Trainer Curriculum 02

Treatment for Substance
Use DisordersThe
Continuum of Care for
Addiction Professionals
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THE COLOMBO PLAN
The Colombo Plan Asian Centre for Certication and Education
of Addiction Professionals Training Series
Trainer Manual
ii
Curriculum 2: Treatment for Substance Use Disorders
Acknowledgments
Curriculum 2: Treatment for Substance Use DisordersThe Continuum of Care is part
of a nine-volume training series developed for the U.S. Department of States Bureau
of International Narcotics and Law Enforcement Affairs (INL). The publication was
developed under contract number SAQMPD07D0116, Demand Reduction Support
Services, between INL and Alvarez & Associates, with JBS International, Inc. (JBS),
serving as subcontractor.
Special thanks go to Thomas Browne, Deputy Director, Ofce of Anticrime Programs,
and Gregory R. Stanton, Program Ofcer, for their guidance and leadership throughout
the projects development. Suzanne Hughes, M.A., CASAC, Alvarez & Associates, served
as Project Director, and Sara Lee, M.S.W., LICSW, Alvarez & Associates, served as Senior
Demand Reduction Coordinator. From JBS, Candace L. Baker, M.S.W., CSAC, MAC, served
as Project Director and Lead Curriculum Developer, and Larry W. Mens, M.Div., served
as Curriculum Developer. Other JBS staff members include Erin P. Doherty, Copy Editor;
Frances Nebesky, M.A., Associate Editor; and Claire Macdonald, Senior Graphic Designer.
Staff members of NAADAC, The Association for Addiction Professionals, contributed
signicantly to development of this publication. We would like to thank Cynthia Moreno
Tuohy, NCAC II, CCDC III, SAP, Executive Director; Shirley Beckett Mikell, NCAC II,
CAC II, SAP, Director of Certication and Education and Certication Commission Staff
Liaison; Donovan Kuehn, Director of Operations and Outreach; and Misti Storie, M.A.,
Education & Training Consultant. Other contributors included Suzanne Hall-Westcott,
M.S., Director of Program Development, Daytop International; Diane Williams Hymons,
M.S.W., LCSW-C, LICSW, Principal, Counseling-Consulting-Training-Services; Phyllis
Mayo, Ph.D., Psychologist; and Donna Ruscavage, M.S.W., Ruscavage Consulting.
Some material in this curriculum was previously developed by JBS for Family Health
International (Hanoi, Vietnam) under a contract supported by the U.S. Agency for
International Development.
Special thanks are extended to the international consultants and pilot-test group members
(see Appendix F) who provided invaluable input. Their enthusiastic participation and
creativity contributed greatly to the nished product.
Public Domain Notice
All materials appearing in this curriculum except for those taken directly from copyrighted
sources are in the public domain and may be reproduced or copied without permission
from the U.S. Department of States INL or the authors. Citation of the source is appreciated.
However, this publication may not be reproduced or distributed for a fee without specic,
written authorization from INL.
Disclaimer
The substance use disorder treatment interventions described or referred to herein do not
necessarily reect the ofcial position of INL or the U.S. Department of State. The guidelines
in this document should not be considered substitutes for individualized client care.
Published 2011
iii
Trainer Manual: Trainer Orientation
CONTENTS
Part ITrainer Orientation
Trainer Orientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Part IIMaster Agenda
Master Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Part IIIEvaluation Forms
Daily Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Overall Training Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Part IVTraining Modules
Module 1Training Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Module 2Recovery and Recovery Management . . . . . . . . . . . . . . . . . . . 65
Module 3Factors Affecting Treatment Outcomes . . . . . . . . . . . . . . . . . . 95
Module 4Introduction to Motivation and Stages of Change . . . . . . . . . 139
Module 5Treatment: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Module 6Components of Treatment: The Continuum of Care . . . . . . . 199
Module 7Evidence-Based Practices for Treatment Intervention . . . . . . 341
Module 8Integrating Learning Into Treatment . . . . . . . . . . . . . . . . . . . . 539
Part VAppendices
Appendix AEnergizers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551
Appendix BLearner-Centered Trainer Skills: A Brief Overview . . . . . . . . 555
Appendix CDealing With Difcult Participants During Training . . . . . . . 557
Appendix DGlossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563
Appendix EResources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565
Appendix FSpecial Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . 571
1
TRAINER ORIENTATION
Introduction
The problem
Psychoactive substance use and substance use disorders (SUDs) continue to be major
problems around the world, taking a toll on global health and on social and economic
functioning. The United Nations Ofce on Drugs and Crime (UNODC) reports that, in 2009,
149 to 272 million people between ages 15 and 64 used illicit substances
1
at least once.
2
Of those who use psychoactive substances, a signicant number will develop substance
use problems or SUDs. The UNODC survey notes that between 15 and 39 million people
between ages 15 and 64 used illicit substances at a level dened as problem use.
2
The
wide range is due to difculties collecting complete and accurate data internationally.
SUDs contribute signicantly to global illness, disability, and death. Injection drug use (IDU)
is a signicant means of transmission for serious communicable diseases such as hepatitis
and HIV/AIDS. The World Health Organization (WHO) notes that 136 countries report IDU,
3

and UNODC estimates that 11 to 21 million people injected drugs in 2009.
2
Overall, roughly
10 percent of all new HIV infections worldwide are the result of IDU, and in some regions
IDU is now the main route of HIV transmission.
The numbers are signicant. However, the Executive Director of UNODC, Yuri Fedotov,
notes that there continues to be an enormous unmet need for drug use prevention,
treatment, care and support, particularly in developing countries.
4
The training series
Curriculum 2: Treatment for Substance Use DisordersThe Continuum of Care is part
of a training series developed through funding from the U.S. Department of State to The
Colombo Plan for the Asian Centre for Certication and Education of Addiction Professionals
(ACCE). Information about ACCE can be found at http://www.colombo-plan.org/acce.php.
The overall goal of the training series is to reduce the signicant health, social, and
economic problems associated with SUDs by building international treatment capacity
through training, professionalizing, and expanding the global treatment workforce.
The training prepares counselors for professional certication at the entry level by
providing the latest information about SUDs and their treatment and facilitating hands-on
activities to develop skills and condence in a relatively new treatment workforce.
The curricula also provide an updated review for those who are beginning to supervise
workers who are new to the eld.
1
Illicit substances include opioids, cannabis, cocaine, amphetamine-type stimulants, and other substances (e.g.,
hallucinogens, ecstasy).
2
UNODC. (2011). World drug report 2011. New York: United Nations.
3
WHO. (2010). Management of substance abuse. Geneva: Author. Retrieved October 22, 2010, from
http://www.who.int/substance_abuse/facts/en/index.html
4
UNODC. (2011). World drug report 2011 (p. 9). New York: United Nations.
2
The training series comprises nine separate curricula:
Curriculum 1: Physiology and Pharmacology for Addiction Professionals (this curriculum,
3 days)
Curriculum 2: Treatment for Substance Use DisordersThe Continuum of Care for
Addiction Professionals (5 days)
Curriculum 3: Common Co-Occurring Mental and Medical DisordersAn Overview for
Curriculum 4: Basic Counseling Skills for Addiction Professionals (5 days)
Curriculum 5: Assessment and Intake, Treatment Planning, and Documentation for
Curriculum 6: Case Management for Addiction Professionals (2 days)
Curriculum 7: Crisis Intervention for Addiction Professionals (2 days)
Curriculum 8: Ethics for Addiction Professionals (5 days)
Curriculum 9: Working With Families in Substance Use Disorder Treatment (3 days)
Each curriculum is self-contained; however, participants generally should complete each
curriculum in order. The rst three curricula provide an overall context of SUDs and their
treatment and serve as a foundation for the skills-based and foundational curricula that
follow (Curricula 4 through 9).
Goals and Objectives for Curriculum 2
Training goals
To provide participants with an understanding of recovery and recovery
management;
To provide participants with a comprehensive overview of the nature of change; and
To provide participants with an understanding of the process and elements of
treatment for SUDs.
Learning objectives
Participants who complete Curriculum 2 will be able to:
Dene and describe recovery;
Dene and describe elements of recovery management;
3
Name the six stages of change and describe at least one characteristic of clients in
each stage;
Name at least eight of the U.S. National Institute on Drug Abuse principles of
treatment;
Name at least ve factors that can affect a persons success in treatment;
Dene and provide examples of recovery capital;
Describe the components of treatment;
Dene and provide examples of the continuum of care; and
Briey describe ve evidence-based treatment interventions.
The Trainer
Trainer qualications
This curriculum can be implemented by people with little previous training experience.
However, trainers should have had this or similar training and be familiar with the
subject matter. Trainers for this course should have the following knowledge and skills:
A working knowledge of the curriculum content;
Experience working with the client treatment populations;
Experience using the techniques taught in the course;
Ability to facilitate participant learning, including use of diverse exercises, case
studies, and group exercises that address multiple learning styles;
Understanding of and sensitivity to cultural issues specic to both the participants
and the client treatment populations; and
Ability to work with participants in a positive, empathetic manner.
Two trainers, or co-trainers, are essential for multiday courses. In addition, a support person
to help with logistics is ideal, particularly with training groups of more than 20 participants.
Trainer demeanor
Just like real estate, trainers need curb appeal. If outward appearance is neat and
attractive, people will want to know more about the trainer and what he or she has to offer.
The trainer has only one opportunity to make a good rst impression. In the rst minute
of meeting someone new, people make multiple assumptions about the new person,
including the new persons levels of expertise, success, education, and knowledge. Most
4
people start making these assumptions before a single word is uttered. They process
visual information and quickly form opinions. Attire, grooming, posture, and facial
expressions affect these opinions. The following guidelines may be useful:
Clothing says a lot about a person. Dressing one level above that of the training
participants shows respect for them. On the one hand, dressing too casually or
sloppily signals that the trainer does not take the relationship seriously. On the other
hand, dressing too formally places distance between the trainer and the participants.
Flashy is distracting at best. Flashy or large earrings, necklaces, and watches focus
participants attention on the objects, not on the content of the training.
Careful personal grooming (brushed teeth, combed hair, a fresh shave or trimmed
beard, clean ngernails) says that the trainer cares about what others think of him or her.
Perfumes and colognes can be distracting and should be avoided. Many people
have allergies or simply dislike certain scents. Ensure that fragrances do not force
participants out of the training room!
Neither the trainer nor the participants should chew gum during the training sessions.
Additional suggestions regarding overall presentation are in Appendix B.
The Trainer Manual
This Trainer Manual has ve parts:
Part ITrainer Orientation (this section);
Part IIMaster Agenda;
Part IIIEvaluation Forms;
Part IVTraining Modules; and
Part VAppendices.
Part IIMaster Agenda is included for planning. This training is designed to be
delivered over 5 consecutive days, as reected in the Master Agenda. However, the
modular structure allows for exibility. If necessary, the training could be offered over
several weeks (with some modications), although all six modules should be delivered in
the order in which they are presented in the manual.
The times indicated for module activities are guidelines. Actual times will depend on
each training groups size and participation level. Based on participants learning needs,
more or less time can be allotted by the trainer than is indicated on a particular topic. The
Master Agenda also assumes that the training day begins at 0900 hours and ends before
1800 hours. The trainer should prepare a daily schedule for participants, using actual start
and end times.
5
Part IIIEvaluation Forms include: a Daily Evaluation form for participants to complete
at the end of each day of training and an Overall Training Evaluation form to be used
at the end of the training. The Daily Evaluation helps the trainer identify whether
adjustments need to be made during the training. The Overall Training Evaluation
provides an overall look at participants experiences. Participants need to know that
completing the forms is important and that their feedback will improve training content
and delivery over time.
Part IVTraining Modules provides instructions for presenting the eight modules in
Curriculum 1. Each module in the manual includes:
A Preparation Checklist;
A timeline;
An overview of goals and objectives;
Presentation and exercise instructions;
Exercise materials;
Copies of Resource Pages from the Participant Manual; and
Copies of the PowerPoint slides.
Trainer presentations are written as a script, and script text is italicized (e.g., Say: Please
turn to Module 2 in your manuals.). Trainers should feel free to use their own words and
add examples. Adding real-life examples enriches the training experience but needs to
be balanced with time considerations.
Teaching instructions throughout the modules offer specic guidance, alternative
approaches, or special considerations.
Teaching Instructions: Look like this.
6
Icon Indicates
30 minutes
The approximate time for the section.
The trainer introduces a journal or other writing exercise.
The trainer refers to the Participant Manual.
The trainer uses newsprint.
The trainer introduces a small-group exercise.
The trainer introduces a partner exercise.
Say:

or
Ask:
The trainer begins or continues a presentation or asks a question
of the group.
The curriculum incorporates icons that offer the trainer visual cues:
Part VAppendices includes:
Appendix AEnergizers (a list of activities to invigorate the group);
Appendix BLearner-Centered Trainer Skills: A Brief Overview;
Appendix CDealing With Difcult Participants During Training;
Appendix DGlossary;
Appendix EResources; and
Appendix FSpecial Acknowledgments.
Appendix EResources is particularly important. This appendix provides resources for
background reading on major curriculum topics to help trainers become as familiar as
possible with the curriculum topics.
7
The Participant Manual
Trainers must tell participants to bring their manuals with them each day. The Participant
Manual contains a participant orientation, glossary, and resources and includes, for each
module:
Training goals and learning objectives;
A timeline;
PowerPoint (PPT) slides with space for notes;
Resource Pages containing additional information or exercise instructions and
materials; and
A module summary for future reference.
The trainer also provides each participant with a notebook. It can be a spiral-bound
notebook, a lined notepad, or simply pieces of paper stapled together. Participants use
the notebook as a journal, for specic writing exercises, and to note:
Shared resources they would like to review at a later date;
Topics they would like to read more about;
A principle they would like to think more about;
A technique they would like to try;
Ways to use their new skills and knowledge in their practice; and
Possible barriers to using new techniques.
The CD-ROM
The CD-ROM contains PowerPoint (PPT) presentations for Modules 17; Module 8 does
not use PPT slides. The concert review presentation consists of selected PPT slides that
are to be viewed with accompanying music provided by the trainers. The presentation
should be set to advance slides automatically at 6-second intervals, allowing
participants to review material in a relaxed atmosphere that aids retention.
TAP 21
Developed by the U.S. Department of Health and Human Services Substance Abuse
and Mental Health Services Administration, Technical Assistance Publication (TAP) 21:
Addiction Counseling CompetenciesThe Knowledge, Skills, and Attitudes of
Professional Practice provides a common foundation on which to base training and
8
certication of addiction professionals. The publication addresses these questions:
What professional standards should guide counselors working with people with SUDs?
What is an appropriate scope of practice for those in the eld of SUD counseling?
Which competencies are associated with positive treatment outcomes?
What knowledge, skills, and attitudes should all SUD treatment professionals have in
common?
TAP 21 can serve as a useful reference for training participants, especially as they prepare
for their certication examination. The Trainer Manual provides suggestions for relevant
participant reading assignments from the TAP. However, trainers should emphasize that
it takes time and experience to develop counseling competence. TAP 21 represents an
ideal set of goals, not a starting point. It can be downloaded from http://store.samhsa.gov/
.product/SMA08-4171. Hard copies can be ordered from the same site.
The Learning Approach
The adult learner
Although some didactic presentation by the trainer is necessary, the training series relies
heavily on collaborative exercises and other learner-directed activities. Adults have a
great deal to offer the learning process, having already accumulated knowledge through
their education, work, and other experiences. The curriculum provides opportunities for
the trainer to encourage participants to share their relevant experience and knowledge
with others and to connect them with the curriculum content. This process also
facilitates increased partnerships and collaborations when participants return to their
home communities.
The training series follows the premise that training of adult learners should be based
on the following principles:
Focus on real-world problems;
Emphasize how the information can be applied;
Relate the information to learners goals;
Relate the materials to learners experiences;
Allow debate of and challenge to ideas;
Listen to and respect the opinions of learners;
Encourage learners to be resources for the trainer and for one another; and
Treat learners with RESPECT.
9
The approach
The learning approach for the training series includes:
Trainer-led presentations and discussions;
Frequent use of creative learner-directed activities, such as small-group and partner-
to-partner interactions;
Small-group exercises and presentations;
Reective writing exercises;
Skills role-plays;
Periodic reviews to enhance retention; and
Learning assessment exercises.
Role-plays and other exercises are important parts of the training approach (particularly
in Curricula 4 through 9). The trainer can help participants feel safe during and learn
from these experiences by:
Ensuring that participants understand what they are to do or observe;
Afrming role-players willingness to participate;
Offering assistance as needed; and
Using nonjudgmental language and tone during debriengs (e.g., What was it like
for you being the client? What was the hardest part for you as the worker?).
It can also be helpful to have participants stand up and literally shake off the roles they
were playing before continuing the training.
Preparation
Major training preparation tasks include:
Logistical planning, including scheduling, selecting the site, and obtaining or
arranging for equipment and supplies at the site;
Selecting and preparing participants; and
Becoming thoroughly familiar with the curriculum.
Scheduling and site selection are connected. If a hotel site is used, planning needs to
begin several months ahead of time.
10
The training space
An attractive, well-organized training space can enhance a participants learning
experience. The room must be large enough to accommodate all participants and small
groups. Seating small groups at round tables is ideal because it saves signicant time
moving into and out of small groups for the many exercises. The trainer must be able to
rearrange the room and seating for particular presentations and exercises. Additional
small tables around the edges of the room can hold supplies, learning materials, and
trainer materials.
The ideal space is not always possible, however. If the space is not large enough to
accommodate tables, the small groups can always push back chairs and work on the
oor if participants are comfortable doing so. Using more than one room at a site can
help with space for small-group activities. However, no more than two rooms should
be used because it is helpful to have a trainer present in each room to continuously
monitor the group process. The training space must provide privacy for role-plays and
other activities.
The trainer can create colorful posters or mobiles to add life to the training room.
Posters can present key concepts, such as the stages of change. Playing music softly
as participants enter the training room (and, when appropriate, during some activities)
creates an inviting atmosphere and relaxes participants. Providing tea, coffee, water,
and snacks for refreshment breaks encourages participants to mingle and talk with one
another during these times. Participants will need information on where to get lunch, if
it is not provided.
Equipment and supplies
The PPT presentations require a laptop computer, LCD projector, and screen. A remote
control for the projector allows the trainer to move freely around the room. If a remote
is not available, then the co-trainer who is not currently presenting or a training assistant
can advance slides.
If a PPT projector is not available (or breaks down during the training!), the training
can continue without it. The Participant Manual has copies of all slides, and the
Trainer Manual has all the information to explain each slide.
At least one whiteboard (with markers), several pads or rolls of newsprint, tape, and
colored paper and markers for creative group presentations are essential to the
training. The Preparation Checklist in each module indicates the specic supplies
needed for the module.
11
Master Supply List for All Modules
Newsprint (A LOT! approximately four pads/rolls per curriculum)
One Participant Manual for each participant
One copy of TAP 21 for each participant
One copy of the overall training schedule and Master Agenda for each participant
One notebook for each participant
Small index cards (approximately four per participant)
Colored paper (approximately 50 sheets of each of 8 to 10 colors)
Colored markers:
Washable, unscented, and in multiple colors (one set per table for participant
use)
Multiple black and blue markers for presentation use (black and blue are most
visible on newsprint; light colors can be used for highlighting)
Scissors (one or two pairs per table)
Tape (one or two rolls of masking tape for hanging newsprint; one roll of
cellophane tape per table for exercises)
One or two soft balls or other squishy toys
Funny hats or other unusual items to use during exercises
Poster board (optional for exercises; newsprint can be substituted)
Timer or watch with a second hand
Beans, marbles, small candies, or other small objects to use as counters during
exercises
Some activities in Appendix AEnergizers use items not listed here.
Selecting and preparing participants
Ideally, the training group should be large enough to be divided into at least four small
groups of at least three participants each, but the training materials can be adjusted for
smaller training groups. The training group should not be larger than 20 participants
and should comprise the same members throughout the six training modules.
A training group that includes a mix of participants with various degrees of experience
often facilitates peer-to-peer teaching and learning. The trainer can prepare participants
12
for learning and increase their positive expectations before the training begins by sending
participants a pretraining package that contains items such as:
A friendly, enthusiastic welcome letter;
The training Master Agenda;
Training goals and learning objectives;
A short list of provocative questions that will stimulate interest in the material (e.g., Is
addiction really a disease?);
A quiz that participants can either send back or bring with them to the rst session;
and
A list of positive (anonymous) comments about the training from past participants.
The trainer also could ask participants to bring a picture or object that makes them feel
relaxed and that can be used to decorate the training space. An energizer on the rst day
could involve discussing participants pictures or objects with the group and placing them
in the room. This activity indicates that the trainer cares about participants comfort and
that the training may be different from what participants are accustomed to.
When possible, a personal call from a trainer can engage participants and give the
trainer useful information about them and their level of interest and motivation.
Becoming familiar with the curriculum
Trainers should read the curriculum, study it, and make sure they understand the training
goals and learning objectives of each module and are fully prepared to facilitate the
exercises. The better a trainer knows the material, the more he or she can focus on the
participants. Solid preparation helps a trainer relax and be more engaging. Co-trainers
should strategize their roles and responsibilities ahead of time. The content and timeline
box in each module has a column labeled Person Responsible. This page should be
photocopied so that trainers can use it for multiple training groups. Co-trainers can
specify in this space the training sections for which each will take primary responsibility.
Depending on the match of presentation styles and personalities, some trainers choose to
deliver entire modules before switching roles; others prefer to switch roles more frequently.
Other decisions to make include:
When each co-trainer will capture comments from participants on newsprint or act as
timekeeper;
What the expectations are for individual and small-group process observation; and
Whether content contributions are accepted or expected or both from the
nonpresenting co-trainer.
13
Customizing the curriculum
The trainer should be prepared to share his or her examples. Whenever possible, the
trainer should describe experiences with particular techniques used with clients. The trainer
should discuss any adaptations that were necessary for applying techniques to members of
particular ethnic, cultural, or gender groups. The trainer should also ask participants to share
experiences from their work to ensure that the training addresses specic concerns.
The trainer also must have a good understanding of the needs of the training group and
be prepared to adapt the training accordingly. For example, the trainer may need to:
Simplify the language (particularly clinical terms and jargon) to make concepts easier
to understand;
Allow more time for participants to understand concepts that may be foreign to their
cultural worldview;
Adapt writing exercises for participants with low levels of literacy; and
Be creative (e.g., use metaphor or traditional storytelling to make a point).
Important!
Although the curriculum can and should be adapted to suit participants needs and
trainers personalities and training styles, trainers must maintain the integrity of the
content. For example:
The logistics of an exercise may be changed, but the learning objectives should
remain the same and be met.
Group discussion is a valuable part of learner-directed training, but trainers need
to manage the time well and not let undirected discussion replace information
dissemination or practice exercises.
Trainers should not assume that participants already know certain information;
sections should not be skipped. This training is for new counselors; participants
need all the information in the curriculum.
Training timelines allow for interactivity and creativity. However, trainers must
remember that adding extra exercises and allowing extended discussion will
increase the time needed to complete the module. Ceremonial welcome
Time is allotted in Module 1 for a ceremonial welcome. The trainer may want to invite
a representative from the organization sponsoring the training and/or a guest speaker
(e.g., community leader, local thought leader in the eld of SUD treatment, local
treatment program director) to welcome participants to the training. Such a welcome
can impress on participants the importance of the training.
14
Getting Started: Preparation Checklists
1 to 2 months before the rst session
Review the curriculum carefully.
Review Appendix EResources for background reading.
Determine who will attend the training.
Develop a pretraining package for trainees.
Develop an overall schedule for the training, including dates and times for each
module.
Arrange for the training space and audiovisual equipment.
Obtain all necessary training materials.
Invite guest speakers.
Make arrangements for refreshments, including lunches if they are provided.
Prepare a list of local resources for additional training and support for participants.
The list could include:
o Other training programs that are or will be available;
o Names of local individuals or programs that may be helpful; and
o The trainers email address or telephone number and an invitation for
participants to contact the trainer with questions or issues (if appropriate).
1 to 2 weeks before the rst session
Conrm participants registration.
Conrm guest speakers.
Select background music.
Secure enough copies of the Participant Manual.
Download enough copies of TAP 21.
Check space and equipment arrangements.
Load the PPT presentations onto the laptop computer.
Review the entire training manual.
Prepare and make a copy of daily schedules for each participant.
Select energizer activities to use and obtain required supplies. Trainers can select
energizers from Appendix A, use their own activities, and/or have participants
design and facilitate their own exercise.
15
1 to 2 days before the rst session
Finalize room and equipment arrangements.
Verify onsite lunch arrangements if necessary.
Set up the room.
Prepare name badges, if necessary.
Make copies of the rst days Daily Evaluation form.
Gather all supplies, including the Participant Manual, notebooks, and copies of
TAP 21, daily schedules, and evaluation forms.
Review Before every session (below).
Before every session
Review this checklist before presenting each module.
The training space
Arrange chairs for each session in a comfortable way, keeping in mind that space is
needed for both small- and large-group exercises.
Prepare posters illustrating key concepts and terms, and post them around the
training room.
Save and post key newsprint pages and posters generated during the training to
use for review.
Create a relaxed atmosphere by playing background music as participants gather.
Equipment and materials
CD player for instrumental background music.
Computer, LCD projector, and screen.
Newsprint pads, easel, and crayons or markers.
Evaluation forms.
Pins, tacks, or tape to post newsprint on walls.
All other materials needed for the session.
A timer (optional).
General preparation
Review the Preparation Checklists and the modules.
Assemble and test necessary equipment, materials, and supplies.
Prepare to have fun!
16
After each session
Review completed Daily Evaluation forms for suggestions for the next days
delivery.
Secure creative and/or key newsprint resources (e.g., denitions, creative artwork,
energizer information) developed by participants for use as a nal review and in
future trainings.
Add into the curriculum content information contributed by participants and/or
the co-trainers.
Module 1Training Introduction
Time of
Day
Time of
Session
Content
09000920 20 minutes Ceremonial welcome
09200930 10 minutes Trainer welcome, housekeeping, and ground rules
09301030 60 minutes Partner exercise: Introductions
10301045 15 minutes Presentation: Training materials
10451100 15 minutes Break
11001115 15 minutes Presentation: Why this training?
11151130 15 minutes Large-group exercise: Training expectations
11301200 30 minutes Small-group exercise: What is recovery?
DAY 1 Date:_______________________________
MASTER AGENDA
Module 2Recovery and Recovery Management
Time of
Day
Time of
Session
Content
12001205 5 minutes Introduction to Module 2
12051225 20 minutes Presentation: A consensus denition of recovery
12251300 35 minutes Small-group exercise: Guiding principles of recovery
13001400 60 minutes Lunch
14001500 60 minutes
Small-group exercise: Guiding principles of recovery
(continued)
15001520 20 minutes Presentation: Introduction to recovery management
Module 3Factors Affecting Treatment Outcomes
Time of
Day
Time of
Session
Content
15451615 30 minutes
Small-group exercise: Identifying factors that may affect
treatment outcomes
16151630 15 minutes Presentation: Recovery Capital
16301645 15 minutes Day 1 review and introduction to case study exercise
16451700 15 minutes Wrap-up and Day 1 evaluation
End of Day 1
DAY 2 Date:_______________________________
MASTER AGENDA
Module 4Introduction to Motivation and Stages of Change
Time of
Day
Time of
Session
Content
10501120 15 minutes Exercise: Personal change
11251155 30 minutes Interactive presentation: The nature of motivation
11551205 10 minutes Presentation: Introduction to the stages of change model
12051300 55 minutes
Small-group presentations: Characteristics of clients in
each stage of change
Module 5Components of Treatment: Continuum of Care
Time of
Day
Time of
Session
Content
14051515 70 minutes Exercise: Ways of Looking at Treatment
15301630 60 minutes Small-group exercise: Principles of Effective Treatment
16301700 30 minutes Learning Assessment
17001710 10 minutes Day 2 wrap-up and evaluation
Module 3Factors Affecting Treatment Outcomes (continued)
Time of
Day
Time of
Session
Content
90009010 5 minutes Day 2 welcome
90101030 80 minutes Small-group Exercise: Case Study
DAY 3 Date:_______________________________
MASTER AGENDA
Module 6Components of Treatmen: The Continuum of Care
Time of
Day
Time of
Session
Content
09000920 20 minutes Welcome, review of day 2, and introduction to Module 6
09201020 60 minutes Presentation: Pretreatment components
10201100 40 minutes Small-group exercise: Pretreatment components
11151140 25 minutes Presentation: Case management
11401210 30 minutes Small-group exercise: Case management components
12101220 10 minutes Presentation: Primary treatment, Part 1Group counseling
12201320 60 minutes Small-group presentations: Types of groups
14201430 10 minutes
Presentation: Primary treatment, Part 2Individual
counseling
14301515 45 minutes Presentation: Primary treatment, Part 3Other components
15301610 40 minutes Small-group exercise: Primary treatment
16101625 15 minutes Presentation: Continuing care
16251640 15 minutes Day 3 Wrap-up and evaluation
End of day 3
Module 7Evidence-Based Practices for Treatment Intervention
Time of
Day
Time of
Session
Content
11351200 25 minutes
Presentation: Ways of looking at evidence-based
practices
12001230 30 minutes Presentation: Cognitive-behavioral therapy
12301245 15 minutes
Small-group exercise: Cognitive-behavioral therapy
Part 1, preparation
13451355 10 minutes
Part 1, preparation (continued)
13551415 20 minutes
Part 2, presentation
14151445 30 minutes Presentation: Motivational approaches
14451505 20 minutes
Small-group exercise: Motivational approaches
Part 1, preparation
15201540 20 minutes
15401605 25 minutes Presentation: Family-based approaches
16051615 10 minutes Exercise: Journal writing
16151625 10 minutes Day 4 wrap-up and evaluation
End of Day 4
DAY 4 Date:_______________________________
MASTER AGENDA
Module 6Components of Treatment: The Continuum of Care (continued)
Time of
Day
Time of
Session
Content
09001000 60 minutes Small-group exercise: Continuing care
10001130 90 minutes Small-group exercise: Case study
Module 8Integrating Learning Into Practice
Time of
Day
Time of
Session
Content
14401450 10 minutes Module 8 and review exercise introduction
14501525 45 minutes
Small-group exercise: Developing a practice integration
plan
15401555 15 minutes
Partner exercise: Developing a practice integration plan:
Sharing and feedback
15551615 20 minutes Learning assessment competition
16151630 15 minutes Overall training evaluations
1630 30+ minutes Program completion ceremony and socializing
DAY 5 Date:_______________________________
MASTER AGENDA
Module 7Evidence-Based Practices for Treatment Intervention
Time of
Day
Time of
Session
Content
09000910 10 minutes Day 5 review and welcome
09100955 45 minutes Small-group exercise: Family-based approaches
09551015 20 minutes Presentation: Therapeutic community
10151100 45 minutes Small-group exercise: Therapeutic community
11151135 20 minutes Presentation: Contingency management
11351155 45 minutes Small-group exercise: Contingency management
11551210 15 minutes Presentation: Pharmacotherapy for opiod dependence
12101255 45 minutes
Small-group exercise: Pharmacotherapy for opiod
dependence
13551425 30 minutes Small-group discussion: Evidence-based practices
14251440 15 minutes Large-group discussion: Evidence-based practices
DAILY EVALUATION
Date: ________________ Trainer 1: ____________________
Trainer 2: ____________________
To be completed at the end of each day by training participants.
Please indicate your agreement with these statements
about todays training session.
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1. The training was well organized. 5 4 3 2 1
2. The trainers were knowledgeable about the subject. 5 4 3 2 1
3. The trainers were well prepared for the course. 5 4 3 2 1
4. The trainers were open to participant comments and
questions.
5 4 3 2 1
5. The training topic(s) were relevant to my work. 5 4 3 2 1
6. I expect to use the information gained from this training. 5 4 3 2 1
7. I would recommend this training to a colleague. 5 4 3 2 1
Please complete the following statements:
One thing I learned today that I plan to use in my work is...
What I liked best about todays training was...
I wish there had been more information about...
Todays training could have been better if...
Other comments
Treatment for Substance Use DisordersThe Continuum
of Care for Addiction Professionals
Please indicate your agreement with these statements about
the training OVERALL.
Training Methodology
1. The training objectives were clearly stated. 5 4 3 2 1
2. Objectives of the training were achieved. 5 4 3 2 1
3. Material was clearly presented. 5 4 3 2 1
4. The training activities/exercises allowed the practice of
important concepts.
5 4 3 2 1
5. The training provided balance among presentations,
activities, participant questions, and discussions.
5 4 3 2 1
6. The training topic(s) were relevant to my work. 4 4 3 2 1
7. I expect to use the information gained from this training. 5 4 3 2 1
8. I would recommend this training to a colleague. 5 4 3 2 1
9. The training modules were presented in a logical order. 5 4 3 2 1
Training Materials
1. Visual aids were adequate and facilitated the learning process. 5 4 3 2 1
2. Manuals were helpful and facilitated understanding of the
topics.
5 4 3 2 1
3. Translation services (if applicable) were adequate and facilitated
the learning process.
5 4 3 2 1
Trainers (for each trainer)
1. a.Trainer 1 was well prepared. 5 4 3 2 1
b.Trainer 2 was well prepared. 5 4 3 2 1
2. a.Trainer 1 was knowledgeable about the subject matter. 5 4 3 2 1
b.Trainer 2 was knowledgeable about the subject matter. 5 4 3 2 1
3. a.Trainer 1 communicated the material in a meaningful way. 5 4 3 2 1
b.Trainer 2 communicated the material in a meaningful way. 5 4 3 2 1
4. a.Trainer 1 provided clear answers to participant questions. 5 4 3 2 1
b.Trainer 2 provided clear answers to participant questions. 5 4 3 2 1
5. a.Trainer 1 promoted engagement and participation. 5 4 3 2 1
b.Trainer 2 promoted engagement and participation. 5 4 3 2 1
OVERALL TRAINING EVALUATION
Date: ________________ Trainer 1: ___________________________
Trainer 2: ___________________________
Treatment for Substance Use DisordersThe Continuum
of Care for Addiction Professionals
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(continued on back)
Please complete the following statements:
The most useful module was
The least useful module was
Before this training is presented again, I suggest the following changes:
I would be interested in having further training on these topics:
Other comments
27
MODULE 1
TRAINING INTRODUCTION
Ceremonial welcome ................................................................................. 31
Trainer welcome, housekeeping, and ground rules .................................. 32
Partner exercise: Introductions .................................................................. 35
Presentation: Training materials ................................................................ 37
Presentation: Why this training? ................................................................ 40
Large-group exercise: Training expectations............................................. 59
Small-group exercise: What is recovery? ................................................... 60
29
Trainer Manual: Module 1Training Introduction
Module 1 Preparation Checklist
Review Getting Started for general preparation information.
Preview Module 1.
Prepare for the ceremonial welcome.
If you are not providing lunch, prepare a list of possible options for participants.
Write on newsprint the following ground rules, leaving room for more items:
o Ask questions;
o Make mistakes;
o Collaborate; and
o Have fun!
Tape two sheets of newsprint together, label them Training Expectations, and
post the sheets in a spot where they can stay until the training ends.
In addition to the materials listed in Getting Started, assemble the following:
o A Participant Manual for each participant;
o A copy of the overall training schedule and Master Agenda for each
participant;
o A notebook for each participant;
o A copy of Technical Assistance Publication (TAP) 21: Addiction Counseling
CompetenciesThe Knowledge, Skills, and Attitudes of Professional Practice
for each participant;
o Index cards; and
o One glue stick or roll of tape for each table.
Place one index card on each chair.
Prepare an afternoon energizer.
30
Module 1 Goals and Objectives
Training goals
To create a positive learning community and environment;
To give participants background information about why the training is being done;
To give participants a summary of the overall training goals, objectives, and learning
approach of the curriculum; and
To provide participants with a brief introduction to the concept of treatment for
substance use disorders (SUDs).
Learning objectives
Participants who complete Module 1 will be able to:
Explain the overall training goals and at least four objectives of the 5-day training;
State at least one personal learning goal; and
Briey describe the broad goal of treatment for SUDs.
Content and Timeline
Activity Time
Person
Responsible
Ceremonial welcome 20 minutes
Trainer welcome, housekeeping, and ground rules 10 minutes
Partner exercise: Introductions 60 minutes
Presentation: Training materials 15 minutes
Break 15 minutes
Presentation: Why this training? 15 minutes
Large-group exercise: Training expectations 15 minutes
Small-group exercise: What is recovery? 30 minutes
31
Teaching Instructions: The ceremonial welcome will vary depending on the sponsor
and/or invited speakers. If possible, coach the rst speaker to tell participants they
made an important decision by coming to the training.
Slide 1.1
Teaching Instructions: Give each participant a copy of the Master Agenda, a
Participant Manual, a copy of TAP 21, and a notebook as he or she enters and signs in.
Ceremonial welcome
20 minutes
32
Welcome! We want to thank you for taking the time to attend this training. Your
presence here shows that you care about the people you work with and are interested in
improving the health of the citizens of your communities.
My name is ________________________, and my co-trainer is ________________________.
Well be working together to facilitate this training.
However, we want this training to be a collaborative process among all of us. Each of
you brings experience, knowledge, and skills to share with others. The training will also
be experiential; you will be actively involved in creating a learning community.
Say:
Trainer welcome, housekeeping, and ground rules
10 minutes
Lets take a few minutes to look at some ground rules for our time together.
Ground rules help ensure a positive learning environment. Ive written some very basic
rules on this newsprint:
Ask questions;
Make mistakes;
Collaborate; and
Have fun!
All of these contribute to learning. Something else we need to add is condentiality.
Say:
Teaching Instructions: Add condentiality to the list of ground rules.
