual's thoughts and feelings - Agreeing or praising: Offering approval or praise may seem positive, but it can limit the exploration of deeper emotions or challenges - Shaming or ridiculing: Using ridicule, labels, or shame damages self-esteem and closes off communication - Interpreting or analysing: Providing interpretations or analyses the individual's behaviour can make them feel misunderstood or judged - Summaries A way of gathering what has already been said. It puts together a group of reflections: Helps show the person you are listening. Helps make sure you understood correctly. Helps preparing the person to move on -How to summarise? 1.Begin with a statement indicating you are making a summary ("let me see if I understand") 2.Give special attention to Ambivalence and Change Statements (problem recognition, concern, intent to change, optimism0 3.Be concise 4.End with an invitation to agree, disagree or add ("is this correct, did I miss anything?) 5.Sometimes the summary will be followed by exploring or planning next steps **[Cognitive behavioural Therapy (CBT) for addictions and Relapse Prevention]** -Objectives of CBT: - change cognitive patterns that lead to substance use or addictive behaviours - Teach skills for manage stress, difficult emotions, and triggers without resorting to addiction - Encourage the adoption of healthy habits and coping strategies that promote long term well-being - Prepare individuals to prevent relapse and develop confidence in their ability to maintain sobriety or control -Types of interventions: - Individual vs group - Outpatient vs closed - Psychopharmacological vs psychosocial -Individual vs group interventions in CBT: +-----------------------------------+-----------------------------------+ | **INDIVIDUAL** | **GROUP** | +===================================+===================================+ | -In individual therapy, the | -Clients participate in sessions | | therapist works 1-to-1 with the | with others facing similar | | client to address personal | challenges | | trigger, thought patterns and | | | behaviours related to addiction | -Encourages social support and | | | shared experiences, allowing | | -May be especially helpful for | individuals to learn from peers, | | clients with co-occurring mental | reduce feelings of isolate and | | health conditions, personal | foster accountability | | traumas, or those who need | | | privacy to work through specific | -Can be cost-effective and offers | | issues | a communal aspect that many find | | | empowering, especially when | | | addressing addiction, where peer | | | support is a critical factor | +-----------------------------------+-----------------------------------+ -Outpatient vs closed (inpatient) CBT interventions: +-----------------------------------+-----------------------------------+ | **OUTPATIENT** | I**NPATIENT** | +===================================+===================================+ | -Clients receive therapy whilst | -Individuals receive intense | | living independently, meaning | therapy whilst living at a | | they can maintain their work, | residential treatment centre or | | school or family commitments | hospital. | | | | | -Outpatient treatment allows for | -This set up provides a | | integration of CBT techniques | structured, controlled | | into daily life, providing | environment that removes | | immediate real-world application | immediate access to substances | | and adjustments as challenges | and includes continuous support | | arrive | | | | -Especially beneficial for those | | | with severe addiction or in need | | | of medical detoxification or | | | support for co-occurring | | | disorders | +-----------------------------------+-----------------------------------+ -Psychopharmacological vs psychosocial interventions in CBT +-----------------------------------+-----------------------------------+ | **Psychopharmacological** | **Psychosocial** | +===================================+===================================+ | -Combines CBT with medications | -Solely focuses on behavioural | | aimed at managing cravings, | and social support strategies, | | withdrawal symptoms or | without the use of medication | | co-occurring mental health issues | | | | -Learn strategies to help with | | -Medications include | self-regulation, development of | | antidepressants, or some | coping strategies and improving | | medications specific to addiction | social skills, relationships, and | | (such as naltrexone for alcohol | support networks. | | dependence of buprenorphine or | | | opioid addictions) | | +-----------------------------------+-----------------------------------+ -Relapse prevention: - This is a set of cognitive-behavioural techniques and info to teach, train and support abstinence from drug use and the acquisition of new behaviours - CBT for addictions and relapse prevention focuses on modifying problematic thoughts and behaviours, providing patients with the necessary tools to achieve and sustain long-term change -In essence it is teaching and training in skills necessary for abstinence -Work with situations and consequences, whilst understanding beliefs/thoughts, emotions and behaviours. -Strategies to work with in therapy: - Information on substances the consequences and how they work in the body, how the brain changes - Craving management - Communication and social skills - Model A-B-C (the previous mention of emotions, behaviours and thoughts) - Stress management - Problem solving how to solve problems without using substances - Treatment of associated disorders - Information on phases of change or relapses how to prevent, the triggers - Intervention on thoughts - Vocational counselling - Relapse prevention - Improving social and community support - Defence mechanisms: deception and self-deception - Resource advice - Emotional regulation - Managing situations and changing lifestyle - Contingency management -Coping with situations and changing lifestyles examples: +-----------------------------------+-----------------------------------+ | **Managing precipitating | -Once the triggers, both internal | | situations** | and external, and high-risk | | | situations have been assessed: | | | | | | 1: Learn how to avoid higher risk | | | situations (especially in the | | | earlier stages) | | | | | | 2: Develop skills to handle | | | situations that are unavoidable | | | or undesirable to eliminate | | | (examples: changing phone | | | numbers, different route home, | | | not having alcohol in the