Teaching Instructions: Review any important housekeeping items, such as where
the restrooms are, where smoking is permitted, and where refreshment breaks will
be. Turn to the Ground Rules newsprint page you prepared.
33
The training will include exercises in which you will work together and share your
thoughts. To get the most out of the experience, it is important that you feel safe in this
training group. A commitment to maintaining condentiality will help that happen.
Now, what other ground rules do you think we might need?
Say:
Teaching Instructions: Add items to the list as they are mentioned. You may want to
prompt participants if they do not mention things like being on time, no mobile calls
or texting, and so on.
I think we have some great ground rules that will help us get the most out of our
time together.
Todays sessions, Modules 1 and 2, will give you:
A chance to get to know one another (or to know one another better);
An overview of the curriculum and training materials; and
An introduction to the goals of treatment and the process of change.
Say:
34
Slide 1.2
Lets look at the learning objectives for Module 1. By the time we complete this
module, I hope you will be able to:
Explain the overall training goals and at least four objectives of this 5-day training;
State at least one personal learning goal; and
Briey describe the broad goal of treatment for SUDs.
First, were going to do an exercise that will help us get to know one another.
Say:
35
Now please nd a partnerpreferably someone you dont already know. And
include your trainers!
Teaching Instructions: Allow 2 minutes or until everyone seems to have nished writing.
Say:
Partner exercise: Introductions
Slide 1.3
When you came in today, you found two index cards on your chair. Please take
one of the cards out now. Id like you to take 2 minutes to write your answers to the
questions on the slide.
Say:
60 minutes
36
Once you have your partner, you will have 5 minutes each to introduce yourselves to
one another, using the questions and answers on your card as a guide:
What is your name?
What is your job title? What does your job entail?
Can you tell me a recent amusing experience OR one interesting fact about yourself
(this could be a special skill, interest, hobby)?
Once you know your partner better, you will be introducing him or her to the rest of the
training group.
Now, each of us will introduce our partners to the whole training group, using
what we learned from them. Who would like to go rst?
Teaching Instructions: Including yourself in the partner exercise will help reinforce the
collaborative nature of the training. Sharing something interesting or amusing about
yourself will also help participants know you better and increase their comfort levels.
Even though you are participating, watch the time and provide 5- and 2-minute
warnings.
Say:
Say:
Teaching Instructions: Facilitate the introductions by ensuring that each person
takes only a few minutes.
Thank you all for sharing! ________________ will now collect your cards and put
them on the newsprint labeled Participants so you can review them at any time.
37
Presentation: Training materials, goals, and objectives
10 minutes
Slide 1.4
Now were going to take a look at the materials you received as you came in this
morning.
Say:
Teaching Instructions: Call participants attention to the Master Agenda and briey
review it. Hold up each piece as you explain the training materials.
Please refer to your Participant Manual. This manual plays an important role in the
training process. You should bring it with you each day.
Take a minute to look through the manual. It begins with Part IParticipant Orientation,
page 1; read it as soon as you have a chance. Part II, beginning on page 5, includes, for
each module:
Say:
38
Notes pages with the PPT slides;
Resource Pages; these pages have information youll need for exercises, information
to read later, or exercise instructions; and
A module summary for future reference (for Modules 17).
Finally, the manual includes a glossary on page 563 and a list of resources on page 565.
Next, you have a notebook to use as a journal. Well be giving you specic journal
writing exercises from time to time. You can also use the journal to note:
Shared resources you would like to review at a later date;
Topics you would like to read more about;
An idea you would like to think more about; and
Ways you might be able to add some of the things you are learning to your practice.
The last module of this training will be devoted to sharing and discussing, in both small
groups and the whole training group, ideas that you have about integrating the training
into your practice, so keep track of your ideas as we go along.
Now take a look at the blue book, TAP 21, Addiction Counseling Competencies. TAP 21
was developed in the United States to provide a common foundation to guide training
and certication of addiction professionals.
The publication addresses these questions:
What professional standards should guide counselors working with people with SUDs?
What is an appropriate scope of practice for those in the eld of SUD counseling?
Which competencies are associated with positive treatment outcomes?
What knowledge, skills, and attitudes should all SUD treatment professionals have in
common?
This document can be a useful reference for you, but keep in mind that:
It takes time and experience to develop counseling competence.
The TAP represents an ideal set of goals, not a starting point.
Dont let it overwhelm you!
Teaching Instructions: Teaching Instructions: If you have been unable to order or
download a copy of TAP 21 for each participant, provide them with the website URL
so that they can download or order it for themselves:
http://store.samhsa.gov/product/SMA08-4171
39
Slide 1.5
Break
15 minutes
Lets take a 15-minute break. When we come back, well start getting oriented to
the training content.
Say:
40
Slide 1.6
Presentation: Why this training?
10 minutes
Welcome back! Now, lets look at some of the reasons this training series was
developed.
Psychoactive substance use continues to be a global problem. A survey done by the
United Nations Ofce on Drugs and Crime (UNODC) found that, in 2009, 149272
million people between ages 15 and 64 used illicit substances at least once.
1
Illicit substances in the survey included opioids, cannabis, cocaine, other amphetamine-
type stimulants, hallucinogens, and ecstasy, among others.
Say:
1
Teaching Instructions: The statistics regarding global drug use were current at the
time of printing. You can stay up to date by periodically checking the Web sites of
the World Health Organization and United Nations Ofce on Drugs and Crime:
http://www.who.int/substance_abuse/facts/global_burden/en/index.html
http://www.unodc.org/documents/wdr/
41
1
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision).
Washington, DC: Author.
Slide 1.7
Of people who use psychoactive substances, a signicant number develop
substance use disorders (also known as SUDs). Substance use disorder is a general
term used to describe a range of problems associated with substance use (including
illicit drugs and misuse of prescribed medications), from substance abuse to substance
dependence and addiction.
SUD is also a sub-category of Substance-related Disorders as described in the American
Psychological Associations Diagnostic and Statistical Manual IV, Text Revision (DSM
IV-TR).
1
As you see on the slide, SUDs include both substance abuse and substance
dependence.
The broad category of substance-related disorders also includes the sub-category
substance-induced disorders, which includes:
Substance intoxication;
Substance withdrawal; and
Substance-induced mental disorders.
Say:
42
Slide 1.8
SUDs are labeled Harmful Use and Dependence Syndrome in the World
Health Organizations International Classication of Diseases (ICD)-10.
1
Say:
1
World Health Organization. (2007). International statistical classication of diseases and related health problems,
(10th revision). Geneva: Author.
43
Slide 1.9
The United Nations survey found that between 15 and 39 million people between
ages 15 and 64 could be dened as problem drug users.
The countries included in the survey determined problem drug use based on a
number of factors, including:
1
The number of people reported to be dependent on a substance;
The number who injected substances; and
The number reporting long duration of use of opioids, amphetamines, or cocaine.
Say:
2
UNODC. (2011). World Drug Report 2011. New York: United Nations
44
Slide 1.10
The U.N. survey also found that:
1
Between 11 and 21 million people injected drugs in 2009.
About 18 percent of those who inject drugs are HIV positive.
About half of those who inject drugs are infected with the hepatitis C virus.
Say:
1
45
Slide 1.11
Global consequences of SUDs are far-reaching and include, for example:
Higher rates of hepatitis and tuberculosis;
Lost productivity;
Injuries and death due to automobile and other accidents;
Overdose hospitalizations and deaths;
Suicide; and
Violence.
Say:
46
Slide 1.12
The numbers are signicant. However, the director of UNODC, Yuri Fedotov
notes that There continues to be an enormous unmet need for drug use prevention,
treatment, care and support, particularly in developing countries.
Say:
1
UNODC. (2011). World drug report 2011. New York: United Nations. p.9.
47
Slide 1.13
This curriculum is part of a training series developed through funding from the
U.S. Department of State to The Colombo Plan for the Asian Centre for Certication
and Education of Addiction Professionals.
The overall goal of the training series is to reduce the health, social, and economic
problems associated with SUDs by building international treatment capacity through
training, professionalizing, and expanding the global treatment workforce.
The series prepares counselors for professional certication at the entry level by
providing them with necessary information and with specic skills training. You will nd
a list of the curricula included in the training series on Resource Page 1.1, page 26 in
your manuals.
Say:
48
Slide 1.14
So that youll know more about what to expect during the training, were going to
take a few minutes to look at the entire training series.
Curriculum 1, Physiology and Pharmacology for Addiction Professionals, is a 3-day
course that presents a comprehensive overview of addiction; provides an understanding
of the physiology of addiction as a brain disease; and describes the pharmacology of
psychoactive substances.
Well be outlining Curriculum 2, this curriculum, in a few minutes so well skip it for now.
Say:
Say:
49
Slide 1.15
Curriculum 3: Common Co-Occurring Mental and Medical DisordersAn
Overview for Addiction Professionals is a 2-day course. It is also foundational and
provides an overview of the relationship of co-occurring disorders to one another and
to related treatment issues, as well as outlines brief descriptions of the most commonly
co-occurring mental and medical disorders.
Say:
50
Slide 1.16
Curriculum 4: Basic Counseling Skills for Addiction Professionals is a 5-day skills-
based course. It provides an overview of the helping relationship and intentionality, or
focus, in counseling. It also provides opportunities to learn and practice cross-cutting
counseling skills. By cross-cutting, we mean those skills that are essential at every stage
of treatment and in every type of counseling situation. The curriculum also teaches basic
motivational interviewing skills and provides practice in teaching clients recovery skills,
an important aspect of treatment. Basic group counseling and psychoeducational group
skills also are covered.
Say:
51
Slide 1.17
Curriculum 5: Assessment and Intake, Treatment Planning, and Documentation
for Addiction Professionals is a 4-day skills-based course that teaches integrated
assessment and treatment/service planning. It also addresses documentation as a
treatment tool.
Say:
52
Slide 1.18
Curriculum 6: Case Management for Addiction Professionals is a 2-day
foundational and skills-based course that provides an overview of case management
in SUD treatment and provides skills practice in case management functions such as
planning, linkage, monitoring, advocacy, consultation, and collaboration.
Say:
53
Slide 1.19
Curriculum 7: Crisis Intervention for Addiction Professionals, a 2-day course,
addresses the concept of crisis as a part of life and provides guidelines for and
practice in crisis management, including managing suicide risk. It also addresses ways
counselors can avoid personal crisis situations by providing information and exercises
about counselor self-care.
Say:
54
Slide 1.20
Curriculum 8: Ethics for Addiction Professionals is a 5-day course that addresses
professional conduct and ethical behavior, condentiality, ethical principles and
professional codes of ethics, and ethical decision-making. The curriculum also
addresses the importance of supervision as part of ethical practice.
Say:
55
Slide 1.21
Finally, Curriculum 9: Working With Families in Substance Use Disorder Treatment
is a 3-day course that provides an overview of the impact of SUDs on family systems
and the benets of involving family members in treatment. The curriculum addresses
ways of engaging family members in treatment and provides information and practice in
providing a range of family services, such as psychoeducation, conjoint family sessions,
multi-family group counseling. The course also addresses the differences between
family counseling and family therapy, and how to make appropriate referrals for more
intensive services when necessary.
Say:
56
Slide 1.22
Now lets take a look at the goals and objectives of this 5-day training, Treatment
for Substance Use DisordersThe Continuum of Care for Addiction Professionals. The
overall goals of the training are:
To provide participants with an understanding of recovery and recovery
management;
To provide participants with a comprehensive overview of the nature of change; and
To provide participants with an understanding of the process and elements of
treatment for SUDs.
Say:
57
Slide 1.23
At the end of these 5 days, I hope you will be able to:
Dene and describe recovery;
Dene and describe elements of recovery management;
Name the six stages of change and describe at least one characteristic of clients
in each stage;
Name at least eight of the U.S. National Institute on Drug Abuse principles
of treatment; and
Name at least ve factors that can affect a persons success in treatment.
Say:
58
Slide 1.24
You also should be able to:
Dene and provide examples of recovery capital;
Describe the components of treatment;
Dene and provide examples of the continuum of care; and
Briey describe ve evidence-based treatment interventions.
Say:
59
Teaching Instructions: After 1 minute, ask for volunteers to briey share their training
expectations with the group. As each participant gives his or her expectations,
comment as appropriate. For example:
Yes, we will denitely be able to meet that expectation.
Yes, thats an important part of this training.
Actually, we wont be getting into that much detail in this training; well be
talking more about that in Curriculum X.
That is not really in the scope of this curriculum, but I can help you nd some
resources on the topic.
Take no more than 10 minutes for sharing.
Large-group exercise: Training expectations
Before we move on, Id like to take some time to consider your expectations for this
training, given what you know so far. Please take 2 minutes to think about what you would
like to get from these 5 days, then write those expectations on the second index card.
Say:
15 minutes
Slide 1.25
Thank you all for sharing! ______________________ is going to collect your cards now
and attach them to the Training Expectations newsprint. Well leave that newsprint up until
the end of the training so we can check back from time to time and see how were doing.
Say:
60
Teaching Instructions: As participants are forming groups, give each group two
sheets of newsprint.
Small-group exercise: What is recovery?
The overall goal of treatment for SUDs is recovery. Were going to do an exercise
that will help you assess what you already know about recovery from SUDs and that will
help you begin thinking about what treatment and recovery mean.
Please form groups of four or ve people each, and close your manuals for now!
Say:
30 minutes
Slide 1.26
You will have 15 minutes to prepare a brief presentation dening recovery.
Include real-life examples of people you know who are living in recovery. You may use
the newsprint to list key points, draw pictures or diagrams, or anything else you think
will help your group make its points. Be creative!
Say:
61
Teaching Instructions: Provide 5- and 2-minute warnings.
When 15 minutes have elapsed, ask each group to begin its presentation. When
all groups have presented, summarize the similarities and differences and move to
Module 2.
Resource Page 1.1: The Colombo Plan Asian Centre for
Certication and Education of Addiction Professionals
Training Series
Curriculum 1: Physiology and Pharmacology for
Addiction Professionals
Curriculum 2: Treatment for Substance Use
DisordersThe Continuum of Care for
Addiction Professionals (this curriculum)
Curriculum 3: Mental and Medical Disorders That
Often Co-Occur With Substance Use
Disorders
Curriculum 4: Basic Counseling Skills for Addiction
Professionals
Curriculum 5: Screening, Assessment, and Treatment
Planning for Addiction Professionals
Curriculum 6: Case Management for Addiction
Professionals
Curriculum 7: Crisis Intervention for Addiction
Professionals
Curriculum 8: Ethics for Addiction Professionals
Curriculum 9: Working with Families in Substance Use
Disorder Treatment
63
MODULE 2
RECOVERY AND RECOVERY MANAGEMENT
Introduction to Module 2 ...........................................................................67
Presentation: A consensus denition of recovery .......................................69
Small-group exercise: Guiding principles of recovery ................................80
Presentation: Introduction to recovery management .................................81
65
Trainer Manual: Module 2Recovery and Recovery Management
Preview Module 2.
Write Wellness on a sheet of newsprint.
Activity Time
Person
Responsible
Introduction to Module 2 5 minutes
Presentation: A consensus denition of recovery 20 minutes
Small-group exercise: Guiding principles of recovery 35 minutes
Lunch 60 minutes
(continued)
60 minutes
Presentation: Introduction to recovery management 20 minutes
Break 15 minutes
66
Training goals
To provide an overview of the concept of recovery, the overall goal of treatment for
substance use disorders (SUDs); and
To provide an introduction to recovery management.
Learning objectives
Dene recovery;
Dene abstinence in the context of recovery;
List and briey describe at least six guiding principles of recovery;
Dene recovery management; and
Dene recovery-oriented systems of care.
67
Slide 2.1
Introduction to Module 2
5 minutes
You did a great job dening recovery. In this module, well take a look at one
consensus denition of recovery from SUDs developed by a panel convened by the U.S.
Substance Abuse and Mental Health Services Administrations (SAMHSAs) Center for
Substance Abuse Treatment. We are using this denition for two reasons:
It is one of very few attempts to come to a consensus agreement on what recovery
is; and
It was accompanied by a list of guiding principles of recovery.
These principles provide a more thorough look at the process of recovery and some of
the lessons that have been learned over time.
Say:
68
Slide 2.2
Please turn to the Module 2 training goals and learning objectives, page 33 in
your manuals.
By the time we complete this module, I hope you will be able to:
Dene recovery;
Dene abstinence in the context of recovery;
List and briey describe at least six guiding principles of recovery;
Dene recovery management; and
Dene recovery-oriented systems of care.
Say:
69
Slide 2.3
Presentation: A consensus denition of recovery
20 minutes
One problem in the eld of SUD treatment has been the lack of a consensus
denition of recovery. The U.S. SAMHSAs Center for Substance Abuse Treatment
attempted to rectify this by convening a National Summit on Recovery in September
2005. Summit participants were leaders in the treatment and recovery eld. This group
developed this consensus denition of recovery:
1
Recovery from alcohol and drug problems is a process of change through
which an individual achieves abstinence and improved health, wellness and
quality of life.
The group also developed a list of guiding principles of recovery. Were going to take a
look at these principles, but rst lets consider this denition.
Say:
1
Center for Substance Abuse Treatment. (2007). National Summit on Recovery: Conference report. HHS Publication
No. (SMA) 07-4276. Rockville, MD: Health and Human Services Administration. Retrieved May 9, 2011, from
http://www.pfr.samhsa.gov/docs/Summit_Rpt_1.pdf
70
Slide 2.4
First, recovery is dened as a process of continuous growth and improved
functioning. It is not a goal that one achieves. It is instead a process of recovery
management over a persons lifetime.
Say:
71
Slide 2.5
Next, it is generally agreed that abstinence is necessary (though not sufcient) for
recovery.
Abstinence can be dened as not using alcohol or any non-prescribed psychoactive
drugs and not misusing any prescribed psychoactive drugs.
Say:
72
Slide 2.6
Using the term non-prescribed allows for use of psychoactive medications to treat
substance use disorders, mental disorders, or medical conditions (such as severe pain)
when necessary.
Say:
73
Slide 2.7
But what about nicotine and caffeine, both of which are psychoactive substances?
There is little controversy about caffeine because the potential for social or physical
problems related to caffeine use is very low. Nicotine, however, is another matter. Although
it is legal everywhere, its potential for harm is very high. There is controversy about whether
abstinence from nicotine should be included in the general denition of abstinence.
Say:
What do you think about this?
Teaching Instructions: Facilitate a brief discussion.
You make interesting points. For now, anyway, most people in the eld consider
a person who continues to use nicotine after he or she has stopped using other
substances as still abstinent and in recovery.
Say:
Ask:
74
Lets look at the last part of the denition, improved health, wellness and quality
of life.
Say:
What do you think is meant by wellness?
Teaching Instructions: Note responses on the newsprint labeled Wellness.
Ask:
75
Slide 2.8
Great job! As we just heard, there are many ways of looking at wellness. It is clear
that wellness is a concept with multiple dimensions:
Social;
Occupational;
Spiritual;
Physical;
Intellectual;
Emotional;
Environmental; and
Financial.
Say:
76
Slide 2.9
In 2010, SAMHSA again convened a panel to look at what is meant by recovery.
This panel consisted of experts in the elds of both mental disorders and SUDs. They
developed a unied consensus denition of recovery that covers both mental and
substance use disorders:
1
Recovery is a process of change whereby individuals work to improve
their own health and wellness and to live a meaningful life in a
community of their choice while striving to achieve their full potential.
There is signicant overlap between the two denitions: Both speak of a process
of change and address the concept of wellness. Other aspects of the 2010 unied
denition were addressed in the original guiding principles of recovery we mentioned
earlier. Were going to do an exercise with these principles now. This exercise will give
you an in-depth look at recovery. Understanding as much as possible about the process
of recovery provides an important context for learning about the process of treatment
for SUDs.
Say:
1
SAMHSA Blog. (2011, May 20). Retrieved July 5, 2011, from http://blog.samhsa.gov/category/community-and-
recovery-support/
77
Teaching Instructions: While groups are forming, ask a co-trainer to place three
sheets of newsprint on each table.
Slide 2.10
35 minutes
78
Were going to form four groups by counting off. Please count off by fours,
starting with you, _______________. All ones form a group over here; all twos here;
threes here; and fours here. Please take your Participant Manuals with you.
Please open your manuals to page 49, Resource Page 2.1: Guiding Principles of
Recovery.
Each group will be responsible for 3 of the 12 principles. You will prepare presentations
on each principle. Be as creative as possible. Draw pictures, use stories, and include
real-life examples of people you know who are in recovery.
Your groups assigned principles are listed on the slide.
Well take 30 minutes now to prepare presentations, and then break for lunch. After
lunch, you will have 15 more minutes to prepare if you need it.
Say:
Teaching Instructions: Provide 10-, 5-, and 2-minute warnings.
79
Slide 2.11
Lunch
60 minutes
Were going to break for lunch now. When we return from lunch, you will have 15
more minutes to continue working on your presentations if you need them.
Say:
80
Teaching Instructions: When participants return from lunch, remind them that
they can take another 15 minutes to complete their presentations. Provide 5- and
2-minute warnings if necessary, and then begin the presentations. After each group
presentation, ask the whole training group for comments or questions.
Slide 2.12
60 minutes
Great job! Were going to talk now about a concept called sustained recovery
management.
Say:
81
Slide 2.13
Presentation: Introduction to recovery management
20 minutes
Recovery management is the context in which we will examine the continuum of
care. This model of care shifts the focus away from discrete episodes of treatment, or
acute care, toward a long-term, client-directed view of recovery.
Say:
82
Slide 2.14
William White, a thought leader in the eld of SUD treatment, and his colleagues
identify seven elements of a comprehensive program of recovery management:
1

Client empowerment;
Assessment;
Recovery resource development;
Recovery education and training;
Ongoing monitoring and support;
Recovery advocacy; and
Evidenced-based treatment and support services.
Say:
1
White, W.L., Boyle, M.G., Loveland, D.L., & Corrington, P.W. (2005). What is behavioral health recovery
management? A brief primer. Retrieved June 23, 2011, from http://www.bhrm.org/papers/BHRM%20primer.pdf
83
Slide 2.15
Client empowerment includes ensuring that those in treatment participate fully in
their treatment and recovery planning. In a larger context, it also means that people in
recovery are included in the planning, design, and evaluation of treatment programs.
Say:
84
Slide 2.16
Assessment includes identifying both the problems and the strengths of
individuals and their families. Recovery management is a strengths-based model, so
assessing strengths is a critical (and sometimes neglected) aspect of assessment.
Say:
85
Slide 2.17
Recovery resource development means creating a full continuum of treatment
and recovery support services. This includes linking personal, professional, and
indigenous community resources into recovery management teams. It also means
guiding the individual and his or her family into a relationship with a larger community
of shared experience (a recovery community).
In this context, indigenous community resources could mean support groups, spiritual
or religious resources, tribal or community support resources, and so on.
This linking of resources is known as a recovery-oriented system of care. To clarify what
we mean, a recovery-oriented system of care is not a government or nongovernmental
system. Instead, it refers to the complete network of indigenous and professional
services and relationships that can support the long-term recovery of individuals and
families.
Say:
86
Slide 2.18
Recovery education and training refer to enhancing the recovery-based
knowledge and skills of individuals in recovery, their families, service providers, and the
larger community.
Say:
87
Slide 2.19
Ongoing monitoring and support mean continuity of contact and support
over time, usually over a long period. They can include professional checkups, where
program staff keeps in at least minimal and periodic contact with former clients. It also
can include peer mentoring and recovery coaching. The concept of peer mentoring
and recovery coaching is related to sponsorship in 12-Step programs but is not limited
to that. Well be talking more about peer mentoring and coaching later in the week, in
Module 6.
Ongoing monitoring and support are part of a recovery-oriented system of care.
Say:
88
Slide 2.20
Recovery advocacy means advocating for social and institutional policies that
counter the stigma and discrimination we talked about in Curriculum 1. It also means
advocating for systems that promote long-term recovery.
Say:
89
Slide 2.21
Finally, evidenced-based treatment and support services mean replacing less
effective treatment and recovery support services with approaches that have a sturdier
foundation of scientic support. Well be talking more specically about evidence-
based approaches later in the week.
This aspect also includes developing services that remove barriers to recovery and
enhance individuals recovery capital. Well be talking about recovery capital in a few
minutes, in Module 3.
Although White and his colleagues described the seven elements of recovery
management weve just discussed, a practice document published by the United
Nations Ofce on Drugs and Crime (UNODC) describes an 11-element model.
1
Both
models overlap in signicant ways. The UNODC model description is in Resource Page
2.2, page 51 in your manuals. You can read it on your own.
Say:
1
International Network of Drug Dependence Treatment and Rehabilitation Resource Centres. (2008). Drug
dependence treatment: Sustained recovery management. Vienna: UNODC.
Slide 2.22
Were going to take a 15-minute break. When we come back, well begin talking
about some factors that may affect treatment and recovery outcomes.
Say:
Break
15 minutes
Resource Page 2.1: Guiding Principles of Recovery
1
There are many pathways to recovery. Individuals are unique with specic needs,
strengths, goals, health attitudes, behaviors, and expectations for recovery. Pathways
to recovery are highly personal and generally involve a redenition of identity in the
face of a crisis or a process of progressive change. Furthermore, pathways are often
social, grounded in cultural beliefs or traditions. Pathways to recovery involve informal
community resources, which provide support for abstinence. Pathways may include
one or more episodes of psychosocial and/or pharmacological treatment. For some,
recovery involves neither treatment nor involvement with mutual aid groups. Recovery is
a process of change that permits an individual to make healthy choices and improve the
quality of his or her life.
Recovery is self-directed and empowering. The pathway to recovery may involve
one or more periods when activities are directed or guided to a substantial degree
by others. However, recovery is fundamentally a self-directed process. The person in
recovery is the agent of recovery and has the authority to exercise choices and make
decisions based on his or her recovery goals. The process of recovery leads individuals
toward the highest level of autonomy of which they are capable. Autonomy means
the capacity of an individual to be independent and to make informed, un-coerced
decisions. Through self-empowerment, individuals become optimistic about life goals.
Recovery involves a personal recognition of the need for change and transformation.
Individuals must accept that a problem exists and be willing to take steps to address
it; these steps usually involve seeking help for a substance use disorder. The process of
change can involve physical, emotional, intellectual, and spiritual aspects of the persons
life.
Recovery is holistic. Recovery is a process through which one gradually achieves greater
balance of mind, body, and spirit in relation to other aspects of ones life, including
family, work, and community.
Recovery has cultural dimensions. Each persons recovery process is unique and
impacted by cultural beliefs and traditions. A persons cultural experience often shapes
the recovery path that is right for him or her.
Recovery exists on a continuum of improved health and wellness. Recovery is not
a linear process. It is based on continuous growth and improved functioning. It may
involve relapse and other setbacks, which are a natural part of the continuum but not
inevitable outcomes. Wellness is the result of improved care and balance of mind, body,
and spirit. It is a product of the recovery process.
1
U.S. Center for Substance Abuse Treatment. (2007). National Summit on Recovery: Conference report. HHS
Publication No. (SMA) 07-4276. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved
July 12, 2011, from http://www.pfr.samhsa.gov/docs/Summit_Rpt_1.pdf
Recovery emerges from hope and gratitude. Individuals in or seeking recovery often
gain hope from those who share their search for or experience of recovery. They see
that people can and do overcome the obstacles that confront them, and they cultivate
gratitude for the opportunities that each day of recovery offers.
Recovery involves a process of healing and self-redenition. Recovery is a holistic
healing process in which one develops a positive and meaningful sense of identity.
Holistic means relating to or concerned with the whole rather than with individual parts.
In this context, for example, it would mean healing physically, mentally, and spiritually.
Recovery involves addressing discrimination and transcending shame and stigma.
Recovery is a process by which people confront and strive to overcome stigma.
Recovery is supported by peers and allies. A common denominator in the recovery
process is the presence and involvement of people who contribute hope and support
and suggest strategies and resources for change. Peers, as well as family members
and other allies, form vital support networks for people in recovery. Providing service
to others and experiencing mutual healing help create a community of support among
those in recovery.
Recovery involves (re)joining and (re)building a life in the community. Recovery involves
a process of building what a person never had or rebuilding what a person has lost
because of his or her condition and its consequences. Recovery involves creating a
life within the limitation imposed by that condition. Recovery is building or rebuilding
healthy family, social, and personal relationships. Those in recovery often achieve
improvements in the quality of their lives, such as obtaining education, employment,
and housing. They also increasingly become involved in constructive roles in the
community through helping others, productive acts, and other contributions.
Recovery is a reality. It can, will, and does happen.
Resource Page 2.2: The Eleven Principles of Behavioral
Health Recovery Management
Focus on recovery. The Behavioral Health Recovery Management (BHRM) model
emphasizes recovery processes over disease processes by working toward full and
partial recoveries and by emphasizing client strengths and resiliencies rather than client
decits. Recovery reintroduces the notion that any and all life goals are possible for
people with severe behavioral health disorders.
Application of technology. The rapid advances in technology must be applied to
recovery from serious mental illness and addictions. Technology being used in other
elds may be adopted or adapted to addressing behavioral health issues.
Client empowerment. The client, rather than the professional, is at the center of
the BHRM model. The goal is the assumption of responsibility by each client for the
management of his or her long-term recovery process and the achievement of a self-
determined and self-fullling life.
Service integration. Based on the recognition that severe disorders heighten
vulnerability for other disorders and problems, the BHRM model seeks to coordinate
categorically segregated services into an integrated response focused on the person
rather than on territorial ownership of the persons problems.
Fighting stigma. The BHRM model seeks to normalize or otherwise respect a persons
experiences with behavioral health disorders and, subsequently, provides ongoing
support services. The public begins to endorse positive images of behavioral health that
undermine the prejudice and discrimination that frequently accompany service delivery.
Formation of recovery partnerships. In the BHRM model, the traditional professional
role of expert and treatment provider progressively shifts to a recovery
management partnership with the client. Within this partnership, the professional serves
primarily as a recovery consultant.
Use of evidence-based practices. The BHRM model emphasizes the application of
evidence-based interventions at all stages of the disease stabilization and recovery
process, but the ultimate proof is the t between the intervention and the client at a
particular point in time as judged by the experience and response of the client.
Ecology of recovery in the community. The family (as dened by the client) and
community constitute a reservoir of support for long-term recovery from behavioral
health disorders. The BHRM model seeks to enhance the availability and the support
capacities of family, intimate social networks, and indigenous institutions (e.g., mutual
aid groups, faith-based organizations) to persons recovering from behavioral health
disorders. The BHRM model also extends the locus of service delivery from the
professional environment to the natural environment of the client.
Use of clinical algorithms
1
. As knowledge and application of evidence-based
practices advance, the challenge becomes knowing what treatment approaches
to use with specic individuals as they progress through the stages of change and
treatment. Medication algorithms have been developed that specify preferred rst-
line prescriptions for specic diagnoses, dosing, and timeframes for evaluating the
effects. Similar practice support algorithms are needed for clinicians using psychosocial
treatments.
Provision of monitoring and support. The BHRM model emphasizes the need for
ongoing monitoring, feedback, and encouragement; linkage to indigenous supports;
and, when necessary, reengagement and early reintervention. This model of sustained
monitoring and recovery support services contrasts with models that provide repeated
episodes characterized by assess, admit, treat, and discharge, as is traditional in the
treatment of substance use disorders. It also contrasts with mental health programs that
focus on stabilization and maintenance of symptom suppression rather than on recovery
and personal growth.
Continual evaluation. Service and support interventions must be matched to the
unique and stage-specic needs of each client as he or she evolves through the stages
of recovery. In the BHRM model, both assessment and evaluation become continual
activities rather than activities that mark the beginning and conclusion of a service
episode.
1
The term algorithm is borrowed from mathematics. It basically means a step-by-step procedure for solving a
problem in a nite number of steps.
95
MODULE 3
FACTORS AFFECTING TREATMENT OUTCOMES
Introduction to Module 3 ...........................................................................99
Small-group exercise: Identifying factors that may
affect treatment outcomes ......................................................................103
Presentation: Recovery Capital.................................................................106
Day 1 review and introduction to case study exercise .............................123
Day 2 welcome .........................................................................................126
Small-group exercise: Case Study ...........................................................127
97
Trainer Manual: Module 3Factors Affecting Treatment Outcomes
Preview Module 3.
Copy the Factors Affecting Treatment Outcome: Exercise Phrases pages at the end of
the module, cut out the phrases, and spread them on a table on the side of the room.
Label three sheets of newsprint with the following:
o Individual characteristics;
o Problem severity; and
o Treatment.
Label four newsprint pages with the following:
o Individual factors;
o Program factors;
o Social and familial factors; and
o Womens issues.
Provide a glue stick or tape for each small-group table.
Activity Time
Person
Responsible
Small-group exercise: Identifying factors that may
affect treatment outcomes
30 minutes
Presentation: Recovery Capital 15 minutes
Day 1 review and introduction to case study exercise 15 minutes
Wrap-up and Day 1 evaluation 15 minutes
End of Day 1
Day 2 welcome 5 minutes
Small-group Exercise: Case Study 80 minutes
Break 15 minutes
98
Module 3 Goal and Objectives
Training goal
To discuss the effects that individual, program, and societal factors have on treatment
outcomes.
Learning objectives
List four main categories of factors that can affect treatment;
Provide at least three examples of specic factors for each category;
Dene and provide examples of recovery capital; and
Identify, from a case study, factors that may affect treatment for an individual.
99
Please turn to Module 3, page 57 in your manuals.
On an individual basis, one can never really predict who will do well in treatment and
who wont; too many factors (including timing) can inuence treatment. Understanding
these factors helps counselors plan treatment and case management services.
Say:
Slide 3.1
15 minutes
100
By the time we complete Module 3, I hope you will be able to:
List four main categories of factors that can affect treatment;
Provide at least three examples of specic factors for each category;
Dene and provide examples of recovery capital; and
Identify, from a case study, factors that may affect treatment for an individual.
Say:
Slide 3.2
101
Research has found that the following factors have an effect on treatment
outcomes:
The characteristics of individuals seeking treatment;
The nature and severity of their problems;
The treatment process and the services provided;
Environmental and social conditions (including family), both during and following
treatment; and
The interactions among these factors.
Say:
Slide 3.3
102
Teaching Instructions: For each of the following three questions, note responses
on the three sheets of newsprint you labeled Individual characteristics, Problem
severity, and Treatment.
What individual characteristics do you think might have an effect on treatment
outcomes?
In what ways do you think the nature and severity of problems (substance use and
others) might affect treatment outcomes?
How might the treatment process and the services provided (or not provided) affect
treatment outcomes?
Ask:
103
To take a closer look at these factors, were going to do a group exercise. Please
form four small groups.
Say:
Slide 3.4
Small-group exercise: Identifying factors that may affect
treatment outcomes
30 minutes
Teaching Instructions: As participants form groups, tape up the four newsprint
pages you prepared labeled:
Individual factors;
Program factors;
Social and familial factors; and
Womens issues.
Pull the table with the previously cut-out phrases away from the wall so that people
can walk around it.
104
You will nd strips of paper on the table; each strip has a phrase indicating or
illustrating an individual, program, or social factor that can affect treatment outcome.
The category labeled Womens issues overlaps with other categories but is important
enough to consider separately.
Say:
Teaching Instructions: Assign each group one of the four categories listed on the
newsprint pages. Give each group a glue stick or roll of tape.
As a group, you will have 10 minutes to:
Look through the papers and select the phrases that t in your groups assigned
category;
Glue or tape each phrase to the appropriate newsprint page; and
Consider additional examples that are relevant to your communities and work
environments, create additional strips, and add them to the newsprint.
One, two, threebegin!
Say:
Teaching Instructions: Provide a 2-minute warning, if necessary.
Do you remember that I told you that the items on the Womens issues list
overlap with the other categories? For each item on the womens list, which other
category does it also t?
Ask:
Teaching Instructions: Write I, P, or S next to each item as participants respond:
I=Individual
P=Program
S=Social/familial
Take a few minutes to walk around and read each list.
Say:
105
Teaching Instructions: Allow up to 8 minutes for this before asking participants to
return to their groups.
Do you think the phrases were categorized accurately? If not, what would you move?
Ask:
Teaching Instructions: If participants suggest moving any items, switch the papers
to the correct newsprint sheet as appropriate.
106
Presentation: Recovery Capital
15 minutes
Weve been talking about what the research says are factors affecting treatment
outcome in a general way. Lets now take a closer look at the concept of recovery
capital mentioned in Module 2.
Say:
Teaching Instructions: Note responses on newsprint.
Is anyone familiar with the concept? What do you think recovery capital means?
Ask:
107
Slide 3.5
Good job! The phrase recovery capital was coined by Cloud and Graneld, who
dened it as
1
:
the sum of personal and social resources at ones disposal for addressing
drug dependence and, chiey, bolstering ones capacity and opportunities
for recovery.
Say:
1
Cloud, W. & Graneld, R. (2001) Natural recovery from substance dependency: Lessons for treatment providers.
Journal of Social Work Practice in the Addictions, 1(1). 83104.
108
Slide 3.6
The concept of recovery capital involves identifying and building upon a clients
personal and social assets. Some of these assets may still be alive and well, and some
may have been developed early in the clients life and then lost through addiction.
Recovery capital that never existed in the clients life also can be developed: Social
supports can be marshalled, and clients can learn new skills that support recovery.
Say:
109
Slide 3.7
The practice document we mentioned in Module 2, published by the United
Nations Ofce on Drugs and Crime (UNODC),
1
identies eight domains, or life areas, of
recovery capital:
Physical and mental health;
Family, social supports, and leisure activities;
Safe housing and healthy environments;
Peer-based support;
Employment and resolution of legal issues;
Vocational skills and educational development;
Community integration and cultural support; and
(Re)discovering meaning and purpose in life.
As you can see, these areas correlate to the general categories of factors that have
been found to affect treatment outcomes.
Say:
1
International Network of Drug Dependence Treatment and Rehabilitation Resource Centres. (2008). Drug
dependence treatment: Sustained recovery management. Vienna: UNODC.
110
Slide 3.8
While assets in each of these domains strengthen a persons recovery, a lack of
assets can hamper the recovery process and desired outcomes. This is called negative
recovery capital.
Say:
111
Slide 3.9
White identies three types of recovery capital that can be inuenced by
addictions professionals:
1
Personal;
Family and social; and
Community and cultural.
Say:
1
White, W.L., & Cloud, W. (2008). Recovery capital: A primer for addiction professionals. Counselor Magazine, 9(5). 22-27.
112
Slide 3.10
Personal recovery capital can be further divided into physical and human capital.
A clients physical recovery capital includes things like:
Physical health;
Financial assets;
Safe and recovery-conducive shelter;
Clothing;
Food; and
Access to transportation.
Say:
113
Slide 3.11
Human recovery capital includes a clients:
Values;
Knowledge;
Educational and vocational skills and credentials;
Problem-solving capacities;
Self-awareness;
Self-esteem; and
Self-efcacy (meaning a clients self-condence in managing high risk situations).
Say:
114
Slide 3.12
Human recovery capital also includes a clients:
Hopefulness and optimism;
Perception of his or her past, present, and future;
Sense of meaning and purpose in life; and
Interpersonal skills.
Say:
115
Slide 3.13
Family and social recovery capital includes any intimate relationships, family and
kinship relationships, and any social relationships that are supportive of recovery efforts.
Before we move on, we need to take a minute to dene what we mean by family.
Kinship is straightforward; it means blood ties. Family, however, can be dened in a
number of ways.
Say:
Teaching Instructions: Note all responses on newsprint. Be sure that the denitions
include family of choice, i.e., non-blood-related people a client may consider family.
In what ways could we dene family?
Ask:
116
Slide 3.14
Family and social recovery capital is indicated by:
The willingness of intimate partners and family members to participate in treatment;
and
The presence of others in recovery within the family or among social contacts.
Say:
117
Slide 3.15
Family and social recovery capital is also indicated by:
Access to opportunities for recovery-basedor at least abstinentfellowship and
leisure activities; and
Connections to conventional institutions, like school, a workplace, a place of
worship, and community or tribal organizations.
Say:
118
Slide 3.16
The last type of recovery capital is community and cultural. Community recovery
capital involves community attitudes, policies, and resources related to addiction that
promote recovery.
Say:
119
Slide 3.17
Community recovery capital includes:
Active efforts to reduce stigma;
Visible and diverse local recovery role models (for example, a community leader who
is open about being in recovery);
A full continuum of addiction treatment services; and
Recovery mutual aid and support resources that are accessible and diverse (for
example, 12-step programs).
Say:
120
Slide 3.18
Community recovery capital also includes:
Local recovery community support institutions (recovery centers / clubhouses,
treatment alumni associations, recovery homes, recovery schools, recovery
industries, recovery ministries) and
Sources of sustained recovery support and early re-intervention (for example,
recovery checkups through treatment programs or recovery community
organizations).
Say:
121
Slide 3.19
Finally, cultural capital, a form of community capital, is the local availability of
indigenous cultural pathways of recovery, like incorporating tribal values and practices
into recovery programs.
Say:
122
Slide 3.20
As we learned earlier, many factors affect treatment outcomes. Research is
showing that the concept of recovery capital is a useful way of looking at these factors.
1

Both the quantity and quality of a persons recovery capital may play a major role in
determining the success or failure of treatment and recovery, and counselors play a
critical role in helping clients maximize the recovery capital they already have and
develop additional recovery capital.
Youll be hearing more about recovery capital in this training and in future trainings.
Say:
1
White, W.L., & Cloud, W. (2008). Recovery capital: A primer for addiction professionals. Counselor Magazine, 9(5). 22-27.
123
Slide 3.21
Today we looked at denitions of recovery, introduced the concept of recovery
management, and began looking at factors that may affect treatment outcome,
including the concept of recovery capital.
Say:
Day 1 review and introduction to case study exercise
15 minutes
Teaching Instructions: Allow about 5 minutes for answering these questions and
any discussion that emerges. Ask a co-trainer to distribute the daily evaluation form
during the discussion.
Who can give me a denition of recovery?
What are some factors that may affect treatment outcome?
What is the denition of recovery capital?
Ask:
Tomorrow morning you will be developing a case study to help you further
practice identifying factors that affect treatment outcome.
Say:
124
Slide 3.22
There will be two parts to the exercise. First, you will create case studies in small
groups by describing a client and his or her situation, including characteristics and life
factors that might affect treatment outcome for that client. You will include factors that
may have a positive impact on outcome and those that may have a negative impact on
outcome.
Say:
125
Slide 3.23
Once your group has created its case study, you will trade case studies with
another group. Using that case study, you will:
Identify the factors in the case study that may affect treatment outcome for the
client; and
Brainstorm and list ways that a counselor or treatment program could minimize
negative factors and maximize positive factors.
So that we get a head start tomorrow, lets form four small groups now. That way you
can immediately start working with your group when you come in.
Say:
Teaching Instructions: Allow a few minutes for groups to form.
Be sure to remember who youll be working with in the morning!
Before you leave, please complete the daily evaluation form. Your feedback is important
to us!
Have a good evening; well see you tomorrow.
Say:
126
Slide 3.24
Day 2 Welcome
5 minutes
Teaching Instructions: As participants enter, remind them to sit with the group they
formed yesterday.
Good morning! Welcome back. Before we begin our case study exercise, do you
have any comments or questions about our work yesterday?
Say:
Teaching Instructions: Allow only a few minutes for comments or questions.
127
Slide 3.25
Okay, please get with your small groups and begin the case study exercise. You
will have 30 minutes, starting now, to prepare your case study following the instructions
on the slide.
Say:
When 30 minutes have elapsed, ask each group to pass its newsprint pages to the
group on its right.
Small-group exercise: Case Study
80 minutes
128
Slide 3.26
Your group now has a new case study to work with. In this part of the exercise,
you will:
Identify the factors in the case study that may affect treatment outcome for the
client; and
Brainstorm and list ways that a counselor or treatment program could minimize
negative factors and maximize positive factors.
You will have 20 minutes for this part of the exercise, starting now.
Say:
When 20 minutes have elapsed, ask one group to read the case study to the large
group and present their ndings. Repeat with the remaining small groups. After
each group presents, ask the large group for any additional thoughts.
Great job, everyone! Well now move on to Module 4, Change and Motivation.
Say:
129
Longer term, more severe
substance dependence
complicates treatment
Family history of substance
dependence indicates more
severe problems
Dependence on more than
one substance complicates
treatment and recovery
Psychiatric issues complicate
Cognitive impairment
complicates treatment and
recovery
Factors Affecting Treatment Outcome: Exercise Phrases
Co-dependent Partner
130
Greater levels of criminality
reduce chances of successful
recovery
Family support has a positive
effect on recovery
Lack of community support
has a negative effect on
Lack of family acceptance has
a negative effect on recovery
Co-occurring HIV/AIDS and/or
other chronic conditions can
affect recovery
131
A programs admission
procedures can help or hinder
treatment
The number and type of
services provided affect how
individualized treatment can be
Using evidence-based
practices improves treatment
outcomes
A good mix of staff skills
improves treatment
The quality of program
leadership can improve or hurt
treatment outcomes
132
Familial substance use can
hinder recovery
Poor family relationships
hinder recovery
Employers reluctance to
hire someone in recovery is a
barrier to continued recovery
Duration and intensity of
program services affect
outcomes
133
A counselors ability to
establish a helping alliance
and good interpersonal skills
can be more important than
a counselors professional
training or experience
Providing a variety of case
management services is crucial
to recovery
A clients level of motivation
or readiness for recovery
can have a major effect on
treatment outcome
134
Women who use treatment
services fear losing their
children; these children are
often taken into ofcial care
Where services are located
has a big effect on treatment
adherence; how hard is it to
get there?
Counselor style may be one of
the most important factors in
treatment success, affecting
outcome even more than
client characteristics
135
Studies have found that the
perceived stigma associated
with substance use is more
strongly felt by women than
by men
Women who use substances
may be encouraged to begin
substance treatment, but few
treatment services meet their
specic needs
Women are much more likely
to conceal their substance use
(and avoid treatment) to avoid
public disapproval
136
Relationship issues seem to play
a bigger role in treatment and
recovery for women than they
do for men
Research has found that women
who use substances are highly
likely to have a male sex partner
who injects drugs
Many women who use
substances frequently experience
domestic violence and
intimidation and may be coerced
into substance use by a partner
Research shows that womens
access to substances mainly
occurs through male sex
partners
137
The social and economic
vulnerabilities of women in
society can play a signicant role
in female substance use
Poverty may force women into
the sex industry; to cope with
the resulting emotional stress
and unhappiness, some women
resort to substance use
In some situations, brothel
owners introduce women
to substances; the women
may become dependent on
substances and unable to escape
from the exploitive environment
138
Women may enter the
sex trade to get money to
buy substances, putting
themselves at increased risk of
contracting HIV
Homelessness may make
more difcult
139
MODULE 4
FACTORS AFFECTING TREATMENT OUTCOMES
Introduction to Module 4 .........................................................................143
Exercise: Personal change ........................................................................146
Interactive presentation: The nature of motivation ..................................149
Presentation: Introduction to the stages of change model ......................159
Small-group exercise: Characteristics of clients in each stage of change 161
141
Trainer Manual: Module 4Change and Motivation
Preview Module 4.
Prepare newsprint labeled Motivation, and write under it Staticeither does or
does not have and Dynamicpurposeful, intentional, positive, changeable.
Prepare two newsprint pages labeled Internal Factors and External Factors
Activity Time
Person
Responsible
Exercise: Personal change 15 minutes
Break 15 minutes
Interactive presentation: The nature of motivation 30 minutes
Presentation: Introduction to the stages of change
model
10 minutes
Small-group presentations: Characteristics of clients in
each stage of change
55 minutes
Lunch 60 minutes
142
Training goals
To provide an overview of the concept of motivation;
To provide an overview of the nature and stages of change; and
To give participants a chance to explore the characteristics of people in each stage
of change.
Learning objectives
List at least three characteristics of motivation;
List the six stages of change; and
Describe two or three characteristics of clients in each stage of change.
143
Slide 4.1
5 minutes
In Module 4 well begin to talk about the concepts of change and motivation.
Say:
144
Slide 4.2
Treatment and recovery are ultimately about change. As we all know, change is
not always easy for people.
Before we begin to talk about the process of treatment, it is important to understand
the process of change. This module introduces the concept of motivation for change
and a model of stages of change.
The stages of change model is used around the world to address a range of issues
including:
Medically necessary lifestyle changes;
Following medication schedules (e.g., in treating heart disease or diabetes);
Coping with mental disorders; and
Stopping substance use.
This module is only an introduction to the stages of change model. A counselor could
devote many training hours to fully learning how to incorporate the stages of change
model and motivational approaches to treatment into practice.
Later in this training, and in future curricula, you will learn more about approaches to
treatment that are based on the concepts of motivation and stages of change.
Say:
145
Slide 4.3
Please turn to Module 4, page 83 in your manuals. Lets take a quick look at the
learning objectives for the module. By the time we complete this module, I hope you
will be able to:
List at least three characteristics of motivation;
List the six stages of change; and
Describe two or three characteristics of clients in each stage of change.
Say:
146
Slide 4.4
Change regularly occurs:
In daily life;
Among all people;
In relation to many behaviors; and
With or without professional intervention.
Say:
Exercise: Personal change
15 minutes
147
Slide 4.5
Say:
Teaching Instructions: Provide a 2-minute warning before the end of the writing
time. Ask for a few volunteers to share their experience of change. Allow 5 minutes
for sharing.
To help you begin thinking about and better understand the change process, Im
going to ask you to do a writing exercise. Id like you to:
Think about a personal change you have made in your life; and
Write in your journal everything you can remember about the process, using the
questions on the slide as a guide.
No one will see your notes; you are free to share or NOT to share anything you write.
You will have 10 minutes for writing, starting now.
148
Slide 4.6
Say:
Great job! Were going to take a 15-minute break now. When we come back well
begin talking about a critical aspect of change: motivation.
149
Slide 4.7
It is important to understand the concept of motivation because motivation for
change is closely related to the level of probability that a person with a substance use
disorder (or SUD) will:
Enter treatment;
Continue in treatment; and
Adhere to a specic change strategy.
Say:
Interactive presentation: The nature of motivation
45 minutes
Lets study the word motivation.
150
How would you dene motivation?
Ask:
Teaching Instructions: Note responses on newsprint. Ensure that the denitions
include the following:
A reason or desire to act; and
That which gives purpose and direction to behavior.
Post these denitions on the wall.
Turn to the newsprint labeled Motivation.
Motivation often has been considered static, something a person either does or
does not have. According to the view of motivation as static:
A counselor has little chance of inuencing a clients motivation; and
If a client is not motivated to change, that lack of motivation is the clients problem
(or even his or her fault).
Say:
151
Slide 4.8
But motivation has been found to actually be dynamic rather than static and is:
Purposeful;
Intentional;
Positive; and
Changeable.
Say:
Teaching Instructions: Cross Static off the newsprint list with a large X.
152
Slide 4.9
Research and experience suggest that motivation is a dynamic state that can
uctuate over time and in relation to different situations and can go back and forth
between conicting goals. For example, a person may be motivated to quit using drugs
so that he can focus on nishing school but also he may be motivated to t in with or
please his friends, which may mean continuing drug use.
Motivation also varies in intensity, slowing in response to doubts and increasing as
doubts are resolved and goals are envisioned clearly. It also can vary greatly among
potential behavior changes. For example, a clients motivation to quit injecting heroin
may be very high, whereas her motivation to quit smoking marijuana may be very low.
A person in active addiction is also likely to have impaired judgement and decision-
making capabilities, which will affect normal motivational processes.
Say:
Motivation is inuenced by these and other internal factors and by external factors as
well.
Teaching Instructions: Write and underline Internal Inuences on a sheet of
newsprint.
153
Slide 4.10
Internal inuences can include a clients:
Emotional states;
Life goals;
Perceptions about risks and benets of behaviors; and
Cognitive appraisals of the situation (what the client thinks about the situation).
For the next few minutes, Ill be asking you for examples of each type of internal
inuence. Think back on your personal change writing assignment for ideas.
Say:
Teaching Instructions: Write and underline the subheading Emotional states on
the newsprint.
What are some examples of emotional states that might inuence motivation? In
what way might they have that inuence?
Ask:
154
Teaching Instructions: Note responses on the newsprint. Ensure that responses
include examples like the following:
Anger, depression, anxiety, fear, or insecurity can decrease a persons motivation
for change.
The same emotional states could increase motivation if the person believes a
change would lead to an improved emotional state.
Write and underline Internal Inuences on a new sheet of newsprint, followed by
the subheading Life goals.
In what ways do you think a persons life goals might affect motivation?
Ask:
Life goals that increase motivation for change include wanting to nish ones
education, start a family, or obtain a better job or keep a current one.
A lack of life goals could decrease motivation for change.
the subheading Perceptions about risks and benets.
In what ways do you think a persons perceptions about the risks and benets of a
behavior might affect motivation?
Ask:
A person could perceive that smoking marijuana has no health risks, so she may
not be motivated to change her smoking behavior.
Another person could believe that not smoking marijuana would increase
concentration at school, so she may be motivated to change her behavior.
the subheading Cognitive appraisals of the situation.
155
In what ways do you think a persons cognitive appraisal, or what she thinks about
a behavior, might affect motivation?
Ask:
A persons thoughts may decrease motivation. For example: My father smoked
marijuana, so I do too. Its just the way it is.
Another person may think, I dont get much work done if I stay up late and use
cocaine with my friends. Such thoughts may increase motivation to change
substance use behavior.
156
Slide 4.11
You did a great job of coming up with examples of internal inuences on
motivation. Now lets look at some external inuences.
Say:
External factors can include a clients:
Family and friends;
Situations and experiences; and
Community support (or lack of community support).
Say:
Teaching Instructions: Write and underline External Inuences on a sheet of
newsprint.
Teaching Instructions: Write the subheading Family and friends on the newsprint.
157
In what ways could a persons family and friends affect motivation?
Ask:
One persons family members may express concerns about their loved ones
drug use and support his efforts to change.
Another persons family may use drugs regularly and may not support or may
even actively undermine their loved ones efforts to change.
A family member who protects (enables) the person from consequences of use
may facilitate decreased motivation for change.
A persons peer group can either increase or decrease his or her motivation for
change.
Write and underline External Inuences on a new sheet of newsprint, followed by
the subheading Situations and experiences.
How could a persons situations and experiences affect motivation?
Say:
Critical life events can affect motivation for change. Such events could include
pregnancy, a wedding, death of a loved one, or a friends overdose.
A person may be forced to consider change when faced with consequences for
not making a change, such as after an arrest.
Write and underline External Inuences on a new sheet of newsprint, followed by
the subheading Community support.
158
How could community support (or lack of community support) affect a persons
motivation?
One way of looking at motivation is to examine how it changes over time. The
stages of change model helps us look at this process.
Ask:
Say:
Communities can support a persons change efforts by providing adequate
treatment programs.
The availability of support groups may play a role.
Lack of employment or housing opportunities may reduce motivation for
change.
Negative public views of substance use may discourage people from asking for
help.
Tape the completed newsprint pages to the wall.
159
Slide 4.12
The stages of change model was developed based on a study of how people
change; the study found that people go through predictable stages as they attempt to
change.
1
Understanding the process of change, including how people change without
professional help, can help counselors develop and use interventions to increase clients
motivation to change their behavior.
Say:
Presentation: Introduction to the stages of change model
10 minutes
1
Prochaska, J., Norcross, J., & DiClemente, C. (1994). Changing for good. New York: William Morrow and Company.
Teaching Instructions: If you have a pointer or laser, point to each stage as you
describe it.
160
A person in the precontemplation stage is not thinking about change or is
unwilling or unable to change.
A person in the contemplation stage acknowledges concerns about behavior and
is considering the possibility of change but is ambivalent (has mixed feelings) and
uncertain.
A person in the preparation stage is planning to make a change in the near future but is
still considering what to do and how to do it.
A person in the action stage is taking steps to change but has not yet reached a stable
state.
A person in the maintenance stage has achieved initial goals such as abstinence and is
now working to maintain the change.
Recurrence of substance-using behavior (lapse or relapse) is sometimes considered a
sixth stage of change. Recurrence is between maintenance and precontemplation on
the graphic, but it can happen at any time in the change process. Many clients move
through different stages several times before achieving stable abstinence; recurrence is
normal but does not have to happen.
You may have noticed that there are no directional arrows on the diagram. Thats
because people typically do not go through the stages smoothly but rather move back
and forth among the stages.
The change process is inuenced by a persons level of motivation, which we have
learned is not static but changeable.
People often linger in the early stages of change, and they go through the stages at
different rates.
Say:
161
Slide 4.13
Now were going to take a closer look at the stages of change. In small groups, you
will develop short presentations on the characteristics of clients in each stage of change.
Please form six small groups.
Say:
Small-group presentations: Characteristics of clients in each
stage of change
55 minutes
Teaching Instructions: For this exercise, up to six small groups (one for each stage
of change) are feasible. If your group is not large enough for at least three small
groups (two stages of change per group), have participants work in pairs.
While groups are forming, give each group two pieces of poster board or sheets of
newsprint for each stage of change it is assigned.
162
Please turn to Resource Page 4.1, page 96 in your manuals. To prepare for your
presentations, you will:
Read the material for your assigned stages of change;
Create posters that illustrate the characteristics of clients in your assigned stages of
change;
Include the types of interventions clients need in that stage; and
Prepare two or three real-world examples.
Examples can include clients statements or behaviors that indicate their stage of
change. You can also act out the stage in a 1-minute skit to give others a sense of what
clients experience in the stage.
You will have 30 minutes to create your posters and develop examples and skits,
beginning now.
Say:
Teaching Instructions: While groups are working, walk around and observe. If group
members have difculty developing an example, suggest one.
Provide 15- and 5-minute warnings. After 30 minutes, ask each group to select one
person to present its posters and examples.
After each group has presented, ask the large group for other examples of
behaviors that clients may exhibit in that stage and ask whether participants have
any questions for the presenting group.
Post the presentations on the wall; cover or remove other newsprint pages if necessary.
163
Slide 4.14
Counselors can enhance their clients motivation for change at each stage of the
change process. Its important to understand where a client is in the stages of change
because clients need and use different kinds of motivational support according to their
stage of change.
We will be talking about motivational enhancement as an intervention later in the training.
Say:
164
Slide 4.15
Were going to break for lunch now. When we come back well begin talking
about ways of looking at treatment.
Say:
165
Resource Page 4.1: Characteristics of Clients in Each Stage
of Change
Precontemplation
During the precontemplation stage, people who use substances are not considering
change and do not intend to change behaviors in the foreseeable future. People in this
stage tend to defend their substance-using behavior. They may be partly or completely
unaware that a problem exists or that a change is needed. They may need help to
change. They may be defensive when others pressure them to quit. They also may be too
discouraged to change their behavior. Individuals in this stage may not have experienced
adverse consequences or crises because of their substance use and often are not convinced
that their pattern of use is a problem or even risky. Even people who have previously
recognized that they have a problem and have made efforts to change may revert back to
the precontemplation stage. They may say to themselves, Its really not that bad.
People in the precontemplation stage must raise their awareness before they can
consider change.
Contemplation
As individuals become aware that a problem exists, they begin to realize there may be
cause for concern and reasons to change. Typically, they are ambivalent, simultaneously
admitting reasons to change and reasons not to change. Individuals in this stage are
still using substances, but they are thinking about stopping or reducing use in the near
future. At this point, they may seek relevant information, reevaluate their substance-using
behavior, or seek help for possibly changing behavior. They typically weigh positive and
negative aspects of making a change (I know I need to quit using, but ...). Individuals
frequently remain in this stage for long periods, often for years, vacillating between
wanting and not wanting to change.
People in the contemplation stage need help resolving their ambivalence and choosing
positive change over their current situation.
Preparation
Once a person begins to plan for change, he or she enters the preparation stage,
during which commitment is strengthened. Preparation entails specic planning
for change, such as deciding whether treatment is needed and, if so, what kind.
Preparation also involves an examination of perceived ability to change. Individuals in
the preparation stage are still using substances, but typically they intend to stop using
very soon. They may experiment with small changes as their determination to change
increases. They may have already attempted to reduce or stop use on their own or may
be experimenting with ways to quit or cut back. They begin to set goals for themselves
and make commitments to stop using, even telling people close to them about their
plans. Too often, people skip this stage; they try to move directly from contemplation
into action and are unsuccessful because they have not adequately researched or
accepted what is required to make a major lifestyle change.
People in the preparation stage need help identifying potential change strategies and
choosing those that are most appropriate for them.
Action
Individuals in the action stage choose a strategy for change and begin to follow it.
At this stage, clients believe they can change their behavior and actively modify their
habits and environment. They make drastic lifestyle changes and may face challenging
situations and experience the physiological effects of withdrawal. In this stage,
individuals develop plans to deal with both personal and external pressures that may
lead to slips. They begin to reevaluate their self-image as they move from excessive or
hazardous use to abstinence or safe use. People in this stage also tend to accept help
and seek support from others. The action stage can last from 3 to 6 months following
termination or reduction of substance use.
People in the action stage need help carrying out and sticking with change strategies
and learning to prevent or minimize recurrence.
Maintenance
During the maintenance stage, people try to sustain the gains achieved during the
action stage. People work to stay abstinent and prevent recurrence. Extra precautions
may be necessary to avoid problem behaviors. Individuals learn to detect and guard
against dangerous situations and other triggers that may cause them to use substances.
People in maintenance look at how they live their lives. They work on acquiring new
skills to deal with challenges and avoid relapse. This often means changing routines,
making new friends, and trying new activities. People can anticipate relapse situations
and prepare coping strategies. In most cases, individuals attempting long-term
behavior change return to use at least once and revert to an earlier stage. Recurrence of
symptoms is part of the learning process. Knowledge about personal cues for substance
use is helpful for future change attempts. Maintenance requires prolonged behavioral
changeby remaining abstinent or reducing consumption to acceptable, targeted
levelsand continued vigilance for a minimum of 6 months to several years.
People in the maintenance stage may need help develolping new skills and social
networks for maintaining a recovery lifestyle.
Recurrence
Most people do not immediately sustain the new changes they are attempting to make,
and a return to substance use after a period of abstinence is the rule rather than the
exception. These experiences provide information that can help or hinder subsequent
progression through the stages of change. Recurrence, often referred to as relapse, is
the event that triggers the individuals return to an earlier stage of change and cycling
through the process again. Individuals may have had unrealistic goals, used ineffective
strategies, or put themselves in environments that are not conducive to successful
change. Most people who use substances require several cycles through the stages of
change to achieve successful recovery. After a return to substance use, clients usually
revert to an earlier stage of changenot always to maintenance or action but more
often to contemplation. They often feel demoralized and possibly even hopeless about
change. They may even become precontemplators again, temporarily unwilling or
unable to change soon. However, a recurrence of symptoms does not necessarily mean
a client has abandoned a commitment to change.
People experiencing recurrence need help assessing what may have contributed to
recurrence, and help resuming their recovery process.
169
MODULE 5
TREATMENT: AN OVERVIEW
Introduction to Module 5 .........................................................................173
Individual Exercise: Ways of Looking at Treatment ..................................175
Small-group Exercise: Principles of Effective Treatment ..........................185
Learning Assessment ................................................................................188
Day 2 wrap-up and evaluation .................................................................190
171
Trainer Manual: Module 5Treatment: An Overview
Preview Module 5.
Make one copy of Resource Page 5.1 for each participant (participants will be
posting their work). Place a copy on participants chairs while they are at lunch.
In addition to the materials listed in Getting Started, provide the following:
o Plenty of colored markers or colored pencils on each table; and
o One roll of masking tape on each table.
Activity Time
Person
Responsible
Exercise: Ways of Looking at Treatment 70 minutes
Break 15 minutes
Small-group exercise: Principles of Effective Treatment 60 minutes
Learning Assessment 30 minutes
Day 2 wrap-up and evaluation 10 minutes
172
Module 5 Goal and Objectives
Training goal
To provide an overview and framework for understanding addiction treatment.
Learning objectives
Describe at least four ways of looking at treatment;
List at least six principles of effective treatment; and
Identify three ways these principles are currently incorporated into treatment in
participants home areas.
173
Slide 5.1
5 minutes
Welcome back from lunch. Do any of you have questions or comments about
this mornings material? Please open your manuals to Module 5. Module 5 provides
a brief overview of treatment for substance use disorders and offers a look at the
different ways in which treatment is provided. Well also look at some basic principles
of effective treatment.
You will be using the copy of Resource page 5.1 found on your chair a little later.
Say:
174
Describe at least four ways of looking at treatment;
List at least six principles of effective treatment; and
Identify three ways these principles are currently incorporated into treatment in
your areas.
Say:
Slide 5.2
175
Slide 5.3
Individual Exercise: Ways of looking at treatment
70 minutes
There are a number of ways to look at treatment. We can look at:
The setting;
The intensity and duration;
How treatment is provided;
The components of treatment;
The continuum of care; and
Treatment models or practices.
Say:
176
Slide 5.4
Treatment setting refers to where treatment is provided: for example, in a drop-in
center, hospital, clinic, or residence.
Say:
In what other setting might treatment be provided?
Ask:
177
Slide 5.5
Treatment intensity and duration are related to one another. Intensity refers
to how often treatment is provided. Duration refers to how long a person receives
treatment services.
Say:
178
Slide 5.6
Treatment can be provided in a number of ways. For example: one-on-one with an
addiction professional; in a group with peers, or with other family members.
These days, treatment may even be provided over the phone or internet.
Say:
179
Slide 5.7
Treatment components refer to the elements, or pieces, of treatment: for
example, assessment, counseling, education, and so on.
Say:
What other components of treatment can you think of?
Ask:
180
Slide 5.8
The continuum of care is related to the types of treatment and the other services
a person can receive over time. This is another way of looking at ongoing recovery
management.
Say:
181
Slide 5.9
The model of treatment intervention refers to the theoretical basis and specic
techniques a professional uses to provide treatment interventionsfor example,
cognitive-behabioral therapy and other evidence-based practices.
Say:
What other treatment model of practices do you use or are you aware of?
Ask:
182
Teaching Instructions: Provide 15- and 2-minute warnings. After 30 minutes (or
when everyone is nished), ask participants to tape their graphics to the wall, leaving
about half a meter between each if possible.
Now that all of your graphics are on the wall, take about 10 minutes to carefully
look at one anothers work.
Say:
Teaching Instructions: Provide a 2-minute warning if necessary.
Now please pull out your copy of Resource Page 5.1. You will use this page as
a worksheet for an individual exercise. Please turn to Resource Page 5.2, page 117 in
your manuals. This page has extensive explanations of the different ways of looking at
treatment. You will use Resource Page 5.2 to create your own graphic by adding detail
to the blank spaces on Resource Page 5.1.
For example, you could add assessment, education about addiction, and counseling
next to the Interventions heading on Resource Page 5.1.
Use the colored markers or pencils to add drawings and/or text to make the page useful
to you.
You have 30 minutes to complete the exercise, starting now.
Say:
Slide 5.10
183
Does anyone have any comments or questions?
Ask:
Teaching Instructions: Facilitate a brief discussion. Refer any questions about a
graphic to the person who designed it or to the whole group as appropriate.
184
Slide 5.11
Break
15 minutes
Before we study the principles of effective substance use disorder treatment, well
take a 15-minute break.
Say:
185
Small-group exercise: Principles of effective treatment
60 minutes
Please turn to Resource Page 5.3: Basic Principles of Effective Drug Treatment,
page 121 in your manuals.
The U.S. National Institute on Drug Abuse (or NIDA) developed these principles based
on treatment outcome research. The principles have been used extensively around the
world to develop treatment guidelines and standards.
Were going to do a small-group exercise using the principles. Please form small groups
of four or ve people.
First, read the list of principles. When everyone has had a chance to nish reading, briey
discuss how each principle is or is not integrated into treatment currently in your country
and home area. You will have 30 minutes for reading and discussion, starting now.
Say:
Slide 5.12
186
Teaching Instructions: Provide 15- and 5-minute warnings. Label a piece of
newsprint Integrated Principles.
Which principles do you think are currently well integrated into treatment in
your area?
Ask:
Teaching Instructions: Note responses on the Integrated Principles newsprint
page. Label a piece of newsprint Non-integrated Principles.
Which principles are currently not well integrated into treatment in your area?
Ask:
Teaching Instructions: Note responses on the Non-integrated Principles
newsprint page. Leave space between principles. Use additional sheets of newsprint
as needed.
What barriers do you think are preventing these principles from being
integrated into treatment?
Ask:
Teaching Instructions: Note responses under the appropriate principle on the
newsprint.
Do you see any ways in which counselors can help remove some of these
barriers? There are no right or wrong answers to this question; some barriers cannot be
removed by a counselor.
Ask:
187
Slide 5.13
The World Health Organization and the United Nations Ofce on Drugs and
Crime jointly developed a set of principles for drug treatment. These principles are
similar to the NIDA principles, but they are more detailed. They are available from the
Web site listed on the slide. When you have a chance, take a look at this document.
Keep the basic principles of effective treatment in mind as we move toward
understanding the process of treatment in more detail.
Next, well be talking about the common components of treatment.
Say:
188
Slide 5.14
Before we wrap up for today, were going to do a learning assessment exercise.
Please stay in your small groups. You will have 10 minutes to:
Work together to prepare a three-question quiz based on your learning so far; and
Write the quiz questions neatly on a piece of paper, leaving room on the page for
answers.
Start now.
Say:
Learning assessment
30 minutes
Teaching Instructions: Provide a 1-minute warning.
Now Id like you to pass your quiz to the group on your right. Once you have your
quiz, each group will have 10 minutes to:
Select a spokesperson; and
Work together to quickly answer the quiz questions.
Say:
189
Teaching Instructions: While groups are working, quietly give each participant a
Daily Evaluation form.
Provide a 1-minute warning. After 10 minutes, ask each spokesperson to read the
quiz questions and the answers his or her group gave.
If any question is unanswered, refer it to the large group for an answer.
190
You did a great job with your quizzes, both writing and answering questions!
Thank you for being open to new learning.
Before you leave for the day, please complete the Daily Evaluation form. Your input is
very important to us. Thank you, and have a great evening.
Say:
Day 1 wrap-up and evaluation
10 minutes
Resource Page 5.1: Elements of Drug Treatment
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Resource Page 5.2: Ways of Looking at Treatment
Setting (where)
Treatment setting refers to where services are offered. Treatment services are made
available in a variety of settings:
Outreach settings include drop-in centers, homeless shelters, and/or the street.
Outpatient substance-free programs provide treatment at a program site, but the
person lives elsewhere (usually at home). These programs are abstinence based
and do not typically use treatment medications. Outpatient treatment is offered
in a variety of places: health clinics, community mental health clinics, workers
ofces, hospital clinics, local health department ofces, or residential programs with
outpatient clinics. Many programs provide services in the evenings and on weekends
so that participants can go to school or work.
Medication-assisted outpatient treatment for opioid addiction is provided in
outpatient methadone clinics, general medical clinics, or doctors ofces.
Hospital-based inpatient treatment settings typically are separate units in a general
medical hospital. They may provide detoxication and ongoing treatment (usually
short term), as well as treatment of other medical problems.
Nonmedical residential programs provide a living environment with treatment
services. These programs typically do not have full-time medical staff, and clients
must have completed detoxication before entering.
Halfway houses or transitional living facilities provide a supportive living environment
for clients who have typically completed primary residential treatment and are
ready to go back to work and/or school. These facilities typically provide relapse
prevention treatment, behavioral guidelines, and a place to live for those who have
no family or are not ready to return to their families.
Intensity (how often) and Duration (for how long)
Intensity is related to how many hours per day a person is involved in treatment activities:
Restrictive settings (inpatient or residential programs) are more intensive than others
because clients typically spend much of the day involved in treatment activities.
Outpatient programs may be more or less intensive. Outpatient day treatment
or partial hospitalization programs may offer nearly as many hours of treatment
activities per day as residential or inpatient programs, typically 5 days per week.
Intensive outpatient programs may offer treatment activities for 9 to 20 hours per week.
Other outpatient programs may meet once a week for 1 or 2 hours.
Duration is related to how many days a person can be involved in treatment activities:
Duration of treatment varies. For example, treatment programs may provide
structured service for weeks, months, or a year or more.
Research consistently shows that treatment is most effective if it lasts for at least 90
days. However, insurance providers or government-subsidized treatment may permit
only shorter duration treatment.
How Treatment is Provided
Modality refers to how services are offered: in groups with peers, individually, with family
members, or in any combination of the three.
Components of Treatment
Interventions refer to the range of services offered in program settings. Examples of
interventions are:
Detoxication;
Assessment;
Education about substance use disorders for clients and family members;
Counseling;
Treatment for mental health problems;
Establishment of special groups or other services for particular populations, such as
women or prison inmates;
Relapse prevention training;
Medication;
Orientation to support groups;
Case management;
Employment training and general schooling for adolescents and young adults; and
Continuing care.
Module 5 addresses the components of treatment.
Continuum of Care (treatment and other services over time)
A continuum of treatment is the range of treatment and other services offered over time
to a client based on his or her specic needs. This continuum may include:
Moving from a more intensive form of treatment to a less intensive form (e.g., from
residential treatment to a halfway house or from a transitional living program to
outpatient treatment); or
Moving from less intensive to more intensive treatment when necessary (e.g.,
moving from a drop-in group to medication-assisted treatment when the person
needs more help with abstinence).
A continuum also includes consistent case management to make sure clients other
needs are met (e.g., referral for medical care, voluntary counseling and testing [VCT] for
HIV, nancial advice, family therapy, housing, job skills training).
The graphic below shows a continuum of care for one client:
Outreach
Drop-in Group
Case Management
Residential
Treatment
Vocational
Training
Evaluation for
Depression
VCT
A peer outreach counselor talks to an individual about a drop-in center, and the
individual decides to join a group at the center.
The individual continues to use cocaine even though he wants to quit. He has little
family support, and all his friends use drugs. He is referred to a residential program
for more intensive services.
At the same time, his counselor works with him to initiate HIV testing, obtain a
psychiatric evaluation for depression, and (once the client has been on methadone
for a while) become involved in vocational training.
Treatment Models or Practices
A treatment model is a set of guiding principles and specic techniques for working
with clients. Some theoretical models of treatment have been found to be more
effective than others in helping people with substance use problems. These models
have been studied extensively, though primarily in the West.
The primary research-based models (also called evidence-based practices) used in
many countries around the world are:
Medication-assisted treatment for opioid addiction;
Cognitive-behavioral therapy;
Motivational approaches;
Outpatient
Continuing
Care
Matrix model for methamphetamine and other stimulant use;
12-Step facilitation therapy;
Contingency management;
Therapeutic community; and
Family approaches for couples and adolescents.
Module 7 addresses these models.
Resource Page 5.3: Basic Principles of Effective Drug Treatment
1
1. No single treatment is appropriate for all individuals. Matching treatment
settings, interventions, and services to each individuals particular problems
and needs is critical to his or her ultimate success in returning to productive
functioning in the family, workplace, and community.
2. Treatment needs to be readily available. Because individuals who are addicted
may have mixed feelings about entering treatment, taking advantage of
opportunities when they are ready for treatment is crucial. Potential treatment
applicants can be lost if treatment is not immediately available or is not readily
accessible.
3. Effective treatment attends to multiple needs of the individual, not just his
or her substance use. To be effective, treatment must address the individuals
substance use and any associated medical, psychological, social, vocational, and
legal problems.