house) | +===================================+===================================+ | **Lifestyle changes** | -Time management, by means if a | | | diary | | | | | | -Organisation of activities away | | | from situations of consumption | | | | | | -Leaving little free time that | | | may trigger a relapse or relapse | | | due to different negative | | | emotions, such as boredom | | | | | | -Increasing participation in | | | activities that are reinforcing | | | and don't involve drug use | +-----------------------------------+-----------------------------------+ -Communication skills example: - Many people with addiction have problems relating to non-users, co-workers or other people appropriate to their abstinence, attending certain social activities and expressing feelings - Importance of work (through modelling, behavioural rehearsal and feedback) increased communication self-awareness, psychoeducational training, development of communication skills -Problem solving example: - For many people, consumption has been a way of not facing many problems, or making impulsive decisions that were not the most appropriate and that have generated new problems - It is about identifying, analysis and finding solutions to many problems that are encountered when giving up consumption and changing lifestyle - Phases: recognising and defining the problem, brainstorming on different ways to solve the problem, select the most appropriate strategy divided into different parts, monitoring the implementation of the strategy, evaluate the effectiveness -Vocational counselling example: - Satisfaction with job or academic activities is one of the factors related to long-term abstinence (feelings of self-efficacy, self-control, social support, remuneration etc) - Job satisfaction makes it less likely to use while working - Abstinence makes it less likely to lose ones job - Work increases self-efficacy and self-esteem - Work provides the means to access other reinforcers, for example, pay - Work provides social support, friends and social activities, away from drugs -Contingency management example: - Psychological intervention based on the principles of operant conditioning - Con Man is a strategy designed to provide alternative reinforcers that compete with the reinforcement associated with drug use - It has been shown that it is effective, although there is an increase in relapse rates after withdrawal from contingency management programmes. Contingency management programmes should therefore be complemented by other programmes - Principles of Con Man: **Four General Principles** **Examples** ------------------------------------------------------------------ ----------------------------------------------------------------------------------------- 1-Select the target behaviour -Abstinence from the problem substance 2-Frequent monitoring of this condition -Biochemical tests 3-Provide reinforcers for when the target behaviour is performed -The patient receives a pre-agreed reinforcer when a urine test is negative (drug-free) 4-Eliminate reinforces when the target behaviour does not occur -Do not offer reinforcers when urine tests are positive (presence of drugs) - Con Man parameters: All examples 1.Define the behaviours precisely attendance at sessions, therapeutic objectives (abstinence vs reduction), adherence to medication etc +-----------------------------------+-----------------------------------+ | Session Attendance | Patients must attend at least 90% | | | of scheduled sessions | +===================================+===================================+ | Therapeutic Objectives | -Abstinence total abstinence from | | | substances, verified through | | | regular drug/alcohol testing | | | | | | -Reduction for those unable to | | | achieve abstinence, reduce | | | substance use by 50% within 4 | | | weeks | +-----------------------------------+-----------------------------------+ | Medication Adherence | Patients must take prescribed | | | medication 95% of the time, | | | verified via daily logs or pill | | | counts | +-----------------------------------+-----------------------------------+ Attendance Marked dichotomously ("present" or "absent") ---------------------- -------------------------------------------------------- Abstinence Use drug tests to objectively measure substance levels Medication adherence Measured by compliance reports or pill tracking Privileges or activities Access to recreational activities, weekend passes, or extended free time -------------------------- ------------------------------------------------------------------------------------------------------- Reward system Vouchers for goods, services, or gift cards Magnitude Reinforcers' value is scaled (e.g. 10 tokens for small privileges, 100 tokens for high-value rewards) 5.Specify token exchange protocols: - Who therapist or programme coordinator - WhereDesignated office or room - WhenWeekly or daily exchanges - Reinforcement scheduleContinuous or intermittent, depending on behaviour achievement. The programme duration may be 12 weeks, followed by a gradual phasing out of tokens 6.Implement the programme and phase it out Ensure consistency across staff. Combine with other therapies (e.g. CBT) and gradually reduce token rewards as patient maintains behaviour autonomously. -Emotional regulation example: - Improving awareness, understanding and acceptance of emotions - Generate skills to control impulsive behaviours and perform goal-directed behaviours when experiencing negative emotions - Use strategies to modulate the intensity and duration of an emotional response - Willingness to experience negative emotions in the process of achieving desired goals -Other techniques: episodic future thinking, mindfulness, couples therapy, family therapy, executive functions **[Example of a structured treatment programme (MATRIX) ORGANISE LESSON]** **What is the Programme Matrix?