4. An individuals treatment and services plan must be assessed continually and
modied as necessary to ensure that the plan meets the persons changing
needs. A client may require varying combinations of services and treatment
components during the course of treatment and recovery. In addition to
counseling or psychotherapy, a client at times may require medication, other
medical services, family therapy, parenting advice, vocational rehabilitation, and
social and legal services. It is critical that the treatment approach be appropriate
to the individuals age, gender, ethnicity, and culture.
5. Remaining in treatment for an adequate time is critical for treatment
effectiveness. The appropriate duration for an individual depends on his or her
problems, needs, and resources. Research indicates that, for most clients, the
threshold of signicant improvement is reached at about 3 months in treatment.
Because people often leave treatment prematurely, programs should include
strategies to engage and keep people in treatment.
6. Counseling (individual and/or group) and other behavioral therapies are critical
components of effective treatment for addiction. In therapy, clients address
issues of motivation, build skills to resist substance use, replace substance-
using activities with constructive and rewarding non-substance-using activities,
and improve abilities to solve problems. Behavioral therapy also facilitates
interpersonal relationships and the individuals ability to function in the family and
community.
1
Adapted from U.S. National Institute on Drug Abuse. (1999). Principles of drug addiction treatment: A research-based
guide (pp. 35). Bethesda, MD: Author.
7. Medications are an important element of treatment for many clients, especially
when combined with counseling and other behavioral therapies. Methadone is
very effective in helping people who are addicted to heroin stabilize their lives
and reduce their drug use. For clients with mental disorders, both behavioral
treatments and medications can be critically important.
8. Individuals who have addictions or abuse substances and have co-occurring
mental disorders should receive integrated treatment for both disorders.
Because substance use disorders and mental disorders often co-occur, clients
presenting for either condition should be assessed and treated for the co-
occurrence of the other type of disorder.
9. Medical detoxication is only the rst stage of addiction treatment and by itself
does little to change long-term substance use. Medical detoxication safely
manages the acute physical symptoms of withdrawal associated with stopping
substance use. Although detoxication alone is rarely sufcient to help people
who have addictions achieve long-term abstinence, for some individuals it is a
necessary element of effective addiction treatment.
10. Treatment does not need to be voluntary to be effective. Strong motivation can
facilitate the treatment process. However, sanctions or enticements in the family,
employment setting, or criminal justice system can increase treatment entry,
retention rates, and treatment success.
11. Possible substance use during treatment must be monitored continuously.
Lapses to substance use can occur during treatment. The objective monitoring
of a clients drug use during treatment, such as through urinalysis or other tests,
can help the client withstand urges to use substances. Such monitoring also can
provide early evidence of substance use so that the individuals treatment plan
can be adjusted. Feedback to clients who have positive test results for illicit drug
use is an important element of monitoring.
12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and
C, tuberculosis, and other infectious diseases, as well as counseling to help
clients modify or change behaviors that place themselves or others at risk of
infection. Counseling can help patients avoid high-risk behavior. Counseling also
can help people who are already infected manage their illnesses.
13. Recovery from substance addiction can be a long-term process and frequently
requires multiple episodes of treatment. As with other chronic illnesses,
substance use relapses can occur during or after successful treatment episodes.
Individuals who are addicted may require prolonged treatment and multiple
episodes of treatment to achieve long-term abstinence and fully restored
functioning. Participation in mutual-help support programs during and following
treatment often is helpful in maintaining abstinence.
199
MODULE 6
COMPONENTS OF TREATMENT: THE CONTINUUM OF CARE
Welcome, review of day 2, and introduction to Module 6 ...................... 204
Presentation: Pretreatment components ................................................. 211
Small-group exercise: Pretreatment components ................................... 241
Presentation: Case management ............................................................ 244
Small-group exercise: Case management components .......................... 259
Presentation: Primary treatment, Part 1Group counseling .................. 261
Small-group presentations: Types of groups ........................................... 264
Presentation: Primary treatment, Part 2Individual counseling ............. 267
Presentation: Primary treatment, Part 3Other components ................. 273
Small-group exercise: Primary treatment ................................................ 300
Presentation: Continuing care ................................................................. 302
Day 3 wrap-up and evaluation ................................................................ 309
Small-group exercise: Continuing care.................................................... 311
Small-group exercise: Continuum of care case study.............................. 313
201
Trainer Manual: Module 6Components of Treatment: The Continuum of Care
Preview Module 6.
Create a large wall graphic by copying pages 317 through 325 and taping them
to the wall using the guide on page 316. Leave as much space as possible around
each page; participants will be adding to the graphic throughout the session.
Make three copies of the human gure illustration on page 326.
Label separate newsprint pages as follows to prepare for discussion questions:
o Outreach
o Assessment
o Withdrawal syndrome
o Detoxication services
o Service providers
o Drug testing
o Mutual-help programs
o Continuing care
Write the following on four small pieces of paper, then place them in an envelope
labeled Exercise assignments: Pretreatment components
o Outreach
o Screening
o Assessment and treatment planning
o Detoxication
labeled Exercise assignments: Case management:
o Case management denition
o Case management purpose
o Case management functions
o Case management challenges
labeled Exercise assignments: Types of groups:
o Skills development and support
groups
o Special interest and family groups
o Psychoeducation
o Treatment engagement and
relapse prevention groups
Write Individual counseling on a sheet of white paper; you will be adding it to
the wall graphic
Write the following on separate sheets of white paper (you will be adding them to
the wall graphic):
o Testing for drug Use
o Pharmacotherapy
o Mutual-help groups
o Other components (education,
transportation, child care, and so on)
202
In addition to the materials listed in Getting Started, provide the following for each
of four tables:
Activity Time
Person
Responsible
Welcome, review of day 2, and introduction to
Module 6
20 minutes
Presentation: Pretreatment components 60 minutes
Small-group exercise: Pretreatment components 40 minutes
Break 15 minutes
Presentation: Case management 25 minutes
Small-group exercise: Case management components 30 minutes
Presentation: Primary treatment, Part 1Group
counseling
10 minutes
Small-group presentations: Types of groups 60 minutes
Lunch 60 minutes
Presentation: Primary treatment, Part 2Individual
counseling
10 minutes
Presentation: Primary treatment, Part 3Other
components
45 minutes
Break 15 minutes
Small-group exercise: Primary treatment 40 minutes
Presentation: Continuing care 15 minutes
Day 3 Wrap-up and evaluation 15 minutes
End of day 3
Small-group exercise: Continuing care 60 minutes
Small-group exercise: Case study 90 minutes
Break 15 minutes
o One package of colored
construction paper
o Five sheets of newsprint
o Five sheets of white paper
o A set of bold colored markers
o A pair of scissors
o A role of masking tape
o A glue stick
203
Training goals
To provide a comprehensive overview of the various components of effective
treatment; and
To provide an opportunity for participants to understand the concept of continuum
of care by applying it to a client.
Learning objectives
Provide a general description of an effective continuum of care for substance use
disorders (SUDs);
Identify differences between screening and assessment;
Describe detoxication options;
Dene case management;
Name and briey describe at least ve interventions typically offered in primary SUD
treatment;
Name and briey describe four types of groups often used in SUD treatment;
Name and briey describe the self-help/mutual-help options available in the
community/area;
Dene continuing care; and
Apply the concept of continuum of care by identifying an appropriate continuum for
a client via a case study.
204
Welcome back! I hope you had a good evening.
Before we begin Module 6, Id like you to tell me one thing you learned or thought
about yesterday. Who would like to go rst?
Say:
Slide 6.1
Welcome, review of day 2, and introduction to Module 6
20 minutes
Teaching Instructions: Facilitate a very brief review discussion.
205
Slide 6.2
Please turn to Module 6, page 125 in your manuals.
In Module 3 we began answering the question What is treatment? by looking at
treatment in different ways.
Say:
What were some of those ways that people view substance use disorder
treatment (SUD) in your communities?
Say:
Teaching Instructions: If participants have difculty answering the question, refer
them to Module 3, Resource Pages 3.1 and 3.2, in their manuals.
206
Slide 6.3
In Module 6, we will continue to answer the question What is treatment?
by studying descriptions of the components of treatment and the continuum of
care for substance use disorders (or SUDs). On the wall, you can see the outline of a
components of treatment graphic we will be adding to throughout this module.
Continuum of care refers to the whole range of services a client can receive directly
from a treatment program or coordinated by the treatment program, the recovery-
oriented systems of care we learned about in Module 2. We will address these services,
or components, roughly in the order in which a client typically participates in them.
Weve learned that a person usually does not follow a straight path in the stages of
change. Similarly, a person may not follow a linear path from the beginning to the end
of treatment.
Its important to note that Module 6 provides an overview of treatment components, not
step-by-step instructions for providing the services. Other curricula in the training series
focus on developing skills in providing treatment components (e.g., assessment and
treatment planning, basic counseling skills, case management).
Say:
207
Slide 6.4
Provide a general description of an effective continuum of care for SUDs;
Identify differences between screening and assessment;
Describe detoxication options;
Say:
208
Slide 6.5
Dene case management;
Name and briey describe at least ve interventions typically offered in primary
SUD treatment;
Name and briey describe four types of groups often used in SUD treatment;
Say:
209
Slide 6.6
Name and briey describe the self-help/mutual-help options available in the
community/area;
Dene continuing care; and
Apply the concept of continuum of care by identifying an appropriate continuum for
a client via a case study.
Although very few programs have all of the components well be talking about, effective
treatment programs include many of them and arrange referrals (depending on
availability) for clients who need services not directly provided by the program.
Say:
210
Take a look at the graphic on the wall. Well be talking about the components of four
parts of a continuum of care:
Pretreatment;
Primary treatment;
Case management; and
Continuing care, including ongoing recovery management.
You will spend the day listening to presentations and participating in small-group
exercises for each area and a case study exercise. Throughout the day, we will be
adding to the components of treatment wall graphic.
Please form four small groups. You will stay in these groups most of the day, so take
your belongings with you.
Say:
Slide 6.7
211
We will begin with pretreatment components. These parts of the continuum of care
happen before primary treatment:
Outreach;
Screening and brief intervention;
Assessment and treatment planning; and
Detoxication.
Say:
Slide 6.8
Presentation: Pretreatment components
60 minutes
212
Outreach can be dened as the act of reaching out in an effort to build
connections from one group or program to another. It also means extending services or
assistance to people or groups not previously served.
Say:
Slide 6.9
213
Slide 6.10
SUD program outreach includes organized efforts to identify and screen
individuals who might have a problem with substance use, rather than wait for them to
be referred to treatment programs or to decide to enroll in a program themselves.
Say:
214
Slide 6.11
The ultimate goals of outreach are to:
Establish contact;
Build trust;
Develop relationships;
Provide needed healthcare linkages; and
Engage individuals in SUD brief interventions or treatment.
Say:
215
Slide 6.12
Outreach is important because many people who use substances will not
approach SUD treatment programs and other health services. Some reasons for this are
that treatment programs are often seen as:
Intimidating;
Difcult to get to;
Too rigid or judgmental in their approach;
Irrelevant to an individuals immediate needs; and
Too costly.
Say:
216
Slide 6.13
Outreach efforts can be conducted in a variety of ways and in different settings.
For example:
A treatment program can offer community education about SUDs and treatment
options at meetings of business and religious community leaders or community
workshops.
An addiction professional can conduct outreach in homeless shelters, HIV or other
medical clinics, community centers, drop-in centers, and so on. The professional could
be an employee of a local treatment program or of the shelter, clinic, or center.
Professionals or peers (individuals who are in recovery from SUDs) can offer
education and/or screening services in schools, social centers, and clinics.
Say:
217
Slide 6.14
Additionally, outreach efforts can be provided by a variety of staff in other settings:
Paraprofessionals can place literature and be present in dance-clubs and gambling
casinos where substance use is encouraged.
Peer educators can spend time in places frequented by people who are known to
inject drugs or by sex workers.
Medical staff in the emergency room, orthopedic centers, or primary care ofces can
provide brief interventions and/or referrals to SUD professionals.
Although these examples involve specic settings, outreach efforts should target the
cross-section of people who use substances and not focus exclusively on only the most
visible populations.
Say:
Teaching Instructions: Note responses on newsprint labeled Outreach.
What types of outreach are you familiar with in your communities? In what settings
are these efforts taking place?
Ask:
218
Slide 6.15
Screening is the process of identifying individuals with possible SUDs. Screening
provides an opportunity to initiate discussions with individuals about their substance use.
The screening process does not exactly identify what kind of problem the person might
have or how serious it might be; it simply determines whether a problem exists and
whether further assessment is needed.
Say:
219
Slide 6.16
The difference between screening and assessment is that assessment tries to
identify as closely as possible the nature of an SUD and other issues and the level of
intervention that may be needed.
Say:
220
Slide 6.17
Screening should be conducted using a validated brief instrument (i.e., test)
to quickly identify a persons pattern of substance use. The validity of a screening
instrument is the degree to which it actually measures what it claims to measure.
In the past, screening instruments were used to identify active cases of drug
dependence, but, in recent years, screening has expanded to identify individuals across
the full spectrum of usefrom risky substance use to addiction.
The World Health Organization (WHO) has developed two screening instruments that
have been tested and validated with international populations:
AUDIT is a 10-item screening tool developed to identify individuals whose alcohol
consumption has become hazardous or harmful to their health.
The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST),
developed by an international group of SUD researchers for the WHO, identies
substance use and related problems in primary and general medical care settings.
Say:
221
Slide 6.18
Many other screening instruments have been designed for use with adults and
adolescents. Resource Page 6.1 provides a list of available screening instruments. These
instruments have not been validated for all age groups or for all cultural groups.
Say:
222
Slide 6.19
Screening usually identies individuals as having:
No or low risk of an SUD;
Moderate risk of an SUD; or
Severe risk of or active addiction.
Individuals who screen as having no or low risk of an SUD can be congratulated and
encouraged to maintain the status quo. If there is a history of drug dependence in their
family (mother, father, uncle, aunt, grandparent), then information about the genetic
components of addiction should be provided.
Those found to be at moderate risk may need only a brief intervention, whereas those
found to be at high risk should be referred for assessment and treatment.
Say:
Teaching Instructions: If you have a pointer or laser, point to each box as you
describe it.
223
Slide 6.20
Brief intervention focuses on increasing a persons insight into and awareness of
substance use and behavioral change.
Brief intervention can be provided through a single session or multiple sessions of
motivational interventions. These interventions can be provided by and SUD counselor
or peer counsellor. They may also be provided by trained medical or social services
program staff.
Well be talking more about motivational interventions, particularly motivational
interviewing, in Module 7.
Say:
224
Slide 6.21
Individuals who have screening results that indicate a severe risk of developing
SUDs or that indicate an active addiction should be referred to a program for
assessment and treatment planning.
The goals of a comprehensive assessment are to:
Provide a foundation for treatment planning;
Establish a baseline for measuring a clients progress;
Prioritize a clients problems;
Set priorities for treatment and case management intervention; and
Identify client strengths and other recovery capital that can support recovery.
Say:
225
Slide 6.22
Assessment begins with engaging the client, obtaining the clients history,
collecting data on the client, and observing the client during the rst visit. Its important
to remember that although it begins at the rst visit, assessment is an ongoing process
as the clients needs change over time.
Say:
226
Slide 6.23
During a comprehensive assessment, the counselor should obtain at least the
following basic information:
The clients reason for seeking treatment and his or her opinion of the problem;
Current and past substance use and drug treatment;
Family history of substance use;
Medical conditions or complications;
Say:
227
Slide 6.24
Risk of withdrawal and need for supervised detoxication;
Suicide, health, and other crisis risk assessment;
Emotional/behavioral/cognitive status, including the presence of a mental disorder;
Educational and vocational background;
Say:
228
Slide 6.25
Legal status;
Readiness to change;
Natural supports within the family, workplace, and community;
Relapse or continued-use potential; and
Recovery environment (e.g., living situation, barriers and supports for recovery).
Say:
229
Slide 6.26
A number of methods can be used for assessment:
Clinical interview;
Assessment instruments;
Collateral sources, with the clients permission (e.g., family, friends, employer, referral
sources); and
Urine or other testing for substances.
Say:
Teaching Instructions: Note responses on newsprint labeled Assessment.
What methods does your organization use for assessing new clients?
Ask:
230
Slide 6.27
A thorough assessment is the basis of treatment planning. The treatment plan is
an individualized outline for treatment and services based on the clients specic needs
identied in the assessment process.
Treatment planning is a joint activity that involves the counselor, the client, other
treatment providers, and sometimes the clients family members.
Say:
231
Slide 6.28
An effective treatment plan identies and clearly distinguishes needs that:
Will be addressed during treatment;
Require referral to other providers; and
Will be deferred to a later time.
Say:
232
Slide 6.29
The treatment plan needs to be:
Individualized;
Flexible;
Realistic with behavioral objectives that are achievable, observable, and measurable;
Simple so that clients being served, their families, and staff members can understand
them;
Useful with measurable indicators of progress;
Focused on solutions and strengths and not on negative factors;
Clear in identifying the type and frequency of interventions; and
Responsive to changes and progress.
Say:
233
Slide 6.30
The rst step of treatment planning is to decide the level of care the client needs
and is willing to accept, including the intensity, duration, and setting.
This step includes determining whether the program can adequately meet the clients
needs or whether the client should be referred to a different program.
Say:
234
Slide 6.31
Treatment planning includes determining whether:
The program can meet the clients needs or should be referred;
Treatment for co-occurring mental or medical disorders is needed; or
The client is in need of supervised detoxication.
Say:
235
Slide 6.32
Detoxication is the process of
Stopping substance use;
Clearing the substance from the body; and
Managing the withdrawal syndrome.
Say:
Teaching Instructions: Note responses on newsprint labeled Withdrawal
Syndrome. Clarify the following, if necessary:
A withdrawal syndrome is a predictable set of signs and symptoms that occur
when a person abruptly stops taking a psychoactive substance or rapidly
decreases the amount taken.
What is a withdrawal syndrome?
Ask:
236
Slide 6.33
The particular signs and symptoms, the intensity of them, and the risk involved in
withdrawal depend on:
The substance used;
The amounts taken over time; and
The length of time the substance was used regularly.
Many people manage detoxication on their own, but others benet from or must have
additional support and monitoring. Untreated withdrawal may be dangerous or fatal,
particularly withdrawal from benzodiazepines or barbiturates. Withdrawal from other
drugs, like opioids, is not life threatening but can be extremely painful without medical
support.
Medications are available to help with detoxication from opioids, benzodiazepines,
barbiturates, and other sedatives. Currently, no medications can help with stimulant
withdrawal.
Say:
237
Slide 6.34
Medications are available to help with detoxication from:
Opiods;
Benzodiazepines;
Barbiturates; and
Other sedatives.
Scientic literature is still mixed on whether medications should be used with stimulant
withdrawal. In most of the cases, the physical symptoms are very limited after stopping
cocaine or amphetamines. Antidepressant medications do seem to help some clients
cope with the depression that often accompanies withdrawal from stimulants.
Say:
238
Slide 6.35
There are three immediate goals for detoxication:
To provide a safe withdrawal from the substances of dependence and to enable the
person to become drug free;
To provide a withdrawal that is humane; and
To prepare the person for ongoing treatment.
Say:
239
Slide 6.36
There are several types of detoxication services:
Outpatient, home-based, or residential services without medication but with
psychosocial support (sometimes called social detox);
Outpatient services with medication and periodic monitoring (medication
supported); and
Inpatient services with medication (medically managed).
For individuals who are dependent on benzodiazepines or sedatives, a medical
evaluation to determine withdrawal risk is essential.
Say:
Teaching Instructions: Note responses on newsprint labeled Detoxication.
What types of detoxication services are available in your communities?
Ask:
240
Slide 6.37
It is important to understand that, although detoxication is often the rst step
toward recovery, it is only a rst step. Detoxication is not treatment. It does not
address the psychological, social, and behavioral problems associated with addiction.
Detoxication alone does not typically produce the lasting behavioral changes needed
for recovery.
Say:
241
Slide 6.38
For this exercise, you will work in your small groups to summarize one
pretreatment component. Im tossing you your assignments now.
Say:
Small-group exercise: Pretreatment components
40 minutes
Teaching Instructions: Give each group one of the papers you labeled Outreach,
Screening, and so on.
You will have 13 minutes to quickly complete the following three tasks:
Using your notes and manuals, summarize the key elements of your content area;
Write these key elements on newsprint, which you will then use to make a 3-minute
presentation to the rest of the participants;
Write the same information on a sheet of white paper to post on the continuum of care
wall graphic.
Say:
242
Teaching Instructions: After 8 minutes, ask the groups to have two people start
writing their key elements onto the newsprint and the white paper. Provide an
additional 2-minute warning.
Ask each group to present its summary and post the white paper under the
appropriate heading on the wall graphic.
After all four groups have presented their key elements, ask if anyone has additional
information to add to any of the content areas.
243
Slide 6.39
Good job! Were going to begin talking about case management next, but rst
lets take a 15-minute break.
Say:
Break
15 minutes
244
Slide 6.40
The next part of the continuum of care is case management.
Although case management is being discussed separately from treatment, it is actually
an integral part of treatment. Case management begins with screening and assessment
and continues throughout a persons treatment and into ongoing recovery.
Say:
Presentation: Case Management
25 minutes
245
Slide 6.41
There are many denitions of case management, but one simple denition is that
case management is the coordination of professional social and/or medical services to
assist people with complex needs, often for long-term care and protection.
Case management is often used to mean either a role (or job description) or a
set of functions. Because a role or job description varies depending on a persons
organization, this training focuses on case management as a set of functions. A
counselor will not necessarily perform all case management functions as part of his
or her job description but should understand the full range of case management
responsibilities.
Say:
246
Slide 6.42
Case management for people who are addicted is critical for a number of reasons.
First, treatment must be structured to ensure smooth movement between levels of care
(e.g., moving from a residential center to an outpatient program) while avoiding gaps
in service. Treatment services also must be prepared to respond rapidly to the threat of
relapse.
Second, addiction affects so many areas of a persons life that a range of support
services are typically needed to help the individual maintain long-term recovery while
managing to live in the community.
Finally, case management provides the client with a single contact person who is
responsible for nding and mobilizing needed resources, ensuring that the client does
not fall through the cracks.
Say:
247
Slide 6.43
Ideally, a client in SUD treatment could receive all necessary services in one place
or through integrated partnerships of service providers. However, in most places around
the world, services tend to be scattered, like pieces of a puzzle, and difcult to access.
No one program or system can meet all the needs of a person who uses substances.
Say:
248
Slide 6.44
Case managers help put the pieces together for their clients.
Say:
249
Slide 6.45
Case management functions include:
Assessment;
Service planning;
Linkage and referral;
Monitoring; and
Advocacy.
Say:
250
Slide 6.46
Assessment and service planning for case management are closely related to the
initial assessment and treatment plan discussed earlier. A case management plan can
be incorporated into a clients overall treatment plan but can also be done as a separate
process that looks specically at what a client needs in addition to SUD treatment.
Say:
251
Slide 6.47
Linkage and referral occurs both within a program and between programs (inter-
program). Within a treatment program, a case manager helps clients navigate between
levels of care (e.g., outpatient to residential or primary treatment to continuing care).
Inter-program linkage is a critical part of case management because no one program
can meet all of a clients needs. The goal of inter-program case management is to
connect programs to one another to provide more services to clients.
Say:
252
Slide 6.48
A counselor can establish linkages within his or her own program or with other
programs to help clients obtain:
Treatment for mental disorders;
Family therapy;
Child care;
Transportation;
Say:
253
Slide 6.49
Housing assistance;
Financial assistance;
Legal assistance;
HIV/AIDS or other medical testing and care; and
Educational or vocational services.
Say:
Teaching Instructions: Note responses on newsprint labeled Service Providers.
What types of service providers does your program generally work with?
Ask:
254
Slide 6.50
Referring a client for a particular service is not enough. A case manager ensures
that the client engages in services and monitors the clients progress.
The case manager identies barriers (related to both clients and services) and works
with the client and referral source to overcome them.
This type of close coordination requires that a case manager have excellent
communication skills.
Say:
255
Slide 6.51
Advocacy is a process of speaking out on issues of concern to apply inuence on
behalf of a person or persons. Advocating for clients can be difcult at times, but it is an
important function of case managers.
Say:
256
Slide 6.52
Case managers need to advocate with many systems, including other agencies,
healthcare providers, legal systems, and families.
Say:
257
Slide 6.53
Case managers can advocate by educating non-SUD treatment service providers
about the specic needs of a given client or about SUDs in general. At times, the case
manager must negotiate directly with a service provider on behalf of a client.
Case management functions must be adapted to t the particular needs of a treatment
program and its community context.
Say:
258
Slide 6.54
How has advocacy t into the work you do with your clients? In what ways does
the concept of advocacy t or not t into the context of your communities? What
difculties have you encountered while advocating for your clients?
Ask:
Teaching Instructions: Facilitate a brief discussion.
259
Slide 6.55
Were going to do a summary exercise regarding case management. You will have
13 minutes to quickly complete the following three tasks:
Using your notes and manuals, summarize the key elements of your content area;
Write these key elements on newsprint, which you will then use to make a 3-minute
presentation to the rest of the participants; and
Write the same information on a sheet of white paper to post on the Continuum of
Care wall graphic.
You may use colored paper, colored markers, and scissors to add creative detail to your
assigned topic.
Say:
Small-group exercise: Case management components
30 minutes
260
Teaching Instructions: Give each group one of the slips of paper in the envelope
labeled Exercise instructions: Case management.
After 8 minutes, ask the groups to write their key elements on the newsprint and the
white paper. Provide an additional 2-minute warning.
Ask each group to present its summary and post the white paper under the
appropriate heading on the wall graphic.
After all four groups have presented their key elements, ask if anyone has additional
information to add to any of the topic areas.
261
Slide 6.56
Although both individual and group counseling sessions are important parts of
primary treatment for SUDs, group counseling typically is the most frequently used
modality.
Group counseling is a cost-effective way of providing treatment because it allows a single
treatment professional to help a number of clients at the same time. But beyond cost-
effectiveness, group counseling is particularly appropriate for treating SUDs because it:
Provides opportunities for clients to develop communication skills and participate
in socialization experiencesthese activities are particularly useful for individuals
whose socializing has revolved around using drugs;
Creates an environment in which clients help, support, and, when necessary,
confront one another;
Introduces structure and discipline into the often chaotic lives of clients;
Provides norms that reinforce healthful ways of interacting and a safe and supportive
environment that is crucial for recovery;
Say:
Presentation: Primary treatment, Part 1Group counseling
10 minutes
262
Slide 6.57
Helps clients broaden understanding of their recovery capital and barriers to
recovery;
Supports individual assessment of critical risk and protective factors;
Advances individual recovery (group members who are further along in recovery can
help other members); and
Provides a venue for group leaders to transmit new information, teach new skills, and
guide clients as they practice new behaviors.
Say:
263
Slide 6.58
Placement of a client in a group must be based on the clients particular needs
and stage of recovery. In addition, some clients should never be assigned to the same
groups. For example:
Perpetrators and victims of domestic violence must be in separate groups.
Neighbors, friends, relatives, spouses, or signicant others should not be assigned
to the same group (with the exception of family groups). In rural and remote areas,
this may not be possible. In those cases, careful preparation and discussions about
condentiality must take place.
The optimal size of a group is between 8 and 15 members. Groups usually do not last
more than 1.5 hours. People tend to have a difcult time continuing to focus after that
length of time.
Please turn to Resource Page 6.2, page 203 in your manuals. This page lists a number of
the benets of group counseling.
Starting with the person to my left, I would like each of you to read one benet, until we
have completed the list.
Say:
264
Slide 6.59
Treatment programs typically offer a number of different types of groups. In the
next exercise, your small groups will take a look at some of these other types. Not all
programs use all these types of groups.
Say:
Small-group presentations: Types of groups
60 minutes
Teaching Instructions: As you introduce the exercise, give each small group several
sheets of newsprint.
Teaching Instructions: Give each small group one of the slips of paper in the
envelope you labeled Exercise: Types of groups.
265
The group assigned to psychoeducation groups will use Resource Page 6.3 to
prepare. The rest of you will use the appropriate sections of Resource Page 6.4.
You will have 10 minutes to prepare brief presentation on your assigned types
of groups. Include examples of groups that you use in your treatment programs.
Use newsprint, markers, colored paper, and anything else you want to make your
presentation as creative as possible.
Again, please also write key points on a sheet of white paper to add to the wall graphic.
Say:
After 15 minutes, begin the presentations.
After the presentations, ask participants if they have questions or anything to add.
Ask each small group to attach its key points sheet to the appropriate spot on the
wall graphic.
266
Slide 6.60
You all worked very hard this morning! After our lunch break, well talk about another
component of primary treatment: individual counseling. Please be back in an hour.
Say:
Lunch
60 minutes
267
Slide 6.61
Although group counseling has many benets, it is not appropriate for all clients.
For example:
Some socially anxious or very introverted clients cannot tolerate groups well.
These clients should be offered individual counseling until they are comfortable
participating in group sessions or at least placed in low-intensity group sessions that
focus on coping skills training.
Some clients with severe mental disorders, such as schizophrenia or antisocial
personality disorder, cannot participate in groups and can attend individual therapy
only.
Clients who violate the principles of group therapy by failing to honor group
agreements or dropping out regularly and clients who cannot control their impulses
might respond better to individual counseling.
Say:
Presentation: Primary treatment, Part 2Individual counseling
10 minutes
268
Slide 6.62
Although individual counseling may be the only appropriate modality for some,
individual sessions also are benecial for all clients and some are usually provided as
part of treatment.
The focus of individual counseling sessions varies depending on the type of program,
the clients stage of recovery, and the clients individual needs. However, there is usually
some sort of structure to an individual session.
Say:
269
Slide 6.63
In individual counseling a counselor can:
Ask how the client is feeling;
Ask the client for his or her reactions to a recent group meeting; and
Explore how the client spent his or her time since the last session.
Say:
270
Slide 6.64
The counselor also may:
Inquire about substance use;
Ask whether there are any urgent issues;
Review treatment plans and coping strategies; and
Address fears and anxieties related to change.
Say:
271
Slide 6.65
An individual session is also a time for the counselor to:
Provide personalized feedback on substance testing results; and
Probe into sensitive issues that are difcult to discuss in a group.
Counselors also use individual sessions to help clients access services they need that are
outside the treatment programs capabilities and to plan the transition to another level
of care or discharge.
Counselors often give clients individual assignments. People in treatment can be asked
to read certain things (or listen to audiotapes), to complete written assignments (or
record them on audiotapes), or to try new behaviors.
Say:
272
Slide 6.66
A counseling session usually ends with a summary of the clients plans and a
schedule for the next few days.
We will be addressing specic group and individual counseling skills in Curriculum 4,
Basic Counseling Skills for Addiction Professionals.
Before we move on, Im going to add the individual counseling component to the wall
graphic.
Say:
Teaching Instructions: Add the sheet of paper you labeled Individual counseling
to the wall graphic under Primary Treatment.
273
Slide 6.67
In addition to group and individual counseling, programs typically offer other
components as part of primary treatment. Major components can include:
Testing for drug use;
Pharmacotherapy; and
Orientation to mutual-help groups.
Say:
Presentation: Primary treatment, Part 3Other components
30 minutes
274
Slide 6.68
Well begin by talking about testing for substance use. Testing clients for drug use
can be useful in a number of ways. Testing can:
Verify, contradict, or add to a clients self-report of substance use;
Identify a relapse to substance use;
Help assess the efcacy of the treatment plan and the current level of care; and
Encourage abstinence.
Substances show up and can be tested for in blood, urine, saliva, breath, and hair. Most
treatment programs test urine for substances.
Say:
275
Slide 6.69
There are two main types of testing: laboratory testing and point-of-care testing
(POCT).
When a program uses laboratory testing, it collects the sample (urine, for example) at
the program site and sends it to a local laboratory to test.
When a program uses POCT, it collects and tests the sample onsite. A number of POCT
kits are available for testing urine, blood, or saliva; programs usually test urine or saliva
to avoid having onsite medical staff.
Say:
276
Slide 6.70
POCTs have both advantages and disadvantages compared with laboratory
testing. Some advantages are that they:
Reveal results quickly;
Can be less expensive than laboratory testing; and
Are relatively simple to perform.
Say:
277
Slide 6.71
Disadvantages are that:
Some kits test for only a few substances; those that test for many substances may be
more expensive than laboratory testing.
They are usually limited to indicating only positive or negative results. They do not
indicate the level of the substance in the body.
Say:
278
Slide 6.72
Other potential disadvantages are that:
Programs need to have secure storage facilities and provide regular staff training on
the use of POCT.
POCT may not be admissible in court.
Laboratory testing and POCT can be misleading in monitoring abstinence. For example,
clients can abstain from their substance of choice while using other substances that may
not be included in a particular drug test. Programs usually test for the clients substance
of choice as well as other drugs commonly abused in the area.
Say:
Teaching Instructions: Note responses on newsprint labeled Drug Testing.
Do any of your programs conduct drug testing? Which types do they use?
Ask:
279
Slide 6.73
Pharmacotherapy (sometimes called medication-assisted treatment) is the use
of medications to assist in treatment of SUDs. Pharmacotherapy is used in a number of
ways:
To aid in acute withdrawal or tapering from psychoactive substances;
To discourage use of a substance by reducing its reinforcing properties or by
creating negative effects when the substance is used; and
To aid early recovery by reducing cravings or counteracting longer term symptoms
of withdrawal.
Say:
280
Slide 6.74
Medications are available for treating dependence on opioids. These medications
generally need to be prescribed by a doctor. One of the best known forms of
pharmacotherapy is methadone maintenance therapy.
Methadone can be used short term, to aid withdrawal, or long term as a maintenance
therapy. Methadone acts on the opioid receptors in the brain, blocking withdrawal.
However, it is less rewarding than opioids like heroin and morphine. Methadone
maintenance can therefore help people function well in their lives.
There is controversy surrounding methadone maintenance and it is not available or
even legal in many countries.
Say:
281
Slide 6.75
Pharmacotherapy is typically used along with counseling and other treatment
services, not in place of them.
Module 7 will provide more detail on pharmacotherapy in general and methadone
maintenance in particular.
Say:
282
Slide 6.76
Treatment programs typically educate clients about self-help and mutual-help
programs.
Mutual-help programs are alternatives or enhancements to professional counseling.
In these programs, ordinary citizens meet to discuss similar struggles. Participants in
mutual-help groups support and encourage one another to become or stay drug free.
Twelve-step programs are perhaps the best known of the mutual-help programs.
Say:
283
Slide 6.77
Alcoholics Anonymous (AA) was the rst mutual-help group, created in the mid-
1930s in the United States by Bill Wilson and Bob Smith.
Narcotics Anonymous (NA) was developed in the 1950s for those who were dependent
on substances other than alcohol.
AA and NA use the experiences of their members, a 12-step process, and spirituality to
combat substance dependence.
The hallmarks of AA and NA include the 12 Steps to recovery. Please turn to Resource
Page 6.5, page 209 in your manuals.
Starting with the person on my right, please each read one step.
Say:
284
Slide 6.78
Another hallmark of AA and NA is group meetings. Group meetings can be
open, meaning that the general public is welcome to attend, or closed, meaning
that only those with an alcohol use disorder may attend. Meetings are led by members
on a rotating basis. There are different types of group meetings, including:
Discussion meetings, in which a leader introduces a topic with some brief comments
and then invites others to share on the topic;
Speaker meetings, in which the person in recovery shares his or her story; and
12-Step meetings, in which a particular step is discussed.
In addition to the main types of meetings, there also are special meetings for women,
men, gay and lesbian members, and others.
Say:
285
Slide 6.79
Sponsorship is also an important part of 12-Step programs of recovery. A sponsor
is a 12-Step program member who has had successful experience within the program
and who works personally with a member with less experience. A sponsor is similar
to a mentor, but 12-Step programs see sponsorship as a relationship of equals. The
programs strongly recommend that a sponsor be of the same gender as the person
being sponsored.
Say:
286
Slide 6.80
Over the years, many additional recovery programs have developed based on
the AA 12-Step process, including Marijuana Anonymous, Cocaine Anonymous, and
Nicotine Anonymous.
Twelve-Step group meetings can be found in most countries around the world, though
they may be difcult to nd outside large cities in some countries. There are, however,
online meetings for those who cannot attend live meetings.
Say:
287
Slide 6.81
There also are 12-Step programs for family members and friends of those with
SUDs. These programs include:
Al-Anon (for adult or older adolescent family members and friends);
Alateen (for older children and younger adolescents);
Alatot (for young children); and
Nar-Anon (for all family members).
Say:
288
Slide 6.82
Some studies have found 12-Step programs to be an effective program of
recovery, but other studies have not found signicant effects. Twelve-Step programs are
very difcult to study scientically, because:
They are anonymous, so obtaining a roster of participants is impossible; and
Participation is voluntary, so controlled studies are difcult if not impossible.
Say:
289
Slide 6.83
Twelve-Step programs are not for everyone. Some people are uncomfortable with
the spiritual aspects of the program. Although AA and NA literature states that even
atheists can use the programs productively, group meetings tend to include Christian
elements like reciting the Lords Prayer.
Those who have difculty in group and social situations may not be able to effectively
use a group recovery program.
Say:
290
Slide 6.84
Additional mutual-help groups have been developed over the years, including
several that building upon the AA and NA model but use other treatment approaches:
Women for Sobriety
Rational Recovery
SMART (Self-Management and Recovery Training) Recovery
Others focus more on specic faith-based or cultural traditions. Because a local church,
temple, synagogue, or spiritual group often hosts them, they also provide linkage for
the participants into a broader support network.
Examples of these types of groups include:
Celebrate Recovery
Millati Islami
Native American Wellbriety Movement
Say:
291
Slide 6.85
Women for Sobriety is loosely based on rational-emotive-behavioral principles,
but uses certied facilitators to run meetings addressing the unique needs of women in
recovery. They also have Web-based meetings and chat groups.
Rational Recovery is based on the rational-emotive-behavioral approach, but does not
involve group meetings, focusing instead on short-term educational support to help
its members rid themselves of the irrational beliefs that support addiction without the
necessity for a higher power belief.
Say:
292
Slide 6.86
The SMART program, an off-shoot of RR, is based on a short-term, scientic,
rational-emotive-behavioral approach that addresses:
Motivation;
Urges;
Thoughts;
Feelings;
Behaviors; and
Satisfactions.
The SMART Program does not use sponsors, but does have internet-based groups.
Say:
293
Slide 6.87
Celebrate Recovery is one of several Christian-based mutual help groups that
have been established in recent years. Some are based on the AA and NA 12 Steps and
address alcohol and drug abuse.
Others, like Celebrate Recovery are focused on scriptural teachings that parallel the
12 Steps, but are used to address multiple problems a participant might bring. They
typically include a worship component, but avoid challenging participants.
The role of the sponsor is replaced by the congregation and the pastor/priest to
provide support for a SUD client in recovery. In the United States, Celebrate Recovery is
accepted as an alternative mutual-help group by most mental health and drug courts.
Say:
294
Slide 6.88
Millati Islami is a world-wide fellowship of men and women, joined together on
the Path of Peace. Millati Islami is a religiously-specic approach based on spiritual
principals contained in the Quran.
Groups integrate the treatment requirements of both Al-Islam and the 12-step approach
to recovery into a simultaneous program addressing all substances. Participants in
groups share experiences, strengths, and hopes for recovering from active addiction
by looking to Allah for guidance on ways not to be slaves to mind and mood
alteringchemicals and negative people, places, things, and emotions.
Say:
295
Slide 6.89
The Native American Wellbriety Movement was created by the White Bison
Society, an organization which has been giving leadership to addressing substance use
and abuse in the American Indian community for several decades. It was created in
response to research documenting the lack of success American Indians with SUDs had
in non-native treatment and recovery programs.
Rooted in tribal spiritual beliefs and rituals, it incorporates the healthy parts of the
principles, laws, and values of traditional culture. The Wellbriety model has been
used both in AA and NA-type groups and as a public health approach to create sober
and healthy communities where all individuals work toward being balanced mentally,
emotionally, physically, and spiritually.
There are many other mutual-help groups who address certain populations, including
those with co-occurring mental and medical disorders. However, none of the programs
weve talked about have conducted research that documents their effectiveness.
Say:
What mutual-help programs are available in your community?
Ask:
Teaching Instructions: Write answers on the newsprint sheet you labeled Mutual-
help programs.
296
Slide 6.90
SUD treatment counselors should be as familiar as possible with the range of
mutual-help programs so that they can:
Orient clients to what is available;
Encourage clients to try different programs;
Assist clients in selecting a useful support program; and
Advocate for creation of mutual-help groups where they are not available.
Say:
297
Slide 6.91
Weve talked about some basic components of primary treatment: group and
individual counseling, drug testing, pharmacotherapy, and orientation to mutual-help
programs. In addition to these core services, many programs offer other components.
Other components offered to those in treatment depend on the type, setting, and
duration of programs, but these additional components can include:
Medical treatmentfor example, a clinic can offer both medical and SUD treatment
services or a hospital-based SUD program can provide a client with all the medical
care he or she needs.
Treatment for mental disordersfor example, some programs can integrate treatment
for both mental and substance use disorders. Others can provide medication
management and intense case management for those with co-occurring disorders.
General schooling for adolescents or young adultsfor example, a longer term
residential program (like a therapeutic community) can integrate schooling into the
daily schedule.
Say:
298
Slide 6.92
Other services might include:
Employment skills trainingas with general schooling, a longer term residential
program can integrate employment skills training into the program.
Child care for group or individual sessionsfor example, some outpatient programs
provide onsite child care while clients attend treatment sessions. Some residential
programs allow women to bring their children with them to treatment and provide
child care during treatment sessions.
Transportation to treatment activities and mutual-help group meetingsfor
example, outpatient programs can provide transportation to and from treatment
sessions. Residential programs can provide transportation to mutual-help group
meetings.
Say:
299
Slide 6.93
Were going to do an activity regarding primary treatment components, but rst
its time for a break.
Say:
Break
15 minutes
300
Slide 6.94
My co-trainer is going to add to the wall graphic the three components of primary
treatment weve just covered: substance testing, pharmacotherapy, mutual-help groups,
and other components.
Meanwhile, I would like each of your small groups to discuss for 15 minutes how these
components are incorporated into SUD treatment in your community. Please designate
a reporter who will take notes and report out only three signicant ndings in each of
these areas to the large group:
Testing for drug and alcohol use;
Pharmacotherapy;
Mutual-help groups; and
Other components.
Say:
Small-group exercise: Primary treatment
40 minutes
301
Teaching Instructions: One of the trainers should add the four sheets of white paper
labeled Testing for drug Use, Pharmacotherapy, Mutual-help groups, and
Other components to the wall graphic under the heading Primary Treatment.
Provide 5-minute transition warnings to help groups move from one component
discussion to the next.
This is a popcorn exercise: Inform each group that their recorder has only 1
minute to stand and report out their three ndings as you call out their table. Start
with Testing for Drug Use and go around the room, then move to the next topic.
Make or take a reective comment to summarize each component if time permits.
302
Slide 6.95
To complete our continuum of care wall graphic, well now talk about continuing
care.
The continuing care process begins with discharge planning. Discharge planning is
nalized as the treatment relationship enters the nal stage with the client, although it
should begin with the initial assessment and treatment planning. Discharge planning
leads to development of a continuing care plan.
A continuing care plan is a documented plan of action developed before discharge
or transfer to another level of care. It is a structured, goal-oriented list of services
developed jointly by the client and the counselor. The plans purpose is to assist in
maintaining the progress a client has made by linking him or her with supportive
resources in the clients environment.
The plan should incorporate elements of a clients recovery capital as well as possible
limitations or challenges that will affect the clients ongoing recovery. Attention should
be given to family involvement, nancial constraints, physical needs, and ongoing
therapy needs (for example, treatment for mental disorders or trauma, family therapy).
Say:
Presentation: Continuing care
15 minutes
303
Slide 6.96
The plan contains written, treatment-related, measurable objectives for the client
to, for example:
Sustain abstinence;
Develop continuing recovery supports; and
Gain community living.
Say:
304
Slide 6.97
Other objectives would be for the client to:
Gain employment skills;
Gain education;
Obtain gainful employment or attend school; or
Obtain counseling for a co-occurring mental disorder.
Say:
305
Slide 6.98
The plan should also address ways to achieve less concrete goals, like:
Developing a deeper understanding of self and others;
Increasing responsibility;
Working on resolving family difculties;
Consolidating, reinforcing, and becoming comfortable with the changes in his or her
life; and
Integrating into the community with a meaningful role.
Say:
306
Slide 6.99
Options for continuing care include structured continuing care groups (either
onsite or by referral). These groups typically focus on topics such as:
Exploring substance-free social and recreational activities;
Continued work on life skills such as solving problems;
Relapse prevention training;
Health and wellness;
Education and career planning;
Supportive counseling; and
Leadership skills development.
Say:
307
Slide 6.100
Continuing care also includes supports outside structured continuing care groups,
such as:
Mutual-help group attendance;
Individual therapy;
Treatment/medication management for mental disorders;
Methadone maintenance; and
Phone therapy or monitoring.
Say:
308
Slide 6.101
Other supports include:
Religious or spiritual institutions;
Cultural traditions and values that support recovery;
Periodic home visits or booster sessions;
Intensive case management monitoring and supports; and
Job training or other schooling.
Some communities also provide transitional living programs in which a client can
gradually become more independent while not having to worry about housing.
A good continuing care plan and program will include a plan for action in response to a
lapse or relapse, including readmission to primary treatment.
Say:
309
15 minutes
Thank you for your great participation today!
Say:
Teaching Instructions: Encourage participants to ask questions or make comments.
Refer any questions back to the group before answering yourself. As the group is
discussing, distribute the day 3 Daily Evaluation forms.
You each have a Daily Evaluation form. I want to remind you that your input is
very important to us; please complete the form before you leave. Thank you, and have
a good evening.
Say:
310
Slide 6.102
Good morning. Welcome back to Day Four of Curriculum Two. Just prior to the
conclusion of our work yesterday, we had a presentation on continuing care services.
We will be starting today with a follow-up small-group exercise to identify existing and
needed services in your communities.
Say:
Teaching Instructions: As participants enter, ask them to sit in the same groups as
yesterday.
311
At your tables are newsprint and sheets of white paper. Your group will have 15
minutes to list continuing care and ongoing recovery services that are available in your
community on the white paper. On the newsprint, each group will have 15 minutes to
identify services you wish were available for the continuing care component of SUD
treatment in your community.
Please designate a reporter who will take notes and report to the large group. After
each presentation, I will collect your list of existing services and place it on our
components of treatment wall graphic.
Say:
Slide 6.103
Small-group exercise: Continuing Care
60 minutes
312
Teaching Instructions: Provide a 2-minute warning before the end of each
10-minute brainstorming period.
Instruct each recorder that she or he has 3 minutes to report out the list of existing
continuing care services. Provide the same information before the report-out of the
services participants wish were available in their communities.
After each list is reported, take two or three summary comments by asking if there
were similarities or differences across the four group reports.
313
For this nal exercise, were going to use only three small groups.
Say:
Slide 6.104
You will nd three case studies in Resource Pages 6.6, 6.7, and 6.8, starting on
Say:
Teaching Instructions: Ask participants from one of the four small groups to move
into one of the other three groups. While the groups are resettling, give each group
two sheets of newsprint and one of the human gure pages you copied.
Small-group exercise: Continuum of care case study
90 minutes
314
Your group has 60 minutes to develop a continuum of care story based on your
assigned case study. To prepare, follow the guidelines on the slide:
Read your assigned case study.
Take a few minutes to dress your gure appropriately, using the markers.
Develop a presentation that illustrates your clients movement through an
appropriate continuum of care.
Use the information in the case study as a starting point, then add information about
the persons movement through the continuum (as needed).
This exercise is not a test of your assessment or treatment planning skills but simply a
way both to review the material and to demonstrate that you understand the concept of
a continuum of care.
When you complete your work, you will use your gure and the wall graphic to present
your stories, so you dont need to spend time making your newsprint pages pretty.
Say:
Teaching Instructions: Assign one case study to each group.
After 60 minutes, ask each group to present its story.
315
You did a great job on your presentations!
Weve now nished our work on the components of a continuum of care. For the rest of
the day and most of tomorrow, well be looking at evidence-based practices. But before
we start, lets take a 15-minute break.
Say:
Slide 6.105
Teaching Instructions: During the break, tape to the wall the graphic forms you
prepared for the Module 7 presentation on cognitive-behavioral therapy and
motivational enhancement. Be sure to leave plenty of room for participants to add
to the graphic.
316
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Resource Page 6.2: Benets of Group Counseling in SUD
Treatment
Groups provide positive peer support and pressure to abstain from substances of
abuse.
Groups reduce the sense of isolation that most people who have substance use
disorders experience.
Groups enable people who abuse substances to witness the recovery of others.
Groups help members learn to cope with their substance abuse and other problems
by allowing them to see how others deal with similar problems.
Groups can provide useful information to clients who are new to recovery.
Groups provide feedback concerning the values and abilities of other group members.
Groups offer family-like experiences.
Groups encourage, coach, support, and reinforce as members undertake difcult or
anxiety-provoking tasks.
Groups offer members the opportunity to learn or relearn the social skills they need
to cope with everyday life instead of resorting to substance abuse.
Groups can effectively confront individual members about substance abuse and
other harmful behaviors.
Groups allow a single treatment professional to help a number of clients at the same
time.
Groups add needed structure and discipline to the lives of people with SUDs, who
often enter treatment with their lives in chaos.
Groups instill hope and a sense that If she can make it, so can I.
Groups help clients identify community resources and barriers to recovery.
Groups encourage individuals to assess and build on their recovery capital.
Resource Page 6.3: Psychoeducation Groups
Overview
These groups provide a supportive environment in which clients learn about
substance dependence and its consequences.
Psychoeducational groups feature a low-key rather than emotionally intense
environment.
Didactic components often are supplemented by videos or slides to accommodate
different learning styles.
Psychoeducational groups focus on substance use disorders but also may include
education about mental disorders and common co-occurring medical disorders.
Psychoeducation groups may be clients only, include clients and their families, or
include only family members.
Psychoeducational groups start at the beginning of treatment, and topics change
according to clients length of time in treatment.
Typical Sequence of Topics Addressed in Psychoeducational Groups
Early Recovery
Learning about biopsychosocial disease and recovery processes;
Understanding the effect of specic drugs on the brain and body;
Placing symptoms of substance use disorders in the context of other behavioral
health problems;
Learning about early and protracted withdrawal symptoms for specic drugs;
Knowing the stages of recovery and the clients place in the continuum of care;
Learning strategies for quitting and nding the motivation to stop;
Minimizing risks of HIV/AIDS, hepatitis C, and sexually transmitted diseases;
Identifying high-risk situations that are cues or triggers to substance use: people,
places, and things;
Identifying peer pressures and compulsive sexual behavior as triggers;
Understanding cravings and urges, learning to extinguish thoughts about substance
use, and coping with cravings;
Structuring personal time;
Coping with high-risk situations;
Understanding abstinence and the use of prescription and over-the-counter
medications;
Understanding the goals and practices of various 12-Step or other mutual-help
groups;
Identifying and using positive support networks; and
Understanding the relapse process and common warning signs.
Maintenance and Continuing Care
Identifying tools to prevent relapse;
Developing personal relapse plans;
Counteracting euphoria and the desire to test control;
Improving coping and stress management skills;
Learning anger management and relaxation techniques;
Enhancing self-efcacy for handling risky situations;
Responding safely to slips and avoiding escalation;
Finding recovery resources;
Structuring leisure time and nding recreational activities;
Knowing the importance of personal health: diet, exercise, hygiene, and checkups;
Taking a personal inventory;
Handling shame, guilt, depression, and anxiety;
Understanding family dynamics: enabling and sabotaging behaviors;
Rebuilding personal relationships;
Understanding sexual dysfunction and healthy sexual behavior;
Developing educational and vocational skills;
Learning daily living skills: money management, housing, and legal assistance;
Embracing spirituality and recovery and nding meaning in life;
Recognizing grief and loss and the relationship to substance use;
Learning about parenting: basic needs of children and their developmental stages
and developmental tasks; and
Maintaining balance in life.
Resource Page 6.4: Types of Treatment Groups
Treatment Engagement Groups
Treatment engagement groups focus on:
Understanding motivation and committing to treatment;
Counteracting ambivalence and denial;
Determining the seriousness of the substance use problem;
Facilitating self-assessment, setting goals, and self-monitoring progress;
Overcoming common barriers to treatment (transportation, time, child care); and
Learning about treatment goals, expectations, and rules.
Relapse Prevention Groups
Relapse prevention groups focus on helping clients:
Understand cravings and urges;
Learn specic strategies for coping with cravings;
Structure personal time;
Understand abstinence and the use of prescription and over-the-counter medications;
Identify personal issues that could interfere with recovery;
Identify, develop, and use positive social support networks;
Analyze one anothers personal triggers and high-risk situations for substance use
and determine ways to manage or avoid them; and
Learn substance refusal skills by acting out scenarios in which they are invited to use
substances and practice appropriate responses.
Skills Development Groups
These groups offer clients the opportunity to practice specic behaviors in the safety
of the treatment setting.
Common types of skills training include:
Assertiveness training. Clients learn the differences among assertive, aggressive,
and passive behaviors and practice being assertive in different situations.
Stress management. Clients identify situations that cause stress and learn a variety
of techniques to respond to stress.
Problem solving. Clients learn strategies and specic steps to solve problems.
Life skills training. These groups can include learning and practicing employment
skills, leisure activities, social skills, communication skills, goal setting, anger
management, and money and time management.
Support Groups (for example, process-oriented recovery groups)
These groups include clients in the same recovery stageusually a middle to late
phase of treatmentwho are working on similar problems.
Members focus on immediate issues and on:
Practical ways to change negative thinking, emotions, and behavior;
Learning and trying new ways of relating to others;
Tolerating or resolving conict without resorting to violence or substance use; and
Looking at how members actions affect others and the function of the group.
Support groups may be led by either counselors or peers.
Special Interest Groups
These groupsusually organized at a later stage of treatmentfocus on an issue of
particular signicance to and sensitivity for group members.
Special interest groups include:
Mens or womens issues;
Sexual orientation;
HIV/AIDS;
Criminal history/reentry into the community;
Co-occurring mental or physical disorders; and
Physical and sexual abuse.
Family Groups
Family groups can be multifamily and include a mix of spouses, parents, and older
children.
They focus on providing a supportive environment for families to interact and
discuss common concerns and problems.
Family groups also can by psychoeducational, focusing on educating family members
about addiction, its individual and family consequences, recovery, and relapse.
Couples groups focus on the interplay between couples dynamics and issues of
recovery.
Family groups in treatment programs focus on the issues of addiction and are
typically not family therapy, which must be conducted by trained family therapists
and which focuses on serious and longstanding family issues and problems.
An exception would be the family groups in certain models of family treatment for
adolescents. These models will be discussed in Module 7.
Resource Page 6.5: 12 Steps of Narcotics Anonymous
1. We admitted that we were powerless over our addiction, that our lives had become
unmanageable.
2. We came to believe that a Power greater than ourselves could restore us to sanity.
3. We made a decision to turn our will and our lives over to the care of God as we
understood Him.
4. We made a searching and fearless moral inventory of ourselves.
5. We admitted to God, to ourselves, and to another human being the exact nature of
our wrongs.
6. We were entirely ready to have God remove all these defects of character.
7. We humbly asked Him to remove our shortcomings.
8. We made a list of all persons we had harmed, and became willing to make amends
to them all.
9. We made direct amends to such people wherever possible, except when to do so
would injure them or others.
10. We continued to take personal inventory and when we were wrong promptly
admitted it.
11. We sought through prayer and meditation to improve our conscious contact with
God as we understood Him, praying only for knowledge of His will for us and the
power to carry that out.
12. Having had a spiritual awakening as a result of these steps, we tried to carry this
message to addicts, and to practice these principles in all our affairs.
Reprinted by permission of NA World Services, Inc. All rights reserved. The Twelve
Steps of NA reprinted for adaptation by permission of AA World Services, Inc.
Resource Page 6.6: Case StudyDilip
Dilip is 22 years old and single. He is unemployed and does not attend school.
He lives with his parents and two older brothers. His father works in a private
enterprise and spends a lot of time traveling. His mother is a housewife. Both
brothers have graduated from high school and are working. Dilip is close to the
older of his brothers but is not close to his mother. He respects his father a great
deal.
At 16, he started smoking tobacco and cannabis with schoolmates and drinking in
pubs socially on weekends.
In the past 6 months, he has started injecting heroin intravenously. His health has
deteriorated.
Dilip started college 6 months ago but missed a lot of classes; when he did attend,
he tended to nod off during class. His work has been sloppy or incomplete. He was
given several warnings, but he did not change his behavior. His parents tried to
intervene, but eventually he was suspended from the college.
The older of his brothers has been an enabler, covering up for Dilips drug use: he
has paid back Dilips small debts, has not informed their parents about some of
the consequences of Dilips drug use, and has lied to their parents about Dilips
whereabouts.
Dilip does not speak to his other brother. This brother is aware of Dilips drug use
and the resultant problems. He realizes that Dilip needs treatment and has tried to
motivate Dilip to seek help.
Dilip has mood swings; he feels very anxious and has difculty sleeping.
His girlfriend of 2 years broke up with him a month ago because of his drug use, and
at that time he let his brother take him to an outpatient treatment program.
He has been attending group sessions but has been unable to resist his drug
cravings and continues to use. Over the past 2 months, he has become motivated to
join the inpatient treatment program.
Resource Page 6.7: Case StudyHa
Ha is 25 years old and has been a sex worker since she was 16. Her mother was also
a sex worker and died of AIDS a year ago.
Ha started using marijuana and drinking at age 12.
She has used a variety of drugs over the years. She spent 2 years in a rehabilitation
center when she was 20 but stayed in recovery only 9 months.
She tried to change her life at that point, but she could not nd a job that lasted. Ha
eventually went back to sex work and was soon using drugs again. She says sex work
is difcult without being high.
She started injecting heroin 4 years ago. She is currently homeless but stays with
friends when she can.
Her mothers death has scared her, but she hasnt been tested for HIV. She is
ambivalent about being tested. She knows she should be tested, but she is worried
the test results will be positive for HIV.
Ha occasionally goes to a drop-in center. She has told a worker that she feels tired
and old and wants to get out of sex work.
She recently found a job in a shop, but she continues to see old clients from time to
time for extra money.
She has attempted to stop her heroin use on her own but cannot make it through
withdrawal.
She doesnt fully trust the drop-in center staff or volunteers and feels hopeless.
Still, she continues to visit the drop-in center.
Resource Page 6.8: Case StudySekar
Sekar is 39 years old and married. He has worked as an accountant in a private rm
for the past 2 years.
He lives with his wife and 11-year-old daughter. His wife is a schoolteacher. It is a
marriage of choice, and the relationship with his wife and daughter was intimate
until a year ago.
He and his family rent a one-bedroom house in a middle-class community.
Three years ago, during a period of high work stress, Sekar began taking
amphetamines he got from a friend to help him cope with an increased work load.
Because of the stimulant effects, he began having chronic insomnia (inability to sleep).
His doctor prescribed a barbiturate to help him sleep, and Sekar has continued using
both amphetamines and barbiturates, both now bought on the street.
Over the past 4 months, he has missed many days of work. As a result, he received a
formal warning. There have been instances of verbal abuse at home, as his wife has
become angry at his drug use and that he is risking his job.
His health has deteriorated, and he recently developed hypertension.
His wife has difculty running the household with her income. They argue constantly.
His daughter is scared of him and avoids him.
He has borrowed money from friends and money lenders at a high interest rate,
which is a burden on his wife. She faces a lot of abuse from the money lenders.
His wife is on the verge of leaving him. This has motivated him to seek residential
treatment. He is not sure whether his workplace will allow him to come back when he
completes treatment.
He reports that he tried to quit both the amphetamines and barbiturates last year.
He had a seizure during withdrawal from the barbiturates, felt very depressed, and
considered committing suicide.
341
MODULE 7
EVIDENCE-BASED PRACTICES FOR TREATMENT
INTERVENTION
Introduction to Module 7 ........................................................................ 346
Presentation: Ways of looking at evidence-based practices ................... 352
Presentation: Cognitive-behavioral therapy ............................................ 367
Part 1, preparation ................................................................................ 384
Part 2, presentation ............................................................................... 387
Presentation: Motivational approaches ................................................... 388
Small-group exercise: Motivational approachesPart 1, preparation .... 417
Small-group exercise: Motivational approachesPart 2, presentation .. 421
Presentation: Family-based approaches.................................................. 422
Exercise: Journal writing .......................................................................... 449
Day 4 wrap-up and evaluation ................................................................ 450
Day 5 review and welcome ..................................................................... 451
Small-group exercise: Family-based approaches .................................... 452
Presentation: Therapeutic community ..................................................... 455
Small-group exercise: Therapeutic community ....................................... 468
Presentation: Contingency management ................................................ 472
Small-group exercise: Contingency management .................................. 488
Presentation: Pharmacotherapy for opioid dependence ........................ 491
Small-group exercise: Pharmacotherapy for opiod dependence ............ 500
Small-group discussion: Evidence-based practices ................................. 504
Large-group discussion: Evidence-based practices ................................ 506
342
343
Trainer Manual: Module 7Evidence-Based Practices for Treatment intervention
Review Getting Started for general preparation information and preview Module 7.
Prepare ve wall graphics (one for each evidence-based practice) using strips of
newsprint labeled as follows:
o Name of the evidence-based practice (Cognitive-behavioral therapy, for
example)
o Overview: Characteristics
o Primary techniques/applications
o Strengths
o Challenges
Use the diagram at the end of the module as a guide for placement of these labels
on a wall.
Create four tent cards (letter-sized pieces of paper or large note cards folded in
half), number them 1, 2, 3, and 4 on both sides, and place one on each of four
tables for small-group assignment.
Prepare for each small group:
o Ten sheets of letter-sized white paper
o Eight sheets of newsprint
o A set of markers in an array of colors, including black and blue markers
o A role of tape
344
Activity Time
Person
Responsible
Presentation: Ways of looking at evidence-based
practices
25 minutes
Presentation: Cognitive-behavioral therapy 30 minutes
Part 1, preparation
15 minutes
Lunch 60 minutes
Part 1, preparation (continued)
10 minutes
25 minutes
Presentation: Motivational approaches 30 minutes
Part 1, preparation
25 minutes
Break 15 minutes
20 minutes
Presentation: Family-based approaches 25 minutes
Exercise: Journal writing 10 minutes
Day 4 wrap-up and evaluation 10 minutes
End of Day 4
Day 5 review and welcome 10 minutes
Small-group exercise: Family-based approaches 45 minutes
Presentation: Therapeutic community 20 minutes
Small-group exercise: Therapeutic communit 45 minutes
Break 15 minutes
Presentation: Contingency management 20 minutes
Small-group exercise: Contingency management 45 minutes
Presentation: Pharmacotherapy for opioid dependence 15 minutes
Small-group exercise: Pharmacotherapy for opiod
dependence
45 minutes
Lunch 60 minutes
Small-group discussion: Evidence-based practices 30 minutes
Large-group discussion: Evidence-based practices 15 minutes
345
Training goals
To provide an overview of the concept of evidence-based practice;
To provide information about ve evidence-based practices; and
To provide an opportunity for participants to discuss the use of evidence-based
practices in their communities.
Learning objectives
Dene evidence-based practice;
Describe why it is important to know about evidence-based practices;
Identify key components of six specic evidence-based practices; and
Discuss the applicability of these evidence-based practices to their work.
346
Treatment for substance use disorders (or SUDs) has steadily evolved over time.
Our understanding of SUDs has increased tremendously thanks to improved brain scan
imaging and other research techniques. Research on treatment also has become more
rigorous and science based, and we now have a better understanding of what works in
treatment.
This doesnt mean one approach will show the same results for every person. It does,
however, mean that we now have a much better understanding of a range of possible
approaches that are most likely to be helpful. We call these approaches evidence-based
practices (or EBPs).
Say:
Slide 7.1
5 minutes
347
This module provides a brief overview of EBPs in substance use disorder treatment and
will answer the questions:
What does evidence-based practice mean?
Why do we need to know about EBPs?
What specic approaches to treatment are considered EBPs?
348
Please turn to Module 7, page 233 in your manuals. By the time we complete
Module 7, I hope you will be able to:
Dene evidence-based practice;
Describe why it is important to know about evidence-based practices;
Identify key components of six specic evidence-based practices; and
Discuss the applicability of these evidence-based practices to your work.
Say:
Slide 7.2
349
Well be doing a lot of small-group work today and tomorrow, so lets form groups
now. To make sure that we have a range of experience in each group, were going to
form groups a little differently today. I would like you to line up along the wall by the
length of time you have worked as an SUD treatment counselor. Whoever has the most
experience should stand farthest to the left; the person with the least experience should
stand on the far right.
To determine how long you have worked in the eld, you should include full- and part-
time work and periods when you worked as an intern or as a volunteer. Although you
may start arranging yourselves by number of years, you will likely be adding up months
or even days to line up chronologically.
Say:
Slide 7.3
Teaching Instructions: You may need to help participants sort out their order. Exact
order is not critical.
The purpose of this process is to create small groups that will have participants with a
range of experience in the eld. Each small group should have four or ve members.
Now that you have lined up chronologically based on the number of years you
have worked in the eld, I would like you to count off from left to right from 1 to 4 to
form four small groups.
Each of four tables has a numbered tent card on it; please collect your belongings
and move to the table that corresponds to your number. These will be your group
assignments throughout Module 7.
Say:
350
In the last six modules, you learned about:
Recovery, recovery management, and recovery capital;
Factors that may affect treatment outcomes;
The process and stages of change;
Basic principles of treatment; and
Typical components of treatment.
Say:
Slide 7.4
351
In this module well learn about 6 evidence-based practices which are common
to substance use disorder (SUD) treatment. Before we begin to look at individual EBPs,
we rst need to understand what evidence-based practice means.
Say:
Slide 7.5
Teaching Instructions: Note responses on the newsprint you prepared labeled
Evidence-based practice.
What do you think evidence-based practice means?
Ask:
352
Slide 7.6
Good answers. One basic denition of evidence-based practices (EBPs) is
practices for which the evidence is strongest and most acceptedand that are most
likely to have signicant impact on improving care.
1
Say:
Presentation: Ways of looking at evidence-based practices
25 minutes
1
U.S. National Quality Forum. (2007). National voluntary consensus standards for the treatment of substance use
conditions: Evidence-based treatment practices (abridged version). p. v. Washington, DC: Author.
353
The phrase improving care is critical. For example, a study conducted by the
U.S. Institute of Medicine (IOM)
1
found that in the United States substandard treatment
was especially common among individuals with SUDs. The study dened substandard
treatment as treatment that was not:
Safe;
Effective;
Patient-centered;
Timely;
Efcient; or
Equitable (fair).
Say:
Slide 7.7
1
McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., et al. (2003). The quality of health care
delivered to adults in the United States. New England Journal of Medicine, 26352645.
354
Slide 7.8
For example, IOM found that only 10 percent of patients identied with an
alcohol use disorder received recommended care,resulting in increased illness and
mortality.
This nding was related to a lack of sufcient services as well as to substandard care.
Say:
1
McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., et al. (2003). The quality of health care
delivered to adults in the United States. New England Journal of Medicine, 26352645.
Teaching Instructions: Spend 10 minutes taking comments, trying to be sure
that you are hearing from participants representing diverse areas, types of SUDs
addressed, and a spectrum of program services.
Do you think this nding would be accurate in your areas?
Ask:
355
Another aspect of the denition is the term practices. Although evidence-
based practices are usually derived from counseling theories, like behavioral theory,
for example, they are more a set of techniques and approaches. These techniques and
approaches may include elements from several counseling theories.
Say:
Slide 7.9
356
Slide 7.10
In response to the ndings of the Institute of Medicine study, the Institute made
10 recommendations for better care. These recommendations included the use of
evidence-based decision-making in treatment for mental health and substance use
conditions.
The Institute expanded the evidence-based concept to include a combination of:
Science;
Clinical and nancial feasibility; and
Clinical expertise.
Say:
1
U.S. Institute of Medicine. (2006). Improving the quality of health care for mental and substance-use disorders,
Quality Chasm Series. Washington, DC: National Academy Press.
357
Slide 7.11
The science part of evidence-based includes the concept of empirically
validated evidence, meaning evidence that is based on information gained through:
Direct observation;
Experience; or
Experiment.
Say:
358
Slide 7.12
Clinical and nancial feasibility means that the practice is reasonable, achievable,
and economically possible to implement in a real-life treatment situation, not just in a
research setting.
Say:
359
Slide 7.13
Clinical expertise means that the counselors implementing the practice:
Have basic counseling skills;
Can connect with clients; and
Have been trained in the use of the specic practice.
Say:
Slide 7.14
Teaching Instructions: Take two or three responses, then move back to the
presentation.
So, why do we need to know and care about EBPs?
Ask:
361
Slide 7.15
EBPs have been shown to improve treatment outcomes. International
organizations have called for increased use of EBPs to improve treatment globally.
For example, in 2008, the World Health Organization (WHO), in coordination with the
United Nations Ofce on Drugs and Crime (UNODC), issued a discussion paper titled
Principles of Drug Dependence Treatment.
1
Say:
1
WHO and UNODC. (2008). Principles of drug dependence treatment: Discussion paper. Retrieved September
1, 2010, from http://www.unodc.org/documents/eastasiaandpacic//china/UNODC-WHO-Principles-of-Drug-
Dependence-Treatment.pdf
362
Slide 7.16
The discussion paper emphasized, Evidence-based good practice and
accumulated scientic knowledge on the nature of drug dependence should guide
interventions and investments in drug dependency treatment. The high quality of
standards required for approval of pharmacological or psychosocial interventions in all
the other medical disciplines should be applied to the eld of drug dependence.(p. 9)
1
Say:
1
WHO and UNODC. (2008). Principles of drug dependence treatment: Discussion paper. Retrieved December
3, 2010, from http://www.unodc.org/documents/eastasiaandpacic//china/UNODC-WHO-Principles-of-Drug-
Dependence-Treatment.pdf
363
Slide 7.17
In 2007, the U.S. National Quality Forum (or NQF) developed Consensus
Standards for Treatment of Alcohol, Tobacco, and Drug Use Disorders to advocate for
improving treatment for SUDs in the U.S.
1
NQF concluded that certain empirically validated treatment practices should be used
with all clients with SUDs. These include:
Pharmacotherapy (the use of medications to treat SUDs);
Cognitive-behavioral therapies;
Motivational enhancement therapy;
12-Step facilitation therapy; and
Marital and family therapies.
Say:
1
conditions: Evidence-based treatment practices. Washington, DC: Author.
364
Slide 7.18
NQF also identied a number of practices that have been shown to be ineffective
treatments for SUDs and that should not be routinely used. These ineffective treatments
include the use of acupuncture, relaxation therapy, education, drug testing, and
detoxication as stand-alone treatments.
The phrase stand-alone treatment is important to note; the report does not state that
these practices do not have a place in treatment, just that they are insufcient treatment
in and of themselves.
Other treatment approaches noted as ineffective include:
Acupuncture;
Individual psychodynamic therapy;
Unstructured group therapy;
Confrontation as the main approach to treatment; and
Discharge from treatment in response to relapse.
1
Say:
1
Source: U.S. National Quality Forum. (2004). Evidence-based treatment practices for substance use disorders:
Workshop proceedings. Washington, DC: Author.
365
Slide 7.19
The consensus report also indicated that treatment delivery with an empathic,
supportive approach may be just as important as the specic practices used. This means
that a counselors ability to engage and develop a helping relationship with a client is
critical.
A summary of NQFs work on evidence-based practices is in Resource Page 7.1, page 341
in your manuals. Please read this page on your own.
Organizations other than NQF also have studied and identied evidence-based
practices. Additional sources of information about EBPs are in Appendix EResources,
Say:
366
Slide 7.20
Now were ready to begin talking about six specic EBPs:
Cognitive-behavioral therapy;
Motivational approaches;
Certain family approaches;
Therapeutic community;
Contingency management; and
Pharmacotherapy for opioid dependence.
Were focusing on the rst ve because they are the most broadly used globally. We are
also adding pharmacotherapy, or medication-assisted therapy. Although medication-
assisted therapy for opioid disorders is not available everywhere, evidence supports its
effectiveness. In addition, methadone is on the World Health Organizations (WHOs)
list of essential medications, and WHO supports adoption of methadone maintenance
programs.
Resource Pages 7.8 and 7.9 (pages 366369 in your manuals) provide descriptions of
two additional EBPs to read about on your own:
The 12-Step facilitation model, based on the principles of mutual-help groups; and
The Matrix model, an organized set of evidence-based practices originally
developed to treat methamphetamine dependence.
Say:
367
Slide 7.21
Cognitive-behavioral therapy for SUDs merges two treatment modelscognitive
therapy, originally developed by Aaron Beck to treat depression, and behavior therapy,
rst conceptualized by Ivan Pavlov and modied by B. F. Skinner and Albert Bandura.
Say:
Presentation: Cognitive-behavioral therapy
30 minutes
368
Slide 7.22
Cognitive therapy proposes that a persons thoughts and interpretations cause
feelings and behaviors. Feelings and behaviors are not caused by external things, such
as people, situations, and events.
A core belief in cognitive therapy is that people can change the way they think (and feel
and act), even if the situation does not change.
Say:
369
Slide 7.23
Even though it feels as though the things that happen to us directly cause our
feelings and behavior
Say:
370
Slide 7.24
Cognitive therapy tells us that there is another step in the process, one over which
we have some control: our thoughts and interpretations about what happens to us.
Say:
371
Slide 7.25
Behavioral therapy treats emotional and behavioral disorders as learned
responses that can be replaced by healthy ones with appropriate training. Behavioral
therapy helps people identify behavior that is not helping them and try out new ways of
behaving.
Say:
372
Slide 7.26
Behavioral approaches focus on:
Identifying factors that initiate and maintain behavior;
Adaptive and maladaptive behaviors that lead to client discomfort and problems;
and
Observable and measurable behaviors.
Say:
373
Slide 7.27
Strict behavioral approaches do not focus on concepts like self-esteem, thoughts,
values, the unconscious, or defense mechanisms.
Say:
374
Slide 7.28
Other therapy models attempt to answer the question: Why does this individual
do what he or she does? The questions that are central to CBT are:
What keeps a person doing what he or she is doing?
How does he or she change?
The what question addresses the things that reinforce patterns of thought, affect, and
behavior.
The how question relates to building skills.
Say:
375
Slide 7.29
The CBT approach to treating SUDs focuses on teaching clients skills that help
them recognize and learn strategies to:
Reduce risks of relapse;
Maintain abstinence;
Solve problems; and
Enhance self-efcacy (a clients ability to recognize his or her strengths and to
believe that change is possible).
Say:
376
Slide 7.30
CBT techniques include asking questions and teaching clients to ask themselves
questions that explore the relationship of their thinking to their emotional responses to
events. For example:
How do I really know that those people are laughing at me?
Are there any other possible explanations?
Could they be laughing about something else?
Say:
377
Slide 7.31
Other techniques include:
Exploring the positive and negative consequences of continued substance use;
Teaching clients self-monitoring to anticipate and recognize drug and alcohol
cravings early and to identify high-risk situations for use;
Helping clients develop strategies for avoiding or coping with high-risk situations
that trigger the desire to use;
Helping clients develop effective coping strategies (such as a range of relaxation
techniques) for general life challenges that might trigger their SUDs; and
Teaching problem-solving skills.
You are probably familiar with most of these techniques. They are widely used relapse
prevention tools.
Say:
378
Slide 7.32
Homework is a major part of CBT approaches. Clients are:
Given reading assignments;
Asked to keep track of certain behavior and thoughts; and
Asked to practice new skills they have learned in treatment (behavioral rehearsal).
Say:
379
Slide 7.33
One CBT approach is cognitive-behavioral coping skills therapy, originally
developed for work with clients with alcohol use disorders.
1
Coping skills therapy is a structured, manual-based approach. Each session of coping
skills therapy includes:
Discussion of the rationale;
Specic skill guidelines;
Behavioral rehearsal (meaning practicing skills using role-plays); and
Other practice exercises for a particular topic area.
Say:
1
U.S. National Institute on Alcohol Abuse and Alcoholism. (1995). Cognitive-behavioral coping skills therapy manual:
A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Project MATCH
Monograph Series, Volume 3. Bethesda, MD: Author.
380
Slide 7.34
Examples of topic areas are:
Managing thoughts about using substances;
Solving problems;
Developing substance refusal skills;
Planning for emergencies and coping with a lapse; and
Dealing with seemingly irrelevant decisions.
Say:
381
Slide 7.35
Seemingly irrelevant decisions are those decisions, rationalizations, and
minimizations of risk that move people in recovery close to or even into high-risk
situations, although they may seem unrelated to substance use. Seemingly irrelevant
decisions form sort of chain, any one link of which may be insignicant but together
move the person into risky territory. For example:
Ahmed, who had been abstinent for several months, drove home from work on a
night his wife was going to be away.
On the way, he turned left rather than right at an intersection so that he could enjoy
the scenic route.
On this route, he drove past a cafe he had frequented in the past with his friends
who used cocaine with him.
Because the weather that day was hot, he decided to stop in for a glass of cola.
While he was there, he ran into a friend who happened to have a gram of cocaine
and a relapse ensued.
Although deciding to enjoy the scenic route seemed like an insignicant decision, it led
to passing an old using spot, which led to using cocaine.
Say:
382
Slide 7.36
Coping skills training would have helped Ahmed look at each link in the chain of
events that led to his relapse and would have helped him learn to recognize decisions
that can be the start of a process of relapse.
Future curricula will more thoroughly address:
Relapse prevention counseling;
Refusal skills; and
Other cognitive-behavioral counseling techniques.
Say:
383
Slide 7.37
Research has found cognitive-behavioral therapy to be effective for addressing
SUDs involving:
1
Alcohol;
Marijuana;
Cocaine;
Methamphetamine; and
Nicotine.
Clients have also been proven to consistently maintain new skills and other gains for at
least one year after treatment.
2
Say:
1
U.S. National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-based guide, 2nd
Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author. 46-47. Retrieved August 29, 2011 from http://www.
nida.nih.gov/podat/Evidence2.html
2
bid.
384
Slide 7.38
Before we continue, we are going to spend some time in small groups discussing
cognitive-behavioral therapy. Each group will be assigned one task. These tasks will
rotate throughout this module as we review multiple evidence-based practices. For CBT,
your assignments will be as follows:
Group 1: Overview of characteristics
Group 2: Primary techniques/applications
Group 3: Strengths
Group 4: Challenges
Say:
Small-group exercise: Cognitive-behavioral therapyPart 1,
preparation
15 minutes
385
Slide 7.39
Each group will need two recorders:
One to summarize your key points on a sheet of newsprint for a 3- to 5-minute
report-out to the large group; and
One to write the same information on a sheet of the white paper for posting on the
EBPs wall graphic under CBT.
Resources you can use include:
Your notes;
What you already knew about this EBP; and
Resource Page 7.2, page 344 in your manual.
The resource page will be especially helpful to the groups working on strengths and
challenges (look for the table).
In addition to those listed, please discuss and add strengths you can think of. When
discussing challenges, please add any that you think would be particularly relevant in
your area and work environment.
You will have 15 minutes before lunch and another 10 minutes after lunch to prepare.
Say:
Teaching Instructions: Walk around the room and observe preparations, answering
any questions. In 15 minutes, move to the next slide and break for lunch.
386
Slide 7.40
Its time to break for lunch. When you return, go right into your groups for your
nal 10 minutes of preparation time.
Say:
Lunch
60 minutes
387
Slide 7.41
Great job! Next, were going to talk about motivational approaches.
Say:
preparation (continued)
10 minutes
Teaching Instructions: As participants come back into the room, remind them to go
directly to their groups and begin work.
Provide a 2-minute warning. When 10 minutes have elapsed, begin the presentations.
presentation
10 minutes
Teaching Instructions: When each group has nished its presentation, ask a group
member to tape the white paper summary to the wall graphic.
388
Slide 7.42
Motivational approaches include motivational interviewing (or MI) and
motivational enhancement therapy (or MET).
We will look at each of these approaches in a few minutes, after weve reviewed general
characteristics of motivational approaches.
Say:
Presentation: Motivational approaches
30 minutes
389
Slide 7.43
Motivational approaches are based on the principles of motivational psychology
and the trans-theoretical model of change, also known as the stages of change model,
which was developed by James Prochaska and Carlos DiClemente. These perspectives
tell us that:
Change occurs in stages;
Motivation for change varies over time; and
Motivation can be enhanced.
We learned about motivation and the stages of change in Module 4.
Say:
390
Slide 7.44
Motivational counseling approaches are methods of counseling that are client
centered and use nondirective methods. These approaches use strategies that:
Acknowledge that substances of abuse have rewarding properties that can disguise,
at least temporarily, their hazards and negative long-term effects;
Help clients resolve ambivalence about engaging in treatment and stopping
substance use;
Say:
391
Slide 7.45
They also use strategies that:
Use the internal motivation of clients to evoke and sustain rapid change; and
Include problem-solving or solution-focused strategies that build on clients past
successes.
Say:
392
Slide 7.46
Motivational approaches follow the principle that change is created through the
clients will and motivation. They do not focus on a counselors discovery, interpretation,
and guidance. In motivational approaches, the counselor acts as a coach or consultant
rather than as an authority gure, helping the client discover, understand, and build on
past successes.
Say:
393
Slide 7.47
Basic techniques of motivational approaches include:
FRAMES approach;
Decisional balance exercises;
Identifying discrepancies;
Pacing; and
Personal contact with clients not in treatment.
Well look at these techniques one by one.
Say:
394
Slide 7.48
FRAMES is an acronym that stands for:
Feedback;
Responsibility;
Advice;
Menus;
Empathy; and
Self-efcacy.
Frames was originally developed as a brief intervention.
Say:
395
Slide 7.49
After assessment of substance use patterns and associated problems, the
counselor provides feedback to the client regarding her personal risk or impairment.
This feedback may be based on the clinical interview, test results, or a comparison of
the clients use to a population norm.
Say:
396
Slide 7.50
Responsibility for change is placed squarely and explicitly on the client, with
respect for the clients right to make choices for himself or herself. This respect can be
demonstrated by showing interest in what the clients perceptions and thoughts are and
using questions rather than statements. For example:
How do you see the situation?
What do you think you might need to do?
Say:
397
Slide 7.51
Advice about changingreducing or stoppingsubstance use is clearly given to
the client by the counselor in a nonjudgmental manner and, again, with respect for the
clients right to make decisions. The counselor might say:
Given the results of your screening test, Im concerned about the effects of your use
on your health. My advice to you would be to consider treatment. Is that something
youd be willing to talk about?
Say:
398
Slide 7.52
The FRAMES approach includes offering menus of self-directed change options
and treatment alternatives. This might include agreeing to try outpatient counseling
with a client who is unwilling to go into a residential program, even though the
counselor may believe that a residential setting is the more prudent choice.
Say:
399
Slide 7.53
Empathic counselingshowing warmth, respect, and understandingis
emphasized in motivational approaches.
Say:
400
Slide 7.54
The client develops self-efcacy and is encouraged to change. The counselor can:
Help the client explore his or her strengths and past successes;
Identify skills and abilities to make necessary changes; and
Promote the idea that people can change and that recovery is possible.
Say:
401
Slide 7.55
Another technique of motivational approaches is using decisional balance
exercises. Decisional balance is the concept of exploring the pros and consor benets
and disadvantagesof change. People naturally explore the pros and cons of major life
choices.
Say:
402
Slide 7.56
In the context of recovery from substance use, the client weighs the pros and cons
of changing versus not changing substance-using behavior. The counselor assists this
process by asking the client to:
Talk about both the good and less good aspects of using substances; and
Write them down in two columns on a sheet of paper.
Say:
403
Slide 7.57
The purpose of exploring the pros and cons of a substance use problem is to tip
the scales toward a decision for positive change.
The number of reasons a client lists on each side of a decisional balance sheet is not as
important as the weightor personal valueof each one. For example, a 20-year-old
might not put as much weight on losing a girlfriend as would an older, engaged man
who wants a family. The 20-year-old might be very concerned, though, about being
kicked off his soccer team for missing too many practices.
Say:
404
Slide 7.58
One way to enhance motivation for change is to help clients recognize a
discrepancy or gap between their future goals and their current behavior. A counselor
might clarify this discrepancy by asking:
How does your cocaine use t in with having a happy family and a stable job?
When clients see that present actions conict with important personal goals such as
health, success, or family happiness, change is more likely to occur.
Say:
405
Slide 7.59
Each client moves through the stages of change at his or her own pace. The
concept of pacing requires that a counselor meet a client at the stage the client is in.
The counselor uses as much or as little time as is necessary to complete the essential
tasks of each stage of change.
For example, some clients may need frequent sessions at the beginning of treatment
and fewer later. If a counselor pushes a client at a faster pace than the client is ready to
take, the relationship between counselor and client may break down.
Say:
406
Slide 7.60
Motivational interventions can include simple activities designed to enhance
continuity of contact between counselor and client and strengthen the relationship.
Activities can include personal handwritten letters or telephone calls from counselor
to client.
Research has shown that these simple motivation-enhancing interventions are effective
for encouraging clients to:
Return for another clinical consultation;
Return to treatment following a missed appointment;
Stay involved in treatment; and
Increase treatment adherence.
Say:
407
Slide 7.61
Now lets look at how two motivational approaches incorporate those principles
into their unique evidence-based practices. We will start with Motivational Interviewing.
MI is a counseling technique or style that focuses on creating a favorable climate for
change in a person-centered setting. The essence of motivational interviewing is in its
collaborative nature, communicating in a partner-like relationship, where the interviewer
seeks to create a positive interpersonal atmosphere.
Say:
408
Slide 7.62
There are ve primary principles in MI. These are not steps, but concepts to be
applied at all times to enhance the relationship between the counselor and the client.
They are often summarized by the acronym READS:
Roll with resistance;
Express empathy;
Avoid arguments;
Develop discrepancy;
Support self-efcacy.
Say:
409
Slide 7.63
To carry out these ve principles, there are four basic therapeutic skills or methods
an SUD counselor would use in motivational interviewing:
Reective listening or responding to a clients statement by stating back to her or
him the essence or a specic aspect of what was said;
Asking open-ended questions;
Afrming;
Summarizing.
Well be looking at each of these skills in depth in Curriculum 4, Basic Counseling Skills
for Addiction Professionals.
Say:
410
Slide 7.64
In Motivational Interviewing, responsibility for change is left to the client. The
overall goal is to increase the persons intrinsic motivation to make the change that the
client determines to be important, so that change arises from within rather than being
imposed.
Say:
411
Slide 7.65
Motivational interviewing was rst used in treating SUDs to improve adherence.
MI can be used as both an assessment strategy and a therapeutic intervention:
To determine a persons readiness to engage in a target behavior, such as stopping
drug abuse;
To explore and resolve ambivalence (mixed feelings) and resistance; and
To apply specic skills and strategies to create a favorable climate for change based
on the persons level of readiness.
Say:
412
Slide 7.66
Motivational Enhancement Therapy (MET) is another of the motivational
approaches that researchers have documented as being effective. MET seeks to:
Helps clients create their own motivation for change; and
Consolidate a persons decision and plan for change.
This approach is also primarily client-centered, but the counseling sessions are planned
and directed by the counselor.
Say:
413
Slide 7.67
In MET, each client sets his or her own goals:
No absolute goal is imposed by a counselor using MET.
MET counselors may advise specic goals, such as complete abstinence.
A broader range of life goals, such as nding a job or reuniting with family
members, may be explored as well.
Say:
414
Slide 7.68
In MET therapy, SUD problems are viewed as behaviors at least partially under
the voluntary control of the client. Thus, they follow the normal principles of behavior
change.
Say:
415
Slide 7.69
MET is based on principles of cognitive and social psychology. The MET
counselor:
Seeks to help the client perceive a discrepancy between current behavior and
signicant personal goals.
Emphasizes clients self-motivational statements of both the desire for and the
commitment to change.
The MET counselor works from the assumption that internal motivation is not only a
necessary but often the only factor needed to create change.
Say:
416
Slide 7.70
Researchers have found motivational enhancement therapy to be effective for
addressing SUDs involving:
1
Alcohol;
Marijuana; and
Nicotine.
Say:
1
U.S. National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-based
guide, 2nd Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.
417
Slide 7.71
Before we continue, we are going to do a small-group exercise on motivational
approaches. Again, each group will be assigned one task. For this exercise, your
assignments will be as follows:
Group 2: Challenges
Group 4: Strengths
Say:
Small-group exercise: Motivational ApproachesPart 1,
preparation
25 minutes
418
Slide 7.72
As before, each group will need two recorders:
EBPs wall graphic under motivational approaches.
Your notes;
The resource page will be especially helpful to the groups working on strengths and
challenges (look for the table).
You will have 25 minutes to prepare.
Say:
419
any questions.
Provide 10- and 2-minute warnings.
When 25 minutes have elapsed, move to the next slide and announce a break.
420
Slide 7.73
Before we get into the presentations, lets take a 15-minute break.
Say:
Break
15 minutes
421
Slide 7.74
Welcome back! Lets begin our presentations. Group 1, youre up.
Say:
Small-group exercise: Motivational approachesPart 2,
presentation
20 minutes
Teaching Instructions: When each group has nished its presentation, ask a group
member to tape the white paper summary to the wall graphic.
Great job! Next, were going to talk about family-based approaches.
Say:
422
Slide 7.75
Simple family involvement is not a specic model of treatment. However,
extensive research shows that family involvement in treatment programs can
signicantly enhance outcomes for a person experiencing SUDs. Most programs offer
family services in their approach to treatment.
Say:
Presentation: Family-based approaches
25 minutes
423
Slide 7.76
Family services frequently include:
Family psychoeducation;
Family support groups; and
Family counseling.
Say:
424
Slide 7.77
Teaching Instructions: Listen to three or four responses. Afrm these responses,
and if possible mention these responses as appropriate in the presentation.
Why do you think family involvement is important in SUD treatment?
Ask:
425
Slide 7.78
Families of people who abuse substances live in a world shaped by substance
use. In this world:
There may inconsistent behaviors;
There may be few or very rigid rules;
Family members frequently experience anger, shame, guilt, sadness, and
hopelessness;
Individuals may be isolated, create destructive alliances, be overly involved, and get
locked into rigid roles; and
Individuals may develop stress-related medical problems.
Say:
426
Slide 7.79
Family involvement is critical to the strength and duration of the clients recovery
because:
Family members were involved with the client before treatment;
Family members will be involved with the client after treatment; and
Family-based services can ensure that family functioning changes to become a
positive inuence for the recovery of the client.
Say:
427
Slide 7.80
One primary goal of family involvement is to increase members understanding of
substance use disorder as a chronic disease. This helps family members:
Understand how the SUD is intertwined with family problems;
Understand causes and effects of SUDs from a family perspective;
Identify and change family relationship patterns that work against recovery;
Prepare for early recovery challenges; and
Learn about relapse warning signs.
Say:
428
Slide 7.81
Two other goals include helping family members:
Discover and build on family strengths; and
Obtain long-term support for themselves.
Say:
429
Slide 7.82
While families can be critical to the success of a client with SUDs, some family
members may actually need treatment themselves before they can be such a helpful
resource for clients. Many clients are from families that are particularly chaotic and
dysfunctional or have multi-generational substance use disorders, mental disorders, and
other problems.
Say:
430
Slide 7.83
Several specic family approaches are considered evidence-based practices for
treating SUDs:
Behavioral couples therapy for substance abuse (BCT);
Multisystemic therapy (MST) for adolescents;
Multidimensional family therapy (MDFT) for adolescents; and
Brief strategic family therapy (BSFT) for adolescents.
Say:
431
Slide 7.84
Behavioral couples therapy is typically used as an adjunct to other SUD treatment
approaches. BCT is based on the assumptions that:
Intimate partners can reward abstinence; and
Reducing relationship distress reduces chances for relapse.
Say:
432
Slide 7.85
BCT program components include:
A recovery or sobriety contract between the partners and the therapist;
Activities and assignments designed to increase positive feelings, shared activities,
and constructive communication; and
Relapse prevention planning.
Say:
433
Slide 7.86
With BCT, the spouse or partner plays an active role in treatment, minimizing the
sense of helplessness that comes with living with a person with an SUD. Partners attend
between 15 and 20 hour-long sessions over 5 to 6 months.
Sessions follow a particular sequence:
The therapist asks about substance use since the last session;
The couple discusses compliance with the recovery contract;
The couple presents and discusses homework assigned at the last session;
The couple discusses relationship problems since the last session;
The therapist presents new material; and
The therapist assigns new homework.
Say:
434
Slide 7.87
Researchers have found behavioral couples therapy to be effective for addressing
the following populations:
1
Men with alcohol use disorders and their spouses; and
Men and women with drug use disorders and their signicant others.
Say:
1
Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author. 46-47.
435
Slide 7.88
Compared to individual treatment, at one-year follow-up, BCT has been shown to
produce higher:
Treatment attendance;
Naltrexone adherence for opiod users; and
Rates of abstinence.
BCT also showed fewer drug-related, legal, and family problems at that one-year follow-
up point.
Say:
436
Slide 7.89
The second family approach we will review is multisystemic therapy. MST is an
intensive, in-home and in-community approach that focuses on changing the thinking
and behavior of both adolescents with SUDs and their parents. The approach uses
cognitive-behavioral and social-development (risk and protective factors) strategies to
focus on family strengths to facilitate positive change.
Say:
437
Slide 7.90
MST interventions occur in the home to overcome the high dropout rates of other
treatments and focus on:
Promoting responsible behavior;
Decreasing irresponsible actions by family members;
Addressing what is currently occurring in adolescents life; and
Taking immediate actions targeting specic and well-dened problems.
Say:
438
Slide 7.91
Assessing patterns of behavior within and between the various elements of the
adolescents lifefamily, teachers, friends, home, school, and communitythat
sustain the identied problems;
Building the adolescents ability to get along well with peers; and
Acquiring academic and vocational skills that will promote a successful transition to
adulthood.
Say:
439
Slide 7.92
MST does not focus on gaining insights or focusing on the past; nor do MST
counselors label families as resistant, not ready for change, or unmotivated.
Rather, the MST approach avoids blaming the family while it empowers parents (or other
caregivers) to address the familys needs after treatment ends.
In fact, the caregiver is seen as the key to long-term success, whereas the responsibility
for positive treatment outcomes rests completely on the MST team.
Say:
440
Slide 7.93
Researchers have found
1
multi-systemic therapy to be effective in signicantly
reducing adolescent drug use during treatment and for at least six months after
treatment.
Additionally, fewer incarcerations and out-of-home juvenile placements offset the cost
of providing this intensive service and maintaining therapists low caseloads.
Say:
1
Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.
441
Slide 7.94
Multidimensional family therapy (MDFT) for adolescents is the third family
approach. Like multi-systemic family therapy, MDFT views adolescent substance use in
terms of a network of inuences (individual, family, peer, community) and suggests
that reducing unwanted behavior and increasing desirable behavior occur in multiple
ways in different settings.
Say:
442
Slide 7.95
MDFT includes individual and family sessions held in a treatment center, in the
home, or with family members at school, court, or other community locations.
In individual sessions, the counselor and adolescent work on:
Developmental tasks, such as acquiring decision-making, negotiation, and problem-
solving skills;
Vocational skills; and
Skills in communicating thoughts and feelings to deal better with life stressors.
Say:
443
Slide 7.96
Parallel sessions are held with family members, where parents can:
Examine their particular parenting styles, learning to distinguish inuence from
control; and
Learn to have a positive and developmentally appropriate inuence on their children.
Say:
444
Slide 7.97
Researchers have found multidimensional family therapy to be effective for
reducing:
1
The severity of cannabis and alcohol use; and
The overall severity of substance use-related problems.
Say:
1
U.S. National Registry of Evidence-based Practices and Programs. (2011) Multidimensional Family Therapy. Rockville,
Maryland:SAMHSA. Retrieved August 30, 2011 from http://nrepp.samhsa.gov/ViewIntervention.aspx?id=16
445
Slide 7.98
The nal family approach we will examine is brief strategic family therapy (BSFT).
BSFT is a brief approach delivered in 12 to 16 family sessions. BSFT targets family
interactions that are thought to maintain or worsen adolescent substance use and other
problem behavior, such as:
Conduct problems at home and at school;
Oppositional behavior;
Illegal activities;
Associating with antisocial peers;
Aggressive and violent behavior; and
Risky sexual behavior.
Say:
446
Slide 7.99
BSFT is based on a family systems approach to treatment. The family members
behaviors are assumed to be interdependent such that the symptoms of any one
member indicate, at least in part, what else is going on in the family system.
The role of the brief strategic family therapy counselor is to:
Identify the patterns of family interaction that are associated with the adolescents
behavior problems; and
Assist in changing those family patterns.
BSFT is meant to be a exible approach that can be adapted to a broad range of family
situations in various settings:
Mental health clinics;
SUD treatment programs;
Other social service settings; and
Families homes.
BSFT can also be adapted to various treatment modalities:
As a primary outpatient intervention;
In combination with residential or day treatment; and
As an aftercare/continuing-care service to residential treatment.
Say:
447
Slide 7.100
BSFT is a manual-based, highly structured program, and specic training by the
Brief Strategic Family Therapy
Institute is required.
Say:
448
Slide 7.101
Urban Hispanic families have been the primary recipients of BSFT, although
African-American and European-American families have also participated. Researchers
have found brief strategic family therapy to be effective for:
1
Reducing marijuana and overall substance use;
Reducing conduct problems and socialized aggression; and
Increasing family functioning.
Say:
1
U.S. National Registry of Evidence-based Practices and Programs. (2011) Multidimensional Family Therapy. Rockville,
Maryland:SAMHSA. Retrieved August 30, 2011 from http://nrepp.samhsa.gov/ViewIntervention.aspx?id=151
449
Slide 7.102
Weve nished our discussion of family-based evidence-based practices (EBPs)
and need to wrap up for the day. But rst, Id like you to take out your notebooks and
make a journal entry.
Please take the next 10 minutes to think and write about the questions on the slide:
What was the most important thing you learned today?
What surprised you?
What would you like to learn more about?
Say:
10 minutes
Teaching Instructions: Provide a 2-minute warning. If participants appear to be
nished writing before 10 minutes have elapsed, move on to the wrap-up.
While participants are writing, pass out the day 4 Daily Evaluation form.
Exercise: Journal Writing
450
Slide 7.103
Thank you for your great participation today! Tomorrow well start the day with a
small-group exercise on family-based approaches. When you come in, please sit with
your small group again.
Say:
10 minutes
Teaching Instructions: Encourage participants to ask questions or make comments.
Refer any questions back to the group before answering yourself.
You each have a Daily Evaluation form. I want to remind you that your input is very
important to us; please complete the form before you leave. Thank you, and have a
good evening.
Say:
451
Slide 7.104
Welcome to your last day of training for this curriculum! We are going to nish up
Module 7 this morning by talking about family approaches, therapeutic communities,
and pharmacotherapy. Module 8 will provide you with an opportunity to develop a
personal plan to integrate your new learning into your practices.
Say:
Day 5 welcome
10 minutes
Teaching Instructions: Begin playing a music CD 10 minutes before the start time.
As participants arrive, invite them to review by walking around the room and looking
at the material on the walls and by reviewing their notes.
Allow 5 minutes into the session time for the review, and then begin the welcome.
Teaching Instructions: Take three or four responses, depending on time, before
moving on.
Before we begin our small-group exercise, would any of you care to share
anything you thought about or wrote during our journal exercise yesterday?
Ask:
452
Slide 7.105
Lets begin our small-group exercise on family-based approaches. Again, each
group will be assigned one task. For this exercise, your assignments will be as follows:
Group 2: Challenges
Group 4: Strengths
Say:
Small-group exercise: Family-based approaches
45 minutes
453
Slide 7.106
EBPs wall graphic under Family-Based Approaches.
Your notes;
As always, the resource page will be especially helpful to the groups working on
strengths and challenges (look for the table).
Say:
454
any questions.
When 25 minutes have elapsed, begin the presentations. When each group has
nished its presentation, ask a group member to tape the white paper summary to
the wall graphic.
455
Slide 7.107
Next, well talk about the therapeutic community model of treatment
The therapeutic community (or TC) is an intensive, primarily long-term (up to 1 year)
residential model. TCs use an approach known as community as method;
1
this approach
views the community as a wholeits social organization, its staff and clients, and its
daily activitiesas the therapeutic agent. This community-as-method philosophy and a
distinct therapeutic structure dene TCs.
Say:
Presentation: Therapeutic community
20 minutes
1
De Leon, G. (2000). The therapeutic community: Theory, model, and method. New York: Springer Publishing Company.
456
TCs feature a structured day that includes ordered, routine activities to:
Counter the disordered lives of clients; and
Distract clients from negative thinking and boredom.
The TCs daily activities include group sessions and hierarchical job functions that teach
participants specic behaviors, skills, and roles.
Because of their intense, long-term nature, TCs are particularly appropriate for clients
who have histories of severe substance use disorders and criminal behavior.
Say:
Slide 7.108
457
Slide 7.109
In fact, researchers have documented that restoring warm interpersonal
relationships reverses the damaging changes produced on brain formation, function,
and structure by neglect and abuse during childhood. Within the TC, each participant
has a well-recognized role, is considered with love and respect, and is part of a new
familyall of which lls the affective gaps that may have been created during his or her
destructive personal history.
1

The humanity of caregivers, the warm and friendly relationships with the peers in the
full-time environment of a TC are the real therapeutic engines for the changes that
happen with clients in this setting.
Say:
1
Personal communication: Gilberto Gerra, M.D., Chief , Drug Prevention and Health Branch, United Nations Ofce
for Drug Control.
458
Slide 7.110
The TC model is used in countries around the world. Every continent (except
Antarctica) has professional associations of TCs. The Asian Federation of Therapeutic
Communities (http://www.asianfedtc.org/about.html) has 13 member countries.
Say:
459
Slide 7.111
The TC model can be, and often is, modied to t cultural perspectives but
generally includes the following components:
A sense of community: Community is created partly by a separation from other
organizational or institutional programs and from the drug-using environment. A
TC facility contains communal space for promoting a sense of commonality during
collective activities. Treatment and educational services are delivered within the peer
community.
Peers and staff members as role models: TC members and staff members serve as
positive role models by demonstrating expected behaviors and reecting the values
and teachings of the community. The strength of the community for social learning
rests on the number and quality of its positive role models.
Work as therapy and education: Consistent with the TCs self-help approach, all
clients are responsible for the daily management of the facility. Work roles are
designed to bring about both educational and therapeutic effects.
Group counseling focusing on awareness and emotional growth training: This is
the main therapeutic group. These groups are used to heighten clients awareness
of specic attitudes or behavioral patterns that need to change and to help clients
identify feelings and express them appropriately and constructively.
Say:
460
Slide 7.112
A therapeutic community organizes a clients treatment in four stages:
Introduction;
Treatment;
Commitment; and
Transition/aftercare (or continuing care).
Say:
461
Slide 7.113
The introductory TC program is divided into modules of treatment to help clients
accept responsibility for their SUD behaviors and consequences. Participants take part in:
Groups;
Individual counseling sessions; and
Educational seminars.
At the completion of this stage, clients move to the more focused treatment phase of
the programor request a referral to another organization.
Say:
462
Slide 7.114
In the TC treatment stage, clients live and work in the community and, with the
support and encouragement of staff and peers, help one another develop coping skills:
The social structure is a hierarchy of positions with degrees of responsibility.
Activities focus on normal, daily work projects and leisure pursuits, supported by a
creative therapy program.
Attendance at outside mutual-help meetings is also initiated during this time.
Say:
463
Slide 7.115
The commitment stage is the link between treatment and the start of the
community reintegration phase. During this phase, clients begin to take their place back
in the larger society. Emphasis is placed on:
Career development;
Social relationships; and
Practical living skills.
Say:
464
Slide 7.116
The program provides clients with a supportive and gradual community reentry by
helping them:
Move through voluntary work into full-time employment or education; and
Physically move from the protected environment of the therapeutic community into a
transition house and then into their own accommodation in the general community.
This accommodation could be a place to live by oneself or reintegration into a family
home.
Reentry is accompanied by:
Weekly support groups and counseling sessions with staff; and
Additional support from peers who have successfully negotiated this process and
completed the TC program.
Attendance at Narcotics Anonymous or other similar support groups also continue
during this stage of the program.
Say:
465
Slide 7.117
Some therapeutic communities insist that no resident can leave the program
without:
A full-time job or placement in school;
A place to live; and
A support network.
During the transition/aftercare stage, family reconciliation is also incorporated into
reentry. Maintaining a drug-free lifestyle means learning more coping skills, so this part
of the transition process could take many months.
One of the supports most commonly identied as essential to resident success once
they leave the therapeutic community is transitional housing (a half-way house) and
affordable longer term housing. This is a major obstacle in many places because of a
lack of good basic accommodations.
Say:
466
Slide 7.118
Conclusions of the long-term U.S. Drug Abuse Treatment Outcome Study
(DATOS) found that those who completed treatment in a therapeutic community had
lower levels of:
1
Cocaine, heroin, and alcohol use;
Criminal behavior;
Unemployment; and
Indicators of depression.
Say:
1
National Institute on Drug Abuse (2002). Research report seriesTherapeutic community: What is a therapeutic
community. Bethesda, Maryland: Author. Retrieved August 29, 2011 from http://www.nida.nih.gov/PDF/
RRTherapeutic.pdf
467
Slide 7.119
TCs have also been effective when modied to treat individuals with special
needs, including:
1
Adolescents;
Women;
Homeless individuals;
People with severe mental disorders; and
Individuals in the criminal justice system.
Say:
1
National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-based guide, 2nd Ed.
NIH Publication No. 09-4180. Bethesda, Maryland: Author.
468
Slide 7.120
Its time for a small-group exercise on therapeutic communities. For this exercise,
Group 1: Strengths
Group 3: Challenges
Say:
Small-group exercise: Therapeutic community
45 minutes
469
Slide 7.121
EBPs wall graphic under Therapeutic Communities.
Your notes;
Say:
470
any questions.
the wall graphic.
471
Slide 7.122
Before we move to our next topic, contingency management, lets take a
15-minute break.
Say:
Break
15 minutes
472
Slide 7.123
Research has demonstrated the effectiveness of treatment approaches that
use contingency management principles. Contingency management is based on the
behavioral principle that rewarding a behavior reinforces it, or makes it more likely to be
repeated. A behavior also can be reinforced by removing a negative consequence; this
is called negative reinforcement.
Contingency management in SUD treatment means that clients are given the chance
to earn low-cost incentives, or rewards, for desirable behaviour like showing up for
group sessions, being on time, trying new behaviour, or producing a drug-free urine
test. These incentives can include prizes given immediately or vouchers that can be
exchanged for food items, movie passes, or personal items.
Say:
Presentation: Contingency management
20 minutes
473
Slide 7.124
From a behavioral perspective substance use is considered to be maintained by
the positively reinforcing effects of the substance itself or by the negative reinforcement
of relieving the pain of withdrawal. Therefore, the pull of dependence and its
immediate rewards are very strong for clients with SUDs.
Say:
474
Slide 7.125
The process of becoming abstinent does have its own eventual rewards; for
example:
A healthier lifestyle;
Employment and self-sufciency;
Educational opportunities; and
Maintaining positive relationships.
Say:
475
Slide 7.126
However, the word eventual is key; it typically takes a long time before these
internal rewards are experienced by a client attempting to make such signicant
behavioral changes. So, since abstinence itself might not be sufcient reinforcement
to maintain the motivation to stop using alcohol or drugs, CM uses more immediate
rewards to reinforce both the early stages of abstinence and the lifestyle change.
Say:
476
Slide 7.127
Therefore, CM motivates clients behavioral change and reinforces abstinence by
systematically rewarding desirable behaviors:
Rewards provided are typically positive, pleasurable, and rewarding events or
objects; but
Some negative reinforcers are also effective, such as removing a ne or restriction
after a client has complied with a specic condition.
Say:
477
Slide 7.128
There are a numerous forms of contingency management, each with unique
techniques. However, each form is grounded in a set of guiding principles:
Identifying a behavior that is clearly observable and measurable. For example,
if targeting abstinence as a behavior, onsite drug testing can measure drug and
alcohol use;
Selecting a desired behavior change that can contribute toward meeting treatment
goals;
Rewarding small changes;
Say:
478
Slide 7.129
Choosing rewards that would be important to the clients by asking them which
rewards would be the most desirable;
Rewarding the targeted behavior as immediately as possible;
Providing frequent reinforcers;
Delivering all rewards as promised, so the treatment remains credible; and
Using an escalating series of rewards to provide a greater incentive for sustaining the
desired behavior.
Say:
479
Slide 7.130
Several different types of incentive programs have been researched:
Contingent access to privileges, for example through a system of levels with
increasing privileges;
Onsite prize distribution;
Refunds or rebates;
Vouchers or some other token economy systems.
Say:
480
Slide 7.131
A challenge of contingency management programs is to identify a reward for a
desired behavior that is:
Practical;
Available without too much cost or expenditure of staff energy; and
Sufciently powerful over time to replace or substitute for the very potent,
pleasurable, or pain-reducing effects of the abused substance.
Say:
481
Slide 7.132
One type of contingency management is called community reinforcement (CR)
and uses social, recreational, familial, and vocational reinforcers rather than material
rewards or within-program privileges. CR is based on the premise that environmental
resources can be highly effective in changing substance use behavior. A strong case
management component is essential to using the CR approach.
Say:
482
Slide 7.133
One form of CR, community reinforcement approach plus vouchers, has been
documented as an EBP. The model originally studied
1
was an intensive 24-week
outpatient therapy for treatment of cocaine and alcohol addiction. There were two
primary treatment goals:
For clients to maintain abstinence long enough to learn new life skills to sustain and
reinforce abstinence; and
To reduce alcohol consumption for clients whose drinking was associated with
cocaine use.
Say:
1
Budney, A. J. & Higgins, S. T. (1998). A community reinforcement approach: Treating cocaine addictionTherapy
Manuals for Drug Abuse: Manual 2. NIH Publication Number 98-4309. Bethesda, MD: National Institutes on Health.
483
Slide 7.134
In this program, clients attended one or two individual counseling sessions each
week focusing on:
Improving family relationships;
Learning a variety of skills necessary for reducing drug and alcohol use;
Receiving vocational counseling; and
Developing new recreational activities and social networks.
Say:
484
Slide 7.135
Vouchers were also used, and were provided for cocaine-negative test samples.
The vouchers increased in value with each clean sample. They could be exchanged for
retail goods consistent with a cocaine-free lifestyle.
Say:
485
Slide 7.136
This specic CM approach was found to:
Facilitate clients engagement in treatment; and
Facilitate increasing periods of cocaine abstinence.
Say:
486
Slide 7.137
The community reinforcement approach with vouchers has since been tested
and found effective in increasing treatment retention and promoting abstinence from
substances. Studies have been conducted with a variety of adult and adolescent
populations from a variety of ethnic backgrounds and in a variety of settings, such as
outpatient and residential programs, methadone maintenance clinics, and specialized
programs for adolescents.
Say:
487
Slide 7.138
Contingency management in general has been documented to be an effective
intervention for a range of SUDS involving:
1
Alcohol;
Stimulants;
Opioids;
Marijuana; and
Nicotine
Say:
1
488
Slide 7.139
Lets begin our small-group exercise on contingency management. For this
exercise, your assignments will be as follows:
Group 3: Strengths
Group 4: Challenges
Say:
Small-group exercise: Contingency management
45 minutes
489
Slide 7.140
EBPs wall graphic under Contingency Management.
Your notes;
Say:
490
any questions.
the wall graphic.
491
Slide 7.141
Pharmacotherapy can be briey dened as the use of medically prescribed
psychoactive substances to treat psychiatric and behavioral conditions. It is also known
as medication-assisted treatment (or MAT).
Say:
Presentation: Pharmacotherapy for opioid dependence
15 minutes
492
Slide 7.142
Pharmacotherapy is used in a number of ways:
To replace an opioid, either short or long term;
To discourage use of an opioid by reducing its reinforcing properties; and
To aid early recovery by reducing cravings or counteracting some of the longer term
symptoms of withdrawal.
Say:
493
Slide 7.143
Medications are available for treating dependence on alcohol, opioids, and
nicotine.
Medications for opioids need to be prescribed by a medical practitioner. One of the
best-known forms of pharmacotherapy is methadone maintenance therapy.
services, not in place of them. International guidelines developed by the World
Health Organization call for combining pharmacotherapy with counseling (particularly
cognitive-behavioral therapy and contingency management) and case management.
Say:
494
Slide 7.144
Medication-assisted treatment for opioid use disorders is often the best choice for
opioid addiction. MAT uses one of three medicationsnaltrexone, buprenorphine, or
methadoneto treat addiction to heroin or other opioid drugs.
Say:
495
Slide 7.145
Naltrexone blocks all the effects of opioids, preventing a person from getting
high. To prevent immediate and severe opioid withdrawal symptoms, a person must be
medically detoxied and opioid free for several days before beginning naltrexone.
Say:
496
Slide 7.146
Client adherence to naltrexone therapy is often a problem, and naltrexone is not
often used. A new injectable form of naltrexone (Vivitrol
) that requires only monthly

injection was recently approved in the United States to enhance adherence, which may
increase its use there.
Say:
497
Slide 7.147
Buprenorphine (Subutex
) reduces or eliminates withdrawal symptoms

associated with opioid dependence but, at proper doses, does not produce the
euphoria and sedation caused by heroin or other opioids.
At high doses, buprenorphine can produce euphoria, so it is often combined with
naloxone, a medication that blocks these effects, into a formulation called Suboxone

to avoid this potential problem.
Say:
498
Slide 7.148
Methadone is the best known and most widely used medication for opioid
treatment. Methadone may be used short term as an aid to withdrawal or over a long
period as maintenance or substitution therapy. Methadone is on WHOs list of essential
medications.
Maintenance treatment is usually conducted in specialized settings (e.g., methadone
maintenance clinics). In some countries, clients who are stabilized on methadone and
have participated in counseling services are allowed to take home enough doses for a
few days or a week at a time.
Say:
499
Slide 7.149
At the right dose, methadone:
Prevents opioid withdrawal;
Blocks the euphoric effects of illicit opioid use; and
Decreases opioid craving.
Clients stabilized on adequate, sustained dosages of methadone can function normally.
By taking methadone and stopping or decreasing their injection drug use, clients can:
Work;
Take care of their families;
Avoid the crime and violence of the street culture; and
Reduce their exposure to HIV.
Say:
500
Slide 7.150
OK, now well do our small-group exercise on pharmacotherapy. For this exercise,
Group 2: Challenges
Group 4: Strengths
Say:
Small-group exercise: Pharmacotherapy for opioid
dependence
45 minutes
501
Slide 7.151
EBPs wall graphic under Pharmacotherapy.
Your notes;
Say:
502
any questions.
the wall graphic.
503
Slide 7.152
Great job, everyone. Were going to nish the module on EBPs with some general
discussions, but rst its time for lunch. Ill see you back here in an hour.
Say:
Lunch
60 minutes
504
Slide 7.153
Were going to have small-group discussions on EBPs in general. For these
discussions, we want you to be able to look at EBPs in the context of your work. To help
that process, please form small groups of four or ve people based on the organization,
neighborhood, community, area, region, or country in which you work. If there are many
of you from one particular area, please divide into smaller groups to keep the size
manageable. If you nd you have fewer than four people in your group, you may want
to combine your group with another.
Say:
Small-group discussion: Evidence-based practices
30 minutes
Teaching Instructions: You may need to help participants form the groups. The goal
is to have small groups with something in common. For example, combining two
small groups, both from rural areas, would work.
Now, please identify a facilitator to ensure everyone has an opportunity to talk
and a reporter to summarize the discussion and report it out to the large group.
Say:
505
Slide 7.154
You have a total of 30 minutes. Please allow about 10 minutes for discussion of
each question on the slide:
Which EBPs are you using in your organization and area? Include any we did not
discuss.
Which EBPs are you not using but are of interest to you?
Which EBPs would be hardest to implement, based on your organizational, regional,
and cultural perspectives? What are some of the challenges?
Begin now.
Say:
Teaching Instructions: After 30 minutes, ask each groups reporter to summarize the
discussion for the whole training group. Ask the reporters to take no more than 5
minutes for their summaries.
506
Slide 7.155
To nish off Module 7, lets bring our small-group discussion back to the whole
group.
For the rst question, Which EBPs are you using in your organization and area, what
were the ndings in your small groups?
Say:
Large-group discussion: Evidence-based practices
15 minutes
Teaching Instructions: Repeat the process for the remaining two questions.
Encourage large-group participants to comment and ask questions of each small
group.
Summarize the discussion, pointing out similarities and differences in the use of
EBPS among participants.
Thank you all for your participation! I want to remind you that you will nd
sources of information about EBPs for further reading in Appendix BResources.
Say:
507
Wall Graphic Template
For each EBP, cut out and label newsprint shapes and arrange on the wall, following this
guide. Allow enough room for a letter-sized piece of paper to be posted beneath each
heading.
Overview: Characteristics
NAME OF EBP
Primary Techniques/applications
Strengths Challenges
Resource Page 7.1: U.S. National Quality Forum 2007
Consensus Standards for Treatment of Alcohol, Tobacco, and
Drug Use Disorders
1
One of the more ambitious efforts to respond to substandard treatment for substance
use disorders in the United States was the 2007 call for evidence-based practices by the
National Quality Forum (NQF), which provides guidance for 400 organizations in the
United States, including:
Consumer and client groups;
Health care systems and purchasers; and
Research and quality improvement organizations.
With nancial support from the Robert Wood Johnson Foundation, NQF developed
consensus standards for treatment of alcohol, tobacco, and drug use disorders. The
practice standards require evidence-based practices in four areas:
1. Identication of substance use conditions, including:
Systematic screening for alcohol, tobacco, and drug use; and
Diagnosis and assessment for individuals who screen positive.
2. Initiation and engagement in treatment, including:
Brief interventions for excessive alcohol use;
Support for participation in treatment; and
Pharmacotherapy for withdrawal management.
3. Therapeutic interventions to treat substance use disorders, including:
Empirically validated psychosocial treatments; and
Pharmacotherapy for alcohol, tobacco, and drug use.
4. Continuing care management of substance use disorders, including:
Long-term care; and
Ongoing care management and monitoring.
NQF concluded that:
1
National Quality Forum. (2007). National voluntary consensus standards for the treatment of substance use
conditions: Evidence-based treatment practices. Washington, DC: Author.
1. Empirically validated psychosocial treatment interventions should be initiated for all
clients with substance use disorders that target:
The cessation or reduction of substance use;
Improved psychological and social functioning;
Prevention of relapse or delayed time to relapse; and
Retention in treatment.
2. Empirically validated approaches for effective substance use disorders treatment
should be implemented and include:
Cognitive-behavioral therapies;
Motivational enhancement therapy:
12-Step facilitation therapy; and
Marital and family therapies.
3. Treatment delivery with an empathic, supportive approach may be as important as
the specic psychosocial technique that is used.
4. Supportive pharmacotherapy, based on systematic assessments of the symptoms
and risk of adverse consequences, should be available and provided to manage
those symptoms and the adverse consequences of withdrawal and include:
Methadone or buprenorphine tapering for opioid withdrawal;
Methadone and buprenorphine for opioid dependence;
Benzodiazepines for managing alcohol withdrawal;
Naltrexone and acamprosate for alcohol dependence;
Nicotine replacement therapy, with bupropion; and
Varenicline for tobacco cessation.
5. Interventions should actively promote involvement with community support and
include:
Family, 12-Step, or other mutual-help groups; and
Spiritual support.
1
Powers, E. J., Nishimi, R. Y., Kizer, K. W., Eds. (2005). Evidence-based treatment practices for substance use disorders:
Workshop proceedings (p. ix). Washington, DC: NQF.
NQF also identied several practices that have been shown to be ineffective treatments
for substance use disorders and that should not be routinely included as part of
treatment. These ineffective practices include:
1
The use of acupuncture, relaxation therapy, didactic group education, or biological
monitoring of substance use as a stand-alone treatment;
Detoxication as a stand-alone treatment for dependence;
Individual psychodynamic therapy;
Unstructured group therapy;
Confrontation as a principal approach to treatment; and
Discharge from treatment in response to relapse.
These materials are adapted from the cited document and information found in NQFs
consensus standards document, which can be found at
http://www.qualityforum.org/Publications/2007/09/National_Voluntary_Consensus_
Standards_for_the_Treatment_of_Substance_Use_Conditions__Evidence-Based_
Treatment_Practices.aspx.
Resource Page 7.2: Cognitive-Behavioral Therapy
1,2
Overview
CBT merges two treatment modelscognitive therapy and behavioral therapy.
Cognitive therapy, originally developed by Aaron Beck to treat depression, is based
on the theory that people often have beliefs, assumptions, and automatic thoughts
that inuence their behavior but may be unhelpful and unrealistic.
Cognitive therapy proposes that a persons thoughts and interpretations cause
feelings and behaviors.
A core belief in cognitive therapy is that people can improve the way they think (and
feel and act), even if the situation does not change.
Behavioral therapy, rst conceptualized by Ivan Pavlov and rened by B. F. Skinner
and others, treats emotional and behavioral disorders as learned responses that can
be replaced by healthy ones with appropriate training.
Behavioral therapy helps people identify behavior that is not helping them and try
out new ways of behaving.
Behavioral therapy can include a range of relaxation and coping techniques.
CBT is based on the belief that a client can be helped to recognize and discard
learned self-defeating thoughts, emotions, and behaviors that are causing
dysfunction in his or her life.
Although other therapy models attempt to address why an individual does what he
or she does, the questions that are central to CBT are:
What keeps them doing it?
How do they change?
The what question addresses the reinforcers that maintain patterns of thought,
affect, and behavior. The how question relates to building skills.
The CBT approach to treating SUDs focuses on teaching clients skills that help them
recognize and reduce risks of relapse, maintain abstinence, solve problems, and
enhance self-efcacy (a clients ability to recognize his or her strengths and to believe
that change is possible).
1
Beck, A. T. (1976). Cognitive therapy and emotional disorders. New York: International Universities Press.
2
U.S. National Institute on Drug Abuse. (2010). Principles of drug addiction treatment: A research guide: Evidence-
based approaches to drug addiction treatment: Cognitive-behavioral therapy. Retrieved October 17, 2010, from
http://www.nida.nih.gov/podat/Evidence2.html
Primary techniques
Specic techniques that help clients address their SUDs include:
Asking questions and teaching clients to ask themselves questions to explore
the relationship of their thinking to their emotional responses. Example: How do
I really know that those people are laughing at me? Are there any other possible
explanations? Could they be laughing about something else?
Exploring the positive and negative consequences of continued substance use;
Teaching clients self-monitoring skills to recognize substance cravings early on and
to identify high-risk situations for use;
Developing strategies for coping with and avoiding high-risk situations that trigger
the desire to use;
Anticipating likely problems that could trigger a slip or relapse;
Developing effective coping strategies (such as a range of relaxation techniques) for
general life challenges that might trigger their SUDs; and
Teaching problem-solving skills.
Homework is a major part of CBT approaches. Clients are given reading
assignments, asked to keep track of certain behaviors and thoughts, and asked to
practice new skills.
CBT also is applied to other challenges in recovery, such as repairing relationships
and coping with emotions.
One specic type of CBT approach is cognitive-behavioral coping-skills therapy,
originally developed for work with clients with alcohol use disorders.
1
Coping skills therapy is a structured, manual-based approach.
Each session of coping skills therapy includes discussion of the rationale, specic
skill guidelines, behavioral rehearsal role plays, and other practice exercises for a
particular topic, including:
Managing thoughts about substances and using;
Solving problems;
Substance refusal skills;
Planning for emergencies and coping with a lapse; and
Seemingly irrelevant decisions.
1
U.S. National Institute on Alcohol Abuse and Alcoholism. (1995). Cognitive-behavioral coping skills therapy manual:
Monograph Series, Volume 3: Bethesda, MD: Author.
Strengths and Challenges
CBT actively engages clients in therapy
and experiential learning.
Clients with poor reading or cognitive
skills may need alternatives to written
assignments.
CBT is suitable for clients from diverse
backgrounds and with varying histories
of alcohol and drug use.
The approach requires specic counselor
training in CBT principles and techniques.
CBT provides structured methods for
understanding relapse triggers and
preparing for relapse situations.
Client motivation is critical because of the
extent of homework assignments.
CBT can help clients with a number of
life situations.
CBT was developed as an individual, not
group, counseling approach.
Extensive homework allows clients to
practice and evaluate new behavior in
their own environments.
Resource Page 7.3: Motivational Approaches
1,2
Overview
Motivational approaches (motivational interviewing [MI] and motivational
enhancement therapy [MET]) are based on the perspectives that change occurs in
stages, motivation for change varies over time, and motivation can be enhanced.
Motivational approaches are based on the principles of motivational psychology and
the trans-theoretical model of change, also known as the stages of change model,
which was developed by James Prochaska and Carlos DiClemente and reviewed in
Module 2 (please go back to Resource Page 2.2: Characteristics of Clients in Each of
the Stages of Change to review the stages of change).
Motivational counseling approaches are methods of counseling that are client-
centered and use nondirective methods. These approaches use strategies that:
Acknowledge that substances of abuse have rewarding properties that can
disguise, at least temporarily, their hazards and negative long-term effects;
Help clients resolve ambivalence about engaging in treatment and stopping
substance use;
Use the internal motivation of clients to evoke and sustain rapid change; and
Are not focused on a counselors discovery, interpretation, and guidance.
Motivational approaches operate in the belief that change is created through the
clients will and motivation.
Motivational approaches frequently include other problem-solving or solution-
focused strategies that build on clients past successes.
The counselor acts as a coach or consultant rather than as an authority gure.
Primary techniques
Through empathic listening and skillful interviewing, the motivational counselor
encourages the client to:
Identify discrepancies between signicant life goals and the consequences of SUDs;
Believe in his or her capabilities for change;
Choose among available strategies and options; and
1
Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1994). Motivational enhancement therapy manual:
Monograph Series, Vol. 2. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism.
2
National Institute on Drug Abuse. (2010). Principles of drug addiction treatment: A research guideEvidence-based
approaches to drug addiction treatment: Motivational enhancement therapy. Retrieved on October 17, 2010, from
Take responsibility for initiating and sustaining healthful personal behavior.
Counselors pose questions to clients in a way that solicits information while
strengthening clients motivation and commitment to positive change.
FRAMES
The FRAMES acronym reminds a motivational counselor of his or her role and
responsibilities during treatment.
The FRAMES approach was originally developed as a brief intervention. The
acronym stands for:
Feedback regarding personal risk or impairment given to a client following
assessment of substance use patterns and associated problems.
Responsibility for change is placed squarely and explicitly on the client (and with
respect for the clients right to make choices for himself or herself).
Advice about changingreducing or stoppingsubstance use is clearly given to
the client by the counselor in a nonjudgmental manner.
Menus of self-directed change options and treatment alternatives are offered to the
client.
Empathic counselingshowing warmth, respect, and understandingis emphasized.
Self-efcacy or optimistic empowerment is developed in the client to encourage
change.
Decisional Balance Exercises
Decisional balance is the concept of exploring the pros and consor benets and
disadvantagesof change.
People naturally explore the pros and cons of major life choices.
In the context of recovery from substance use, the client weighs the pros and cons of
changing versus not changing substance-using behavior.
The counselor assists this process by asking the client to articulate the good and
less good aspects of using substances and then list them in two columns on a
sheet of paper.
The purpose of exploring the pros and cons of a substance use problem is to tip the
scales toward a decision for positive change.
The actual number of reasons a client lists on each side of a decisional balance sheet
is not as important as the weightor personal valueof each one. For example, a
20-year-old might not put as much weight on losing a girlfriend as would an older,
engaged man who wants a family. The 20-year-old might be very concerned, though,
about being kicked off his soccer team for missing too many practices.
Identifying Discrepancies
One way to enhance motivation for change is to help clients recognize a discrepancy
or gap between their future goals and their current behavior.
The counselor might clarify this discrepancy by asking, How does your drinking t in
with having a happy family and a stable job?
When an individual sees that present actions conict with important personal goals
such as health, success, or family happiness, change is more likely to occur.
Pacing
Every client moves through the stages of change at his or her own pace.
The concept of pacing requires that a counselor meet a client at the clients level and
use as much or as little time as is necessary with the essential tasks of each stage of
change.
For example, some clients may need frequent sessions at the beginning of
treatment and fewer later.
If a counselor pushes a client at a faster pace than the client is ready to take, the
relationship between counselor and client may break down.
Personal Contact With Clients Not in Treatment
Motivational interventions can include simple activities designed to enhance
continuity of contact between counselor and client and strengthen the relationship.
Activities can include personal handwritten letters or telephone calls from counselor
to client.
Research has shown that these simple motivation-enhancing interventions are
effective for encouraging clients to return for another clinical consultation, to return
to treatment following a missed appointment, to stay involved in treatment, and to
increase treatment adherence.
Motivational Interviewing
Motivational Interviewing (MI) is a counseling technique or style that focuses on
creating a favorable climate for change.
The essence of motivational interviewing is in its collaborative nature,
communicating in a partner-like relationship, where the interviewer seeks to create a
positive interpersonal atmosphere.
There are ve primary principles in MI. These are not steps, but concepts to be
applied at all times to enhance the relationship between the counselor and the
client. They are often summarized by the acronym READS:
Roll with resistance;
Express empathy;
Avoid argument;
Develop discrepancy; and
Support self-efcacy.
To carry out these ve principles, there are four basic therapeutic skills or methods
an SUD counselor uses in motivational interviewing:
Reective listening or responding to a clients statement by stating back to her or
him the essence or a specic aspect of what was said;
Asking open-ended questions;
Afrming; and
Summarizing.
Motivational Enhancement Therapy
Motivational enhancement therapy is another of the motivational approaches that
researchers have documented as being effective. MET seeks to help clients:
Create their own motivation for change; and
Consolidate a personal decision and plan for change.
This approach is also primarily client-centered, but counseling sessions are planned
and directed by the counselor.
In SUD treatment, MET counselors seek to alter the harmful use of drugs and
alcohol. Because each client sets his or her own goals:
No absolute goal is imposed by a counselor using MET.
MET counselors may advise specic goals, such as complete abstinence.
A broader range of life goals, such as nding a job or reuniting with family
members, may be explored as well.
In MET problems are viewed as behaviors at least partially under the voluntary
control of the client. Thus, they follow the normal principles of behavior change.
Motivational Enhancement Therapy is based on principles of cognitive and social
psychology. The MET counselor:
Seeks to help the client perceive a discrepancy between current behavior and
signicant personal goals; and
Emphasizes the clients self-motivational statements regarding both the desire for
and the commitment to change.
The MET counselor works from the assumption that internal motivation is not only a
necessary but often the only factor needed to create change.
MI and MET are client-centered and
relevant to clients personal interests.
MI and MET rely heavily on clients
capabilities and level of self-awareness.
MI and MET focus on realistic, attainable
goals.
Commonly used problem-oriented
assessment instruments are incompatible
with a motivational approach.
MI and MET encourage client self-
efcacy and self-sufciency.
Motivational approaches require signicant
staff training and ongoing supervision.
MI and MET emphasize positive,
empathic support that does not
undermine or elicit anger from clients.
Motivational approaches may be difcult
to combine with approaches that expect
adherence to program-imposed goals.
MI and other motivational approaches
were developed as individual approaches;
their effectiveness for use with groups is
unproved.
Resource Page 7.4: Family-Based Approaches
1,2,3,4,5,6
Overview
Although simple family involvement is not a specic model of treatment, research
shows that family involvement in treatment enhances outcomes.
Most programs offer family education, family support groups, and family counseling
as part of their approach. Some programs, particularly those focusing on adolescent,
may primarily use a family-systems therapy approach.
Family-based services ensure that family functioning adjusts to and positively
inuences the recovery of the client.
One main goal of involving families in treatment is to increase family members
understanding of the clients substance use disorder as a chronic disease.
Family-based services can:
Increase family support for the clients recovery. Family sessions can increase a
clients motivation for recovery, especially as the family realizes that the clients
substance use disorder is intertwined with problems in the family.
Identify and support a change of family patterns that works against recovery.
Relationship patterns among family members can work against recovery by
supporting the clients substance use, family conicts, and inappropriate coalitions.
Prepare family members for what to expect in early recovery. Family members
unrealistically may expect all problems to dissipate quickly, increasing the likelihood
of disappointment and decreasing the likelihood of helpful support for the clients
recovery.
Educate the family about relapse warning signs. Family members who understand
warning signs can help prevent the clients relapses.
Help family members understand the causes and effects of substance use disorders
from a family perspective.
1
Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.
2
Edwards, J. T. (1990). Treating chemically dependent families: A practical systems approach for professionals.
Minneapolis, MN: Johnson Institute.
3
U.S. National Registry of Evidence-based Practices and Programs. (2011) Multidimensional family therapy. Rockville,
Maryland: SAMHSA. Retrieved August 30, 2011 from http://nrepp.samhsa.gov/ViewIntervention.aspx?id=16
4
U.S. National Registry of Evidence-based Practices and Programs. (2011) Behavioral couples therapy for alcoholism
and drug abuse. Rockville, Maryland: SAMHSA. Retrieved August 30, 2011 from http://nrepp.samhsa.gov/
ViewIntervention.aspx?id=134
5
U.S. National Registry of Evidence-based Practices and Programs. Multisystemic therapy (MST) for juvenile offenders.
(2007). Rockville, Maryland: SAMHSA. Retrieved August 30, 2011 from http://nrepp.samhsa.gov/ViewIntervention.
aspx?id=26
6
Edwards, J. T. (1990). Treating chemically dependent families: A practical systems approach for professionals.
Minneapolis, MN: Johnson Institute.
Take advantage of family strengths. Family members who demonstrate positive
attitudes and supportive behaviors encourage the clients recovery. It is important
to identify and build on strengths to support positive change.
Encourage family members to obtain long-term support. As the client begins to
recover, family members need to take responsibility for their emotional, physical,
and spiritual recovery.
While families can be critical to the success of a client with SUDs, some family
members may actually need treatment themselves before they can be such a helpful
resource for clients. Many clients are from families that are particularly chaotic and
dysfunctional or have multi-generational substance use disorders, mental disorders,
and other problems.
Primary techniques
Several specic family approaches are considered EBPs for treating SUDs:
Behavioral couples therapy (BCT);
Multisystemic therapy (MST) for adolescents; and
Multidimensional family therapy (MDFT) for adolescents.
Behavioral Couples Therapy (BCT)
BCT is based on the assumptions that:
Intimate partners can reward abstinence; and
Reducing relationship distress lessens risk for relapse.
The spouse or partner gains an active role in the treatment, minimizing the sense of
helplessness that often comes with living with a person with an SUD.
Program components include:
A recovery or abstinence contract between the partners and the therapist;
Activities and assignments designed to increase positive feelings, shared activities,
and constructive communication; and
Relapse prevention planning.
Partners generally attend 15 to 20 hour-long sessions over 5 to 6 months. Sessions
follow a particular sequence:
The therapist asks about any substance use since the last session;
The couple discusses compliance with the recovery contract;
The couple presents and discusses homework assigned at the last session;
The couple discusses any relationship problems since the last session;
The therapist presents new material; and
The therapist assigns new homework.
BCT is typically used as an adjunct to other SUD treatment approaches.
Multisystemic Therapy (MST)
MST is an intensive, in- home and in-community approach that focuses on changing
the thinking and behavior of both parents and adolescents.
Traveling to the family overcomes the high dropout rates of other treatments,
which often occur because of the difculty caregivers face in getting adolescents to
appointments.
The approach primarily uses cognitive-behavioral and social-development (risk and
protective factors) strategies.
MST focuses on a familys strengths to facilitate positive change.
Interventions are designed to promote responsible behavior and decrease
irresponsible actions by family members.
Interventions focus on the present: what is happening currently in the adolescents
life. Counselors look for action that can be taken immediately, targeting specic,
well-dened problems rather than gaining insight or focusing on the past.
Interventions target sequences of behavior within and between the various
interacting elements of the adolescents lifefamily, teachers, friends, home, school,
and communitythat sustain the identied problems.
A key developmental emphasis is on building the adolescents ability to get along
well with peers and acquire academic and vocational skills that will promote a
successful transition to adulthood.
MST counselors do not label families as resistant, not ready for change, or
unmotivated; their approach avoids blaming the family but rather places the
responsibility for positive treatment outcomes on the MST team.
Interventions are designed to empower caregivers to address the familys needs
after treatment ends. The caregiver is seen as the key to long-term success.
Multidimensional Family Therapy (MDFT)
MDFT views adolescent drug use in terms of a network of inuences (individual,
family, peer, community) and suggests that reducing unwanted behavior and
increasing desirable behavior occur in multiple ways in different settings.
Treatment includes individual and family sessions held in a treatment center, in the
home, or with family members at schools, courts, or other community locations.
During individual sessions, the therapist and adolescent work on important
developmental tasks, such as developing decision-making, negotiation, and
problem-solving skills.
Adolescents acquire vocational skills and skills in communicating their thoughts and
feelings to deal better with life stressors.
Parallel sessions are held with family members. Parents examine their particular
parenting styles, learning to distinguish inuence from control and to have a positive
and developmentally appropriate inuence on their children.
Family involvement in substance abuse
treatment is positively associated with
increased treatment engagement,
decreased dropout rates during
treatment, and better long-term
outcomes.
Engaging families in treatment can be
difcult because of the stigma and shame
associated with substance use.
When families are involved in treatment,
the focus can be on the larger family
issues, not just the substance use. Both
the individual with the substance use
disorder and the family members get the
help they need to achieve and maintain
abstinence.
Staff needs specic training in family
therapy to use the family approaches as the
primary means of treatment. Such training
can be time-consuming and expensive.
Family approaches capitalize on family
strengths, mobilizing ongoing support
for the clients and the familys recovery.
Families may be too dysfunctional (or
involved with substance abuse themselves)
to benet from treatment program
services. Programs need to have a well-
developed referral network of sources for
more intensive therapy when necessary.
Some family approaches are highly
intensive and require signicant staff
resources.
Resource Page 7.5: Therapeutic Community
1,2,3
Overview
The therapeutic community (TC) is an intensive, primarily long-term (up to 1 year)
residential model.
TCs use an approach known as community as method; this approach views the
community as a wholeits social organization, its staff and clients, and its daily
activitiesas the therapeutic agent.
This community-as-method philosophy and a distinct therapeutic structure dene TCs.
In fact, researchers have documented that restoring warm interpersonal relationships
reverses the damaging changes produced on brain formation, function, and
structure by neglect and abuse during childhood. Within the TC, each participant
has a well-recognized role, is considered with love and respect, and is part of a new
familyall of which lls the affective gaps that may have been created during his or
her destructive personal history.
The humanity of caregivers, the warm and friendly relationships with the peers in the
full-time environment of a TC are the real therapeutic engines for the changes that
happen with clients in this setting.
Because of their intense, long-term nature, TCs are particularly appropriate for
clients who have histories of severe substance use disorders and criminal behavior.
TCs feature a structured day that includes ordered, routine activities to counter
the characteristically disordered lives of clients and to distract them from negative
thinking and boredom.
The TC model is used in countries around the world, and every continent (except
Antarctica) has professional associations of TCs.
The Asian Federation of Therapeutic Communities (http://www.asianfedtc.org/
about.html) has 13 member countries.
Primary techniques
TCs center daily activities on group sessions and hierarchical job functions that teach
participants specic behaviors and skills.
1
2
National Institute on Drug Abuse (2002). Research report seriesTherapeutic community: What is a therapeutic
community. Bethesda, Maryland: Author. Retrieved August 29, 2011 from http://www.nida.nih.gov/PDF/
RRTherapeutic.pdf
3
De Leon, G. (2000). The therapeutic community: Theory, model, and method. New York: Springer Publishing
Company.
4
Personal communication: Gilberto Gerra, M.D., Chief , Drug Prevention and Health Branch, United Nations Ofce for
Drug Control.
The TC model can be, and often is, modied to t cultural perspectives, but
generally includes the following components:
A sense of community. Community is created partly by a separation from other
organizational or institutional programs and, more important, from the drug-using
environment. A TC facility contains communal space for promoting a sense of
commonality during collective activities. Treatment or educational services are
delivered within the peer community.
Peers and staff members as role models. TC members and staff members serve
as positive role models by demonstrating expected behaviors and reecting the
values and teachings of the community. The strength of the community for social
learning rests on the number and quality of its positive role models.
Work as therapy and education. Consistent with the TCs self-help approach, all
clients are responsible for the daily management of the facility, and work roles are
designed to bring about essential educational and therapeutic effects.
Awareness and emotional growth training. Groups can heighten clients awareness
of specic attitudes or behavioral patterns that need to change and help them
identify feelings and express them appropriately and constructively.
A therapeutic community might organize a clients treatment in four stages:
Introduction stage: The introductory program would be divided into specic
modules of treatment focused on helping the client accept responsibility for his
or her SUD behaviors and their consequences. Participants would take part in
group and individual counseling sessions and attend educational seminars. At the
completion of this stage, clients would move to the more focused treatment phase
of the programor might request a referral to another organization.
Treatment stage: In the treatment stage clients would live and work in the small
community situation and, with the support and encouragement of staff and their
peers, help one another develop constructive life-coping skills. The social structure
would be a simple hierarchy of positions with degrees of responsibility. Activities
would center on a normal lifestyle of daily work projects and leisure pursuits, which
would be supported by the creative therapy program. Attendance at outside
support meetings would also be initiated during this time.
Commitment stage: Commitment is the link between treatment and the start of
the community reintegration phase. During this phase, clients would begin to take
their place back in society. Emphasis would be placed on career development,
social relationships, and practical living skills. The program would provide clients
with a supportive and gradual community reentrymoving through voluntary
work into full-time employment or education. As clients move from the protected
environment of the therapeutic community into a transition house and then into
their own accommodation in the general community, weekly support groups and
counseling sessions would be held with staff. Clients would also receive additional
support from peers who have successfully negotiated this process. Attendance at
Narcotics Anonymous or other similar support groups would also continue during
this stage of the program.
Transition/aftercare stage: Some therapeutic communities insist that no resident
can leave the program without a full-time job, a place to live, and a support
network. Family reconciliation would also be incorporated into reentry. Maintaining
a drug-free lifestyle would means learning more coping skills, so this part of the
transition process could take many months. One of the supports most commonly
identied as essential to resident success once they leave the therapeutic
community is transitional housing (a half way house) and affordable longer term
housing. This is a major obstacle in many places because of a lack of good basic
accommodations.
The TC approach is effective for
people with long histories of substance
dependence and antisocial behavior.
The approach may be too socially intense
for some clients.
The TC approach is particularly effective
in teaching clients how to plan, set, and
achieve goals and to be accountable.
Effective TC treatment requires extensive
staff training.
The TC approach is effective in reducing
recidivism among clients who have served
time in prison.
Finding an effective mix of professional
clinicians and recovering staff (who may
not be trained in assessment, treatment
planning, and counseling) can take time.
Resource Page 7.6: Contingency Management
1,2,3
Overview
Contingency management (CM) is based on operant conditioning theory and was
developed out of applied behavioral analysis and behavior therapy.
Its roots are grounded in the 1950s work that students of B. F. Skinner did when
they applied operant conditioning principles to the treatment of serious conditions
(for example, those with schizophrenia, juvenile justice populations) using token
economies (see below).
Operant conditioning theory maintains that future behavior is based on the positive
or negative consequences of past behavior.
For example, drug use is maintained by the positively reinforcing effects of the drug
itself or by the negative reinforcement of relieving the pain of withdrawal.
The use of contingency management is based on the premise that the pull of
dependence and its immediate rewards are very strong for clients with substance
use disorders.
The process of becoming abstinent has its own eventual rewards, such as:
Healthier lifestyle;
Employment;
Educational opportunities; and
Maintaining positive relationships.
However, it typically takes a long time before internal rewards are experienced by a
client attempting to make such signicant behavioral changes.
So, abstinence in and of itself, may not be sufciently reinforcing to maintain a
persons motivation to stop using drugs, particularly in early abstinence. Other
rewards must be found that reinforce ongoing abstinence and lifestyle change.
CM motivates clients behavioral change and reinforces abstinence by systematically
rewarding desirable behaviors and ignoring or punishing others.
1
U.S. National Institute on Drug Abuse. (2010). Principles of drug addiction treatment: A research guideEvidence-
based approaches to drug addiction treatment: Contingency management interventions/motivational incentives.
Retrieved September 16, 2011, from http://www.nida.nih.gov/podat/Evidence2.html
2
U.S. National Addiction Technology Transfer Center. (2010). Successful treatment outcomes using motivational
incentives. Retrieved September 16, 2011, from http://www.nattc.org/pami/PPT/PAMI_PolicyMakers.ppt
3
Meyers, R. J., & Squires, D. D. (n.d.). The community reinforcement approach: A guideline developed for the
Behavioral Health Recovery Management Project. Albuquerque, NM: University of New Mexico Center on
Alcoholism, Substance Abuse, and Addictions. Retrieved September 16, 2011 from
Reinforcers are typically positive, pleasurable, and rewarding events or objects, but
some negative reinforcers also are effective.
Removing a ne or restriction after a client has complied with a specied regimen is
an example of negative reinforcement.
Primary techniques
There are numerous forms of contingency management, each with its own unique
techniques. However, each form is grounded in a set of guiding principles for
contingency management:
Identify a behavior to target that is clearly observable and measurable. For
example, if targeting abstinence as a behavior, onsite drug testing can measure
drug use; a clients self-report is not enough. Similarly, if work activity is the target
behavior, it is not enough to ask clients about their attendance or productivity.
Objective, veriable measures that demonstrate accomplishments must be used.
Attendance and compliance with program rules are easy behaviors to measure.
Select a desired behavior change that contributes to treatment goals. Simply
attending counseling sessions may not affect a persons drug use.
Reward small changes. For example, expecting clients who have never submitted
a drug-free urine sample to achieve immediate abstinence may be optimistic.
Abstinence from a specic substance might precede abstinence from all substances.
Because incentives that are perceived as desirable by clients are likely to have a
much greater impact on behavior than those that are perceived as being of less
value or use, it is important to choose rewards that would be important to the
clients by asking them which rewards would be most desirable. Something that is
rewarding for one client may not be for another.
Reward the targeted behavior as immediately as possible.
Provide frequent reinforcers. More frequent reinforcers, even if small, have a greater
effect than larger, more remote rewards or punishments.
Deliver all rewards as promised, so the treatment remains credible.
Use an escalating series of rewards (bigger and better rewards to reinforce bigger
and longer lasting behavior change) to provide a greater incentive for sustaining
the desired behavior.
Several basic types of incentive programs have been researched:
Contingent access to clinic privileges: In a clinical setting, clients are allowed to use
privileges that already exist within that setting; level systems are designed such that
once a level is achieved, the client immediately earns all the privileges for that level
and the levels lower than it.
Onsite prize distribution: Tangible or material goods are distributed when a desired
behavior is exhibited, based on how long the behavior has been exhibited.
Vouchers or some other token economy systems: Points or vouchers, which can be
redeemed for goods or privileges, are given for consistently engaging in specic
activities or for meeting specic treatment plan goals.
Refunds or rebate: Clients pay a fee on entering treatment, but they receive a
refund if they complete treatment and remain abstinent.
A challenge of contingency management programs is to identify a reward for a desired
behavior that is both practical and sufciently powerfulover timeto replace or
substitute for the potent, pleasurable, or pain-reducing effects of the drug. The reward
also must be available without too much cost or expenditure of staff energy.
Community Reinforcement
One type of contingency management, community reinforcement (CR), uses social,
recreational, familial, and vocational reinforcers rather than material rewards or
within-program privileges to make an abstinent lifestyle more rewarding than
substance use.
CR is based on the premise that environmental contingencies can be highly effective
in changing substance use behavior. A strong case management component is
essential to using the CR approach.
One form of CR, community reinforcement approach plus vouchers, has been
documented as an EBP. The original model was an intensive 24-week outpatient
therapy for treatment of cocaine and alcohol addiction. There were two primary
treatment goals:
To maintain abstinence long enough for clients to learn new life skills to sustain that
sobriety; and
To reduce alcohol consumption for clients whose drinking is associated with
cocaine use.
In this program, clients attended one or two individual counseling sessions each
week focusing on:
Improving family relationships;
Learning a variety of skills necessary for reducing drug and alcohol use;
Receiving vocational counseling; and
Developing new recreational activities and social networks.
Vouchers were also provided for cocaine-negative test samples, and increased in
value for each consecutive clean sample. The vouchers could be exchanged for retail
goods consistent with a cocaine-free lifestyle.
This specic CM approach was found to facilitate:
Clients engagement in treatment; and
Systematically gain increasing periods of cocaine abstinence.
CM has been shown to increase treatment
adherence and reduce drug use
signicantly when incentives are used.
Clients may return to baseline drug use
rates when incentives are terminated.
CR and CM can be combined readily
with other psychosocial interventions and
pharmacotherapies.
CM approaches can be labor intensive,
require specialized staff or training for
implementation, and require frequent
client attendance.
CM can be implemented with a variety
of low-cost incentives such as donated
goods or services.
For maximal effectiveness, rewards must
be sufciently largeand increase in
valueto have continuing appeal to
clients.
CR and CM have extensive and robust
scientic support in both laboratory and
clinical studies.
Many research studies demonstrating CR
and CM effectiveness have used small
samples and incurred large costs for
incentives.
Because CR uses environmental
reinforcers, the effects continue after
the structured program is completed,
becoming integrated into the clients
everyday life.
Resources required for implementing CR
and CM (for example, onsite urine-testing
capabilities or alternatives to costly
incentives) may be unavailable.
Resource Page 7.7: Pharmacotherapy
1,2
Overview
Pharmacotherapy can be briey dened as the use of medically prescribed
psychoactive substances to treat psychiatric and behavioral conditions. It is also
known as medication-assisted treatment (MAT).
Pharmacotherapy is used in a number of ways:
To replace a psychoactive substance, either short or long term;
To discourage use of a substance by reducing its reinforcing properties or by
creating negative effects when the substance is used; and
To aid early recovery by reducing cravings or counteracting some of the longer term
symptoms of withdrawal.
Medications are available for treating dependence on alcohol, opioids, and nicotine.
These medications generally need to be prescribed by a medical practitioner,
though medications for nicotine dependence are available without a prescription.
One of the widest used and best known forms of pharmacotherapy is methadone
maintenance therapy for opioid dependence.
services, not in place of them.
Primary applications of pharmacotherapy
Treatment that includes medication is often the best choice for opioid addiction.
MAT uses one of three medicationsnaltrexone, buprenorphine, or methadoneto
treat addiction to heroin or other opioid drugs.
Naltrexone blocks all the effects of opioids, preventing a person from getting high.
To prevent immediate and severe opioid withdrawal symptoms, a person must be
medically detoxied and opioid free for several days before beginning naltrexone.
1
World Health Organization. (2009). Guidelines for the psychosocially assisted pharmacological treatment of opioid
dependence. Geneva: Author.
2
Center for Substance Abuse Treatment. (2005). Medication-Assisted Treatment for Opioid Addiction in Opioid
Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 05-4048.
Rockville, MD: U.S. Department of Health and Human Services.
Client compliance with naltrexone therapy is often a problem, and naltrexone has
seldom been used. The newer injectable form of naltrexone (Vivitrol
) was recently
approved in the United States for use with opioid dependence, which may increase
its use.
Buprenorphine (Subutex
) reduces or eliminates withdrawal symptoms associated

with opioid dependence but, at proper doses, does not produce the euphoria and
sedation caused by heroin or other opioids.
At high doses, buprenorphine can produce euphoria, so is often combined
with naloxone, a medication that blocks these effects, into a formulation called
Suboxone
to avoid this potential problem.

Methadone is the best know and most widely used medication for opioid treatment.
Methadone may be used short term, as an aid to withdrawal, or over a long period
(maintenance or substitution therapy).
Methadone is on the WHOs list of essential medications.
Maintenance treatment is usually conducted in specialized settings (for example,
methadone maintenance clinics).
In some countries, clients who are stabilized on methadone and have participated in
counseling services are allowed to receive take-home doses for a few days or a week
at a time.
At the right dose, methadone:
Prevents opioid withdrawal;
Blocks the euphoric effects of illicit opioid use; and
Decreases opioid craving.
Clients stabilized on adequate, sustained dosages of methadone can function
normally. By taking methadone and stopping or decreasing their injection drug use,
clients can:
Work;
Take care of their families;
Avoid the crime and violence of the street culture; and
Reduce their exposure to HIV.
Strengths and Challenges (pharmacotherapy for opioid dependence)
Clients stabilized on adequate,
sustained dosages of methadone
can function normally and become
contributing members of society.
Methadone must be prescribed and
monitored carefully by medical personnel.
Clients may come to the program for
methadone but stay for the counseling,
enhancing overall recovery.
In some places in the world, methadone
maintenance is not available or even legal.
Implementing such a program could take
many years of advocacy and education on a
policy level.
Pharmacotherapy can help clients
avoid exposure to HIV and other
infectious diseases.
Some clients will need to take methadone
for life, thus requiring consistent, long-term
monitoring and care.
Serious attention must be paid to security to
avoid theft and diversion of methadone to
the street.
Resource Page 7.8: Twelve-Step Facilitation Therapy
1
Overview
Twelve-Step Facilitation Therapy is based on the concepts of 12-Step mutual-help
groups, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and
Cocaine Anonymous (CA).
The steps of these programs focus on:
Admitting there is a problem;
Seeking help;
Engaging in a thorough self-examination;
Making a condential self-disclosure;
Making amends for harm done; and
Helping others who want to recover.
Twelve-Step Facilitation Therapy focuses on helping clients understand AA/NA
principles, start working through the 12 steps of recovery, learn about and accept
their addiction, achieve abstinence, and become involved in community-based 12-
Step groups.
Group work focuses on accepting the disease, assuming responsibility for the
recovery process and ones actions, renewing hope, establishing trust, changing
behavior, practicing self-disclosure, developing insights into ones behavior, and
making amends.
Clients are encouraged strongly to:
Accept their addiction;
Develop or adopt spiritual values;
Develop a sense of fellowship with others in recovery; and
Attend meetings in the community.
Primary techniques
Twelve-Step Facilitation Therapy is manual-guided and time-limited; it is implemented
with individual clients over 12 to 15 sessions spread over approximately 12 weeks. The
initial assessment session runs 11/2 hours, and regular sessions last 1 hour.
1
U.S. National Registry of Evidence-based Programs and Practices. (2010). Twelve-step facilitation therapy. Retrieved
on September 1, 2011 from http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=55
The assessment session within the model has both informational and motivational
goals. These goals include:
Establishing client-facilitator rapport;
Conducting a collaborative assessment of drug abuse (history);
Discussing the clients efforts to stop or control use;
Discussing negative consequences associated with use;
Sharing a diagnosis with the client and attempting to have it be a collaborative
decision;
Outlining the program; and
Attempting to get a commitment from the client to give the program and AA/NA a
try and to keep an open mind.
Each regular session begins with a 10-minute discussion of the clients recovery
week, including:
Any use that occurred;
Any urges to use that the client experienced;
Reactions to recovery tasks and other specic suggestions made at the end of the
last session;
Reactions to meetings attended; and
Overall progress in getting active in AA or NA.
Since the program is based on the principles of 12-Step fellowships, the counselor
must work within this framework. For example, participation in self-help groups is
central and is regarded as the primary agent of change. Specic objectives include:
Attending 90 AA or NA meetings in 90 days;
Getting and using members phone numbers;
Getting a sponsor; and
Assuming responsibilities within a meeting.
The Twelve-Step Facilitation Therapy manual can be ordered from the U.S. National
Institute on Alcohol and Alcoholism ($6.00 per copy) at http://pubs.niaaa.nih.gov/
publications/match.htm#ordering
Twelve-Step Facilitation Therapy
emphasizes an array of recovery tasks in
cognitive, spiritual, and health realms.
It can be difcult to monitor accurately
clients compliance with assigned step
tasks, including meeting attendance.
Research has found that the 12-step
approach can be effective with clients
from diverse backgrounds.
12-Step groups emphasis on a higher
power may be unacceptable to some
clients.
Although 12-Step programs are available
throughout the world, meetings are
not always available in a particular area
(especially rural areas).
Resource Page 7.9: Matrix Model
1,2
Overview
The Matrix model was developed during the 1980s as an effective way to treat
people dependent on stimulant drugs, particularly cocaine and methamphetamine.
The model has been modied to include treatment for people who use other
drugs, including heroin, although research has not yet been done to evaluate the
effectiveness of this approach with groups other than stimulant users.
Matrix is a manual-based program. The manual materials, including handouts
for clients that form the basis of therapeutic sessions, were selected through
a behavioral analysis of the type of problems encountered by cocaine and
methamphetamine users as they proceeded through periods of cocaine abstinence.
The Matrix model integrates several research-based techniques (including cognitive-
behavioral, motivational enhancement, education, and family approaches) to target
clients behavioral, emotional, cognitive, and relationship issues.
The Matrix approach includes:
Establishing a strong therapeutic relationship between the client and counselor;
Teaching clients how to structure time and live an orderly and healthful lifestyle;
Providing accurate, understandable information about addiction;
Providing opportunities to learn and practice relapse prevention and coping
techniques;
Involving family and signicant others in the therapeutic and educational processes
to gain their support forand prevent their sabotage oftreatment;
Encouraging clients to participate in community-based support groups; and
Conducting random urinalyses or breath tests to assess treatment effectiveness.
Primary techniques
Detailed treatment manuals contain worksheets for individual sessions; other
components include family education groups, early recovery skills groups,
relapse prevention groups, combined sessions, urine drug tests, 12-Step program
attendance, relapse analysis, and social support groups.
1
Rawson, R. A., Marinelli-Casey, P., Anglin, M. D., Dickow, A., Frazier, Y., Gallagher, C., et al. (2004). A multi-site
comparison of psychosocial approaches for the treatment of methamphetamine dependence. Addiction, 99(6), 708717.
2
Obert, J. L., London, E. D., & Rawson, R. A. (2002). Incorporating brain research ndings into standard treatment: An
example using the Matrix model. Journal of Substance Abuse Treatment, 23(2), 107113.
The elements of the Matrix treatment approach are a collection of group sessions
(early recovery skills, relapse prevention, family education, and social support) and
3 to 10 individual sessions delivered over a 16-week intensive treatment period.
Specically during those 16 weeks, the Matrix model requires:
Three individual/conjoint family sessions;
Eight early recovery skills group sessions;
Thirty-two relapse prevention group sessions;
Twelve family education group sessions; and
Thirty-six social support group sessions.
Clients can begin attending social support groups, which focus on continuing
care, once they have completed the 12-session family education group but are still
attending the relapse prevention group sessions. The Matrix program has found
that overlapping the social support group attendance with the intensive phase of
treatment helps ensure a smooth transition to the 36-week continuing care phase.
Free Matrix Model treatment manuals can be downloaded from: http://www.kap.
samhsa.gov/products/manuals/matrix/index.htm
The model integrates a cognitive-
behavioral approach with family
involvement, psychosocial education,
12-Step support, and urine testing.
Some materials may need to be
modied for clients whose cognitive
functioning is impaired.
The Matrix manuals provide step-by-
step descriptions to explain how sessions
should be conducted and provide
handouts and all other necessary materials.
Specic staff training and supervision are
highly recommended and may be costly.
The model has been used extensively with
people dependent on stimulants and has
been shown to be effective.
The highly structured content may not
appeal to all clients.
The tight structure and schedule may
not leave enough time for effective case
management.
539
MODULE 8
INTEGRATING LEARNING INTO PRACTICE
Module 8 and review exercise introduction .............................................543
Small-group exercise: Developing a practice integration plan ................544
Sharing and feedback ............................................................................546
Learning assessment competition ............................................................547
Day 5 and overall training evaluations .....................................................548
Program completion ceremony and socializing .......................................549
541
Trainer Manual: Module 8Integrating Learning Into Practice
Preparation Checklist
Preview Module 8, including Resource Page 8.1.
Make copies of the list of local resources (see Getting Started) you prepared for
additional participant training and support.
Copy one Daily Evaluation form and one Overall Training Evaluation form for each
participant.
Bring to the session:
o Beans, small candies, or other small items to use as point counters for the
learning assessment competition;
o A personalized Training Completion Certicate for each participant;
o An appropriate music CD to play during the completion ceremony; and
o Beverages and snacks for socializing after the completion ceremony (optional).
Activity Time
Person
Responsible
Module 8 and review exercise introduction 10 minutes
Small-group Exercise: Developing a practice
integration plan
45 minutes
Break 15 minutes
Partner exercise: Developing a practice integration
plan: Sharing and feedback
15 minutes
Learning assessment competition 20 minutes
Day 5 and overall training evaluations 15 minutes
Program completion ceremony and socializing 30+ minutes
542
Module 8 Goals and Objective
Training goals
To encourage participants to think about resources, barriers, and strategies for
change; and
To provide an opportunity to develop a personal practice integration plan.
Learning objective
Participants who complete Module 8 will have developed a personal practice
integration plan.
543
Training is valuable only if it leads to changes in practice. Making a commitment
and writing it down can help people make changes. This afternoon you will have a
chance to think about what you have learned during the past 5 days of training and to
develop a written plan for integrating new learning into your practice.
But rst, were going to prepare for a learning competition. Please tear a sheet of paper
into three equal pieces. Take 10 minutes to develop three quiz questions that cover
some of the topics we discussed over the past 5 days.
Think of one easy question, write it on a piece of paper, and write 1 point under it.
Then, think of a moderately difcult question, write it on a second piece of paper, and
write 2 points under it. Finally, think of a difcult question, write it on a third piece of
paper, and write 5 points under it.
You may use your manuals or get help from others to help develop the questions. When
you are nished, please fold up your pieces of paper and place them in the box. Begin now.
Say:
Module 8 and review exercise introduction
10 minutes
Teaching Instructions: Provide a 2-minute warning.
544
Completing a personal practice integration plan will help you commit to making
changes in how you work, based on the training.
Please form small groups of four or ve people each, and turn to Resource Page 8.1:
Practice Integration Plan, page 400 in your manuals.
Say:
Small-group exercise: Developing a practice integration plan
45 minutes
Teaching Instructions: Review the elements of the Practice Integration Plan, and
ensure that participants understand the task.
Please feel free to talk to others at your table and help one another by sharing
ideas for overcoming barriers, identifying possible resources (including one another),
and so on.
Say:
545
Next you will have an opportunity to share your plan with a partner. But rst well
take a 15-minute break..
Say:
Break
15 minutes
546
Sharing and feedback
15 minutes
Please select a partner from a different group. Id like you to share your plan
with your partner and to listen to your partners plan. Listen carefully to each other. Ask
questions or make suggestions as appropriate. You will have 15 minutes for sharing ideas.
Say:
547
Are you ready for a little competition?
Ask:
Learning assessment competition
20 minutes
Teaching Instructions: Ask as many questions as possible in 15 minutes. It is most
efcient if one co-trainer asks the questions and the other hands out the counters.
After 15 minutes, ask participants to add up their counters. In case of ties, ask
participants for tie-breaking ideas (e.g., who can stand on one foot the longest).
While the winners are being determined, one of the trainers should distribute the
Daily Evaluation and Overall Training Evaluation forms.
Ask the winners to stand up and take a bow, and call for a round of applause.
Ill be selecting questions at random from the box and reading them aloud. If you
know the answer, raise your hand as quickly as possible. The rst person to raise a hand
gets to answer the question.
If that person answers correctly, he or she will receive the same number of counters as
the points listed with the question. If that person does not answer correctly, Ill ask the
question again.
Say:
548
You did a great job with the review questions!
Before we have our certicate of completion ceremony, please complete both the Daily
Evaluation form and the Overall Training Evaluation form. Your input is very important
and will help us improve the training for the next group.
Say:
Day 5 and overall training evaluations
15 minutes
Teaching Instructions: When all participants have completed the evaluation forms,
ask whether anyone has nal thoughts or questions. Give participants the list of
resources for additional training and support you prepared before the session.
549
Thank you for actively participating in the training. Your commitment to
enhancing your practice is admirable, and you deserve this completion ceremony.
Say:
Program completion ceremony and socializing
30+ minutes
Teaching Instructions: Start the music CD. Call each participant by name, and
present each participant with a personalized Training Completion Certicate. As
each participant receives his or her certicate, ask the person to tell the group
the response to statement one on his or her practice integration plan: The most
important thing I learned from this training, and dont want to forget, is
Encourage participants to applaud one another.
Invite participants to stay for refreshments and socializing.
1. The most important thing I learned from this training, and dont want to forget, is:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. Changes I will make in my practice based on what I have learned are:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. Some things that could interfere with my plans are (e.g., anticipated barriers):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. Ways I could overcome these barriers include:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5. The following people (include supervisors, potential mentors, and so on) and
resources (further training, reading) could help me in the following ways:
Person or Resource Possible Ways To Help
Resource Page 8.1: Practice Integration Plan
551
Trainer Manual: Appendix AEnergizers
APPENDIX AENERGIZERS
Energizers on this list are from http://www.wilderdom.com/games/ unless otherwise
indicated. Wilderdom.com encourages sharing!
Some energizers are cooperative; some are competitive. It is best to use each type and
to base your choice on the mood and functioning of the group.
Balloon Juggle and Sort
Supplies: Balloons (one+ per person)
Challenge participants to keep all balloons in the air.This gets the group moving and
cooperating.Once participants get the hang of it, make it harder by adding more
balloons, placing restrictions (e.g., no hands to keep balloons up), or asking participants
to keep juggling the balloons.
Balloon Frantic
Supplies: Balloons (two or three per person)
Stopwatch or watch with a second hand
Give each person one balloon, with the rest in a nearby pile.Everyone begins bouncing
the balloons in the air.Every 5 seconds, another balloon is added.See how long the
group can keep the balloons bouncing before it receives six penalties.Apenalty is
announced loudly (to create stress!) by the energizer leader when a balloon hits the
oor (or, once on the oor, if it is not back in play within 5 seconds).The leader keeps
a cumulative penalty score by shouting out one, two, and so on.When the leader
calls six, time is stopped.After some discussion, the group tries to improve its record
with another attempt.
Balloon Games
Balloons work best for games at about 85 percent of ination capacity.Eighty-ve
percent ination also allows a handy distance for tying a thumb-knot in the neck of
the balloon.
You can turn the ideal ination into a game and demonstration: Show the ideal
ination, and walk around coaching people as they inate their balloons. Some
participants may need help tying the balloon; encourage cooperation among
participants rather than do it yourself.
A hygienic alternative is to use a balloon pump for ination.
552
Ha-Ha
Supplies: None
This is a short, fun, physically engaging energizer and laughter-generating activity.
However, know your audience! Some people may not be comfortable with it.
Each person lies on the oor, placing his or her head on another persons tummy so that
everyone is connected.The facilitator should set a mock serious tone to start. The rst
person says Ha, the second person says Ha-Ha, and so on.The goal is to get all the
way through the group without anyone laughing. It is almost impossible!
Musical Chairs
(Classic game; original source unknown)
Supplies: Chairs (one chair per person)
Music CD and player
Place chairs in a circle, and ask each person to stand in front of one. Remove one chair.
Tell participants that when the music starts, they are to start walking in a circle around
the chairs. When the music stops, they are to try to sit. The person left without a chair
is out of the game. Continue removing chairs and playing until only one person is left.
Give this person a round of applause.
Musical Chairs Variation
Supplies: Chairs (one chair per person)
Place chairs in a tight circle (chairs touching one another), seats facing toward the
center of the circle. Have participants sit in the chairs; then have one person stand
in the middlethere is now a vacant chair. The person in the middle tries to sit in an
empty seat. The group prevents the person from sitting by people moving from seat
to seat, creating a new vacant seat. The game moves fastbecause of the strategic
bum-shufing by the group, the place of the empty seat is in constant movement,
like a wave, changing directions, tempting, then moving fast. Eventually the person in
the middle makes a successful lunge for a seat (it can get very dramatic), and the group
member who was aiming for the seat (group consensus) now goes in the middle. And
so on. As an alternative, once four or ve people are out, stop the game and have the
group come up with a punishment for those people.
553
Trainer Manual: Appendix AEnergizers
Chicken Stretch
Supplies: None
IMPORTANT!! Do not reveal the name of this activity until afterward!It relies on an
element of surprise.
Have participants form a circle and explain that it is important to warm up ones body
from head to toe before participating in physical games and activities. Starting with
legs, ask people to try to get one of their knees to touch their chin. Try each leg
alternately. Ask for 10 knee-to-chin touches. It is not easy: some can do it, many cant.
Then move on to the arms. One side at a time, stick a thumb under the armpit and
move the elbow up and down and do a side stretch. Do this three times on each side.
Then explain that its important to warm up ones vocal cords for group games. Grab
the skin on your neck to demonstrate and waggle it side to side. Ask for some guttural
noises, as much as possible; then ask for some animal noises.
Finally, have participants put it all togetherwalking around raising knees in air,
apping both arms, and making animal noises (at some point start encouraging the
chicken noises), and you have a clucking and squawking chicken yard. Very funny.
Simon Says
(Classic game; original source unknown)
Supplies: None
The trainer is Simon (use your own name). Simon instructs participants to follow his
or her instructions, but ONLY if he or she says Simon says rst. Simon can have the
group do anything possible and safe (e.g., Simon says raise your right leg or Simon
says turn in a circle). If a participant follows an instruction made without Simon
says preceding it or doesnt follow a Simon says instruction, that participant is out.
Continue the game until four or ve participants are out, then stop the game, and have
the group come up with a punishment for those people.
Blob Tag
http://www.funattic.com/game_tag.htm
Note: You will need a fair amount of open space for this one.
Start this tag game with two people as the blob. They have to lock their arms together
and cannot come apart. Once the blob tags someone, that person becomes part of the
blob and adds to the end. The blob becomes bigger and bigger. Only the people on
either end of the blob can tag someone, so players can run through the blob, if possible
without getting tagged. Give the last person standing a round of applause.
554
Hot Pepper
http://www.reproline.jhu.edu/english/5tools/5icebreak/icebreak3.htm
Participants sit or stand in a circle away from tables and close their eyes. The trainer
gives a small ball to one participant, who is instructed to pass the ball quickly to the next
person, saying Hot! Participants continue to pass the ball around the group. As the
ball is passed from participant to participant, the trainer turns his or her back, closes eyes,
and calls out Pepper! The person who is holding the ball when Pepper! is called is
removed from the circle. The ball continues to be passed until only one person is left.
Hidden Surprise
http://www.funattic.com/game_circle.htm#anchor2
Supplies: Pill bottle or other container
Tape
Newspaper
Dice
Take the empty pill bottle or other container and place money or a prize in it. Wrap
it up with layers of newspaper and duct tape or any other kind of tape. You can even
layer it with different types and make a huge tape ball. Have everyone stand in a circle.
Take a set of dice and place them in a at box. The rst participant to roll a double
goes inside the circle and starts working on getting the tape ball apart. That person
continues unwrapping until the next person rolls a double. The process keeps going
until someone successfully opens the container.
555
Trainer Manual: Appendix BLearner-Centered Trainer Skills: A Brief Overview
APPENDIX BLEARNER-CENTERED
TRAINER SKILLS: A BRIEF OVERVIEW
When delivering this curriculum in a way that matches adult learning theory, trainers
need to know and use both platform skills and facilitation skills.
Platform Skills
Platform skills include how one presents, both verbally and visually.
Verbal platform skills for good trainers include the following:
Eliminate weak words/phrases, such
as sorta and later.
Replace nonwords (like um, ah,
and er) with pauses.
Use vivid language.
Use simple and direct language.
Emphasize beginnings and endings;
transitions are important.
Project your voice so everyone can
hear, but not too loud.
Vary vocal pitch and inection for
emphasis.
Vary vocal pace and rhythm to keep
participants attention.
Use pauses for emphasis and to allow
participants to think about what was
just said.
Enunciate clearly.
Practice breath control for smooth
delivery.
Be natural; loosen up (keep training
serious, but also fun).
Visual platform skills include the following:
Stand up straight and condently.
Move around the room to talk with all
participants, but dont move so much
that it is distracting.
If it is culturally appropriate, use eye
contact to keep participants attention.
Use hand gestures for emphasis, but
not to the point of distraction.
Vary facial expressions for emphasis
and to indicate your own interest.
Maintain a match between visual
and verbal elements.
556
Denes his or her role for participants;
Is positive;
Doesnt judge;
Focuses participants energy on a task;
Suggests methods or procedures for
accomplishing the task;
Protects individuals and their ideas
from attack;
Helps nd win/win solutions by seeking
agreement on problems and process;
Gives everyone an opportunity to
participate;
Resists the temptation to give
immediate advice and offer solutions
by redirecting questions back to the
group; and
Is not afraid to make mistakes.
1
Karger, T. (1987). Focus groups are for focusing, and for little else. Marketing News, (21), 5257.
Facilitation Skills
Rather than simply provide information and give answers to questions, facilitating
trainers create a positive and productive environment that supports learning. The good
facilitator:
Effective communication skills for facilitators include:
Listening with full focus on the speaker;
Focusing the training groups attention;
Recognizing progress;
Scanning/observing;
Modeling;
Summarizing; and
Using silence appropriately.
The ideal facilitator was dened by Karger.
1
Although he was writing about facilitating
marketing focus groups, his principles are apt for training facilitation as well. His
denition (with terms modied slightly) is as follows:
The best facilitator has unobtrusive chameleon-like qualities; gently draws group
members into the process; deftly encourages them to interact with one another for
optimum synergy; lets the dialogue ow naturally with a minimum of intervention;
listens openly and deeply; uses silence well; plays back group member statements in
a distilling way that brings out more rened thoughts or explanations; and remains
completely nonauthoritarian and nonjudgmental. Yet the facilitator will subtly
guide the proceeding when necessary and intervene to cope with various kinds of
troublesome participants who may impair the productive group process. (p. 54)
557
Trainer Manual: Appendix CDealing With Difcult Participants During Training
APPENDIX CDEALING WITH DIFFICULT
PARTICIPANTS DURING TRAINING
During the course of training, you may encounter participants who display difcult
or challenging behavior. As the trainer, you have the responsibility of ensuring a
comfortable and safe environment for the other members of the group. Remember the
following points:
Project condence and good humor.
Be prepared.
Dont take it personally.
Use effective communication skills.
Avoid an authoritarian/lecturing approach.
Have clear guidelines for the group.
Avoid sarcasm.
Be patient and polite.
Redirect.
Assess whether you need to change your approach.
Ignore bad attitude.
You will encounter a range of learning styles across the group. If possible, try to
establish the expectations of the participants and incorporate different strategies to
meet these expectations in a range of ways to engage all learning styles.
Prevention and Early Interventions
Make the environment comfortable and the program interesting.
Explore participants motivations for being in the group.
Establish group rules and boundaries.
Involve participants in decisionmaking.
Establish a positive relationship and encourage relationships in the groupmodeling.
Source: Government of Queensland, Australia, Brisbane North Institute of Technical and Further Education.
558
Aim your intervention at the behavior and consequences, not at the person (the
same principle applies for groups and individuals).
The intention isnt to apportion blame; its to resolve the problem.
Coping Strategies
Assess the situationkeep yourself and participants safe.
Ignore negative or nondamaging behavior.
Remain calmdont argue with the other person or make accusations; be discreet.
Avoid ultimatums.
Use active listening skills to check your understanding of the situation.
Refer back to group rules set up at the beginning of the sessionwhat behavior will
or will not be acceptedand dont get pushed beyond this limit.
Be persistent and consistent in your response, which conveys to the difcult person
that you mean what you say.
Provide an opportunity for time out or a private chat.
Believe in yourself and your ability to deal with others.
Look for ways to reduce the causes of the behavior.
Monitor the effectiveness of your coping strategy, modifying it where appropriate.
Assess the impact on others.
Seek advice if necessary.
Behavior
The participant is:
Possible Reasons
The participant may be:
What To Do
Overly talkative
to the extent that
others do not have
an opportunity to
contribute.
An eager beaver.
Exceptionally well
informed.
Naturally wordy.
Nervous.
Interrupt with Thats an
interesting point. Lets see what
everyone else thinks.
Directly call on others.
Suggest, Lets put others to
work.
When the person stops for a
breath, thank him or her, restate
pertinent points, and move on.
559
Behavior
The participant is:
Possible Reasons
What To Do
Argumentative
to the extent
that others ideas
or opinions are
rejected or others
are treated unfairly.
Seriously upset about
the issue under
discussion.
Upset by personal or
job problems.
Intolerant of others.
Lacking in empathy.
A negative thinker.
Keep your temper in check.
Try to nd some merit in whats
being said; get the group to
see it, too; then move on to
something else.
Talk to the person privately and
point out what his or her actions
are doing to the rest of the
group.
Try to gain the persons
cooperation.
Encourage the person to
concentrate on positives, not
negatives.
Engaging in side
conversations
with others in the
group.
Talking about
something related to
the discussion.
Discussing a personal
matter.
Uninterested in
the topic under
discussion.
Direct a question to the person.
Restate the last idea or
suggestion expressed by the
group, and ask for the persons
opinion.
Unable to express
himself or herself
so that everyone
understands.
Nervous, shy, excited.
Not used to
participating in
discussions.
Rephrase, restating what the
person said and asking for
conrmation of accuracy.
Allow the person ample time to
express himself or herself.
Help the person along without
being condescending.
560
Behavior
The participant is:
Possible Reasons
What To Do
Always seeking
approval.
Looking for advice.
Trying to get the
trainer to support his
or her point of view.
Trying to put the
trainer on the spot.
Having low self-
esteem.
Avoid taking sides, especially
if the group will be unduly
inuenced by your point of view.
Show support without
favoritism.
Bickering
with another
participant.
Carrying on an old
grudge.
Feeling very strongly
about the issue.
Emphasize points of agreement
and minimize points of
disagreement.
Direct participants attention to
the objectives of the session.
Mention time limits of the
session.
Ask participants to shelve the
issue for the moment.
Uninvolved and
unwilling to
commit to new
tasks.
Lazy.
Too busy already.
Feel he or she should
not have been made
to attend the session
in the rst place.
Unaware of his or
her own skills and
abilities.
Ask the person to volunteer
for tasks (others in group must
volunteer as well).
Clearly explain the purpose
of the training and the
benets to individuals and the
organization.
Identify how the outcomes can
be applied in the workplace.
Privately ask why the person
wont become involved and
is unwilling to commit to new
tasks.
Provide constructive feedback
and provide reassurance and
encouragement.
561
Dealing with difcult behavior can be emotionally tiring. Caring for yourself during this
time is vital to the effective management of the situation:
Recognize the effect an interaction has on you.
Allow yourself recovery time.
Be aware of things that help you recover effectively and quickly.
Use your co-trainer for support.
563
Trainer Manual: Appendix DGlossary
Breathalyzer
TM
A device used for estimating blood alcohol content (BAC)
from a breath sample. Breathalyzer is a brand name but
is often used to indicate any device that measures BAC
using breath.
case management A set of administrative, clinical, and evaluative functions that
helps clients nd and use the resources they need to recover
from a substance use or other problem; the coordination of
professional social services to assist people with complex
needs, often for long-term care and protection. The
resources an individual seeks may be external in nature
(e.g., housing, education) or internal (e.g., identifying and
developing skills).
continuum of care The range and types of treatment and other services a
person may receive over time.
detoxication The process of stopping substance use, clearing the
substance from the body, and managing the withdrawal
syndrome.
evidence-based
practices
Those practices for which the evidence is strongest and most
accepted and that are most likely to have signicant impact
on improving care.
1
motivation A reason or desire to act; that which gives purpose and
direction to behavior.
outreach Organized efforts to identify and screen individuals who may
have a problem with substance use, instead of waiting for
them to be referred to treatment programs or to decide to
enroll in a program themselves.
psychoeducation Education provided to clients who have a mental or
substance use disorder. Psychoeducation also is provided to
clients family members. A primary goal of psychoeducation
is to help the client and his or her family better understand
and learn to cope effectively with the disorder.
1
conditions: Evidence-based treatment practices (abridged version) (p. v). Washington, DC: Author.
APPENDIX DGLOSSARY
564
stages of change A model based on a study of how people change. The
study found that people go through predictable stages:
precontemplation, contemplation, preparation, action,
maintenance, and recurrence.
theory A fact-based framework for describing a phenomenon (an
event or series of occurrences); a particular concept or view
of a phenomenon; an evidence-based system of rules or
principles.
treatment
interventions
The components of treatment (e.g., assessment, counseling,
education, case management).
treatment intensity
and duration
How often and for how long a person receives treatment
services.
treatment modality How treatment is provided (e.g., one-on-one with an
addiction professional, in a group with peers, with other
family members).
treatment plan An individualized outline for treatment and services based
on the clients specic needs identied in the assessment
process; a joint activity involving the counselor, the client,
other treatment providers, and (at times) the clients family
members.
treatment setting Where treatment is provided (e.g., drop-in center, hospital,
outpatient program).
withdrawal syndrome A predictable set of signs and symptoms that occur when
a person abruptly stops taking a psychoactive substance or
rapidly decreases the amount taken.
565
Trainer Manual: Appendix EResources
APPENDIX ERESOURCES
Global Drug Use Statistics
United Nations Ofce on Drugs and Crime. (2011). World drug report 2011. New York:
United Nations. Retrieved June 29, 2011, from
http://www.unodc.org/documents/data-and-analysis/WDR2011/
World_Drug_Report_2011_ebook.pdf
World Health Organization. (2010). Management of substance abuse: The global
burden. Geneva: Author. Retrieved December 10, 2010, from
http://www.who.int/substance_abuse/facts/global_burden/en/index.html
World Health Organization. (2011). Management of substance abuse: Facts and gures.
Geneva: Author. Retrieved December 10, 2010, from
http://www.who.int/substance_abuse/facts/en/
Treatment for Substance Use DisordersGeneral
Principles and Components
Center for Substance Abuse Treatment. (1999). Brief interventions and brief therapies
for substance abuse, Treatment Improvement Protocol Series 34, HHS Publication
No. (SMA) 99-3353. Rockville, MD: U.S. Substance Abuse and Mental Health Services
Administration.
http://www.ncbi.nlm.nih.gov/books/NBK14512
Center for Substance Abuse Treatment. (1998). Comprehensive case management
for substance abuse treatment, Treatment Improvement Protocol Series 27, HHS
Publication No. (SMA) 98-3222. Rockville, MD: U.S. Substance Abuse and Mental Health
Services Administration.
Center for Substance Abuse Treatment. (2006). Detoxication and substance abuse
treatment, Treatment Improvement Protocol Series 45, HHS Publication No. (SMA) 06-
4131. Rockville, MD: U.S. Substance Abuse and Mental Health Services Administration.
Center for Substance Abuse Treatment. (2006). Substance abuse: Clinical issues in
intensive outpatient treatment, Treatment Improvement Protocol Series 47, HHS
Center for Substance Abuse Treatment. (2005). Substance abuse treatment: Group
therapy, Treatment Improvement Protocol Series 41, HHS Publication No. (SMA) 05-3991.
Rockville, MD: U.S. Substance Abuse and Mental Health Services Administration.
566
Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior
change. American Journal of Health Promotion, 12(1), 3848.
http://www.uri.edu/research/cprc/Publications/PDFs/ByTitle/The%20
Transtheoretical%20model%20of%20Health%20behavior%20change.pdf
U.S. National Institute on Drug Abuse. (1999). Principles of drug addiction treatment:
A research-based guide (2nd ed.), NIH Publication No. 99-4180. Bethesda, MD: U.S.
National Institutes of Health.
http://www.cdhs.state.co.us/adad/PDFs/PODAT.pdf
U.S. Substance Abuse and Mental Health Services Administration. (2010). Family
psychoeducation evidence-based practice kit, HHS Publication No. (SMA) 09-4423.
Rockville, MD: U.S. Department of Health and Human Services.
http://store.samhsa.gov/product/SMA09-4423
World Health Organization and United Nations Ofce on Drugs and Crime. (2008).
Principles of drug dependence treatment. New York: Authors.
http://www.who.int/substance_abuse/publications/principles_drug_dependence_
treatment.pdf
Self- and Mutual-Help Programs
Al-Anon/Alateen/Alatot
http://www.al-anon.alateen.org
Alcoholics Anonymous
http://www.aa.org
Celebrate Recovery
http://www.celebraterecovery.com
Cocaine Anonymous
http://www.ca.org
Marijuana Anonymous
http://www.millatiislami.org
Millati Islami
http://www.ca.org
Nar-Anon
http://www.nar-anon.org/Nar-Anon/Nar-Anon_Home.html
Narcotics Anonymous
http://www.na.org
Native American Wellbriety Movement
http://www.whitebison.org/wellbriety-movement/wellbriety-movement/htm
567
Rational Recovery
https://rational.org/index.php?id=1
SMART (Self-Management and Recovery Training) Recovery

http://www.smartrecovery.org
Women for Sobriety
http://www.womenforsobriety.org
Evidence-Based Practices
General topics
Alcohol and Drug Abuse Institute. (2006). Evidence-based practices for substance use
disorders. Seattle, WA: University of the Washington.
http://adai.washington.edu/ebp
U.S. National Quality Forum. (2007). National voluntary consensus standards for
the treatment of substance use conditions: Evidence-based treatment practices.
Washington, DC: Author.
http://www.rwjf.org/les/research/nqrconsensusreport2007.pdf
U.S. National Registry of Evidence-based Programs and Practices
http://www.nrepp.samhsa.gov/Search.aspx
Specic topics
Cognitive-behavioral therapy
Association for Behavioral and Cognitive Therapies. (n.d.). Learn about CBT. New York:
Author.
http://www.abct.org/Professionals/?m=mPro&fa=learnCBT_menu
Carroll, K. M. (1998). A cognitive-behavioral approach: Treating cocaine addiction,
Therapy Manuals for Drug Abuse 2, NIH Publication No. 98-4308. Rockville, MD: U.S.
National Institute on Drug Abuse.
http://archives.drugabuse.gov/txmanuals/CBT/CBT1.html
Kadden, R. M. (2002). Cognitive-behavior therapy for substance dependence: Coping
skills training. Peoria, IL: Behavioral Health Recovery Management Project.
http://www.bhrm.org/guidelines/CBT-Kadden.pdf
Motivational approaches
Center for Substance Abuse Treatment. (1999). Enhancing motivation for change
in substance abuse treatment, Treatment Improvement Protocol Series 35, HHS
http://www.ncbi.nlm.nih.gov/books/NBK14856/
568
Center for Substance Abuse Treatment. (2006). Enhancing motivation for change inservice
training, HHS Publication No. (SMA) 06-4190. Rockville, MD: U.S. Substance Abuse and
Mental Health Services Administration.
http://www.kap.samhsa.gov/products/manuals/tipcurriculum/pdf/p_complete_manual.pdf
Center on Alcoholism, Substance Abuse, and Addictions. (2009). Motivational
interviewing. Albuquerque, NM: University of New Mexico.
http://casaa.unm.edu/mi.html
Miller, W. R. (n.d.). Motivational enhancement therapy with drug abusers. AddictionInfo.org.
http://www.addictioninfo.org/articles/736/1/Motivational-Enhancement-Therapy-with-
Drug-Abusers/Page1.html
Motivational Interviewing: Resources for Clinicians, Researchers, and Trainers
http://www.motivationalinterview.org
Family approaches
Center for Substance Abuse Treatment. (2004). Substance abuse treatment and family
therapy, Treatment Improvement Protocol Series 39, HHS Publication No. (SMA) 04-3957.
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Trainer Manual: Appendix FSpecial Acknowledgments
Clemente (Junjun) A. Abella, Jr.
Counseling Psychologist
Serenity at the Quarry
Philippines
Muhammad Ayub
Director
Dost Welfare