** -Developed at the Matrix Institute in LA, California -Intensive outpatient treatment for stimulant abuse and dependence -Consists of intensive treatment for 16 weeks and continuation treatment until week 48 -Patients learn about issues critical to addiction and relapses and are monitored for drug use through urine testing -The programme includes training for family members -Consists of 6 components early recovery skills, family education group, relapse prevention, social support group, 12 step/mutual-help group meetings, analysis of drug consumption -Have manuals to work with clients handbook, counsellor's family education manual, counsellor's treatment manual -Components individual/joint sessions, early recovery skills, relapse prevention, mutual-help group meetings/12 STEP, social support group, urine testing, family education group -The role of co-leaders or mentors: =Early Recover Skills and Relapse Prevention groups need cp-leaders because they: - Provide a role model for those in early recover - Help translate the material into real life situations - Can confront directly by using their own experience - Need to make it clear to them that they should not give advice or act as "therapists" - Need to meet with them briefly before and after each group - Need to sign an agreement - Recruitment starts in the RP groups 1.Individual/conjoint session: - GOALS: 1. Provide clients and their families with an opportunity to establish an individualised connection with the counsellor and learn about treatment 2. Provide a setting where clients and their families can, with the counsellor's guidance, work out crises, discuss issues and determine the continuing course of treatment 3. Allow clients to discuss their addiction openly in a nonjudgemental context with the full attention of the counsellor 4. Provide clients with reinforcement and encouragement for positive changes 2.Early Recovery Skills Group: - GOALS: 1- Provide clients and their families with an opportunity to establish an individualised connection with the counsellor and learn about treatment 2-Introduce clients to the basic tools of recovery and aid clients in stopping alcohol and drug use 3-Introduce 12-step or mutual-help involvement and create an expectation of participation as part of treatment 4-hell clients adjust to participation in a group setting such as RP or Social Support group session or 12-step or mutual-help meetings 5-Allow the recovering co-leader to provide a model for strengthening initial abstinence 6-Provide the recovering co-leader with increased self-esteem and reinforce their progress - STRUCTURE: - Total approx. 50 minutes - Introductions new users, co-leaders etc, 5 minutes. The time each person has been abstinent and positive comments about the benefits of abstinence. Mark progress on calendars. Introduction of topic and materials - Discussion of main topic 35 minutes. Agenda and follow-up on homework assignments. Closing session (summary, acknowledgment of unresolved issues, reminder of confidentiality, etc) 3-Relapse Prevention Group: - GOALS: 1. Allow clients to interact with other people in recovery 2. Alert clients to the pitfalls of recovery and precursors of relapse 3. Give clients strategies and tools to use in sustaining their recovery 4. Allow group members to benefit from the long-term sobriety experience of the recovering co-leader 5. Allow the counsellor to witness the personal interactions of clients 6. Allow clients to benefit from participating in a long-term group experience - STRUCTURE: - Introduction (new users, co-leaders etc) and brief description of your consumption history - Introduction of the topic and the materials of the day (15m approx.) - Discussion of the main topic (45m) - Discussion of recent issues (30m) issues addressed includes how things are going, whether they are any new developments in a problem brought up last time, cravings and if so, how were they handles - Closing of the session (summary, acknowledgment of unresolved issues reminder of confidentiality, etc) - Total time is approx. 90m 4-Social Support Group - GOALS: 1. Provide a safe discussion group where clients can practice resocialisation skills 2. Provide opportunities for clients who are advanced in treatment and recovery, to serve as role models for clients who have been in recovery for less time 3. Encourage clients to broaden their support system of abstinence, recovering contacts with whom they can attend 12-STEP or mutual-help meetings 4. Provide a less structured and more independent group environment that helps clients progress from treatment in the more structured environments of Early Recovery Skills and Relapse Prevention groups to recovery maintained with group support but without clinical support 5. 35-group sessions that are held once a week over 36 weeks 6. 90 minutes long 7. Limited to 10 people per group so that each client has time to participate 8. Clients who have been co-leaders during ERS or RP group meetings can act as facilitators, under the counsellor's supervision 9. Client-facilitators should be screened carefully for emotional stability, intellectual competence, and strength or recovery 10. They should commit to attending regular for 6 months and should meet with the counsellor before the group session to be briefed on the topic and issues relevant to individual clients 11. The client-facilitator's job is to help the discussion run smoothly so that clients can get the most benefit - GUIDELINES: - Listen to clients, help them clarify what they are saying, but do not speak for them or provide answers - Encourage group members to accept and support one another - Focus on the members; do not assume a position of authority or monopolise the discussion - Permit clients to depart briefly from the session's topic if the discussion seems to be beneficial to all clients in the group - Steer participants away from lengthy stories of using that might act as triggers for others - Make sure that the group is not dominated by one or two members and that everyone in the group gets time to speak - Avoid making generalisations - Avoid asking "why" questions of members - 36 TOPICS: - Friendships - Guilt - Isolation - Honesty - Intimacy - Masks - Overwhelmed feelings - Anger - Fear - Emotions - Desires -Family Education Groups - GOALS: - Present accurate info about addiction, recovery treatment, and the resulting interpersonal dynamics - Help clients and family members understand how the recovery process may affect current and future family relationships - Provide a forum for families to discuss issues of recovery - Present accurate info about the effects of drugs - Teach, promote, and encourage clients' family members to care for themselves whilst supporting the client in their recovery - Provide a professional atmosphere in which clients and their family are treated with dignity and respect - Encourage participants to get to know other recovering people and their families - STRUCTURE: - 12 weeks with a different theme each week - Meetings once a week - Use material relevant to the population being addressed - Both participants and family members can attend - Not 'family therapy' but a Family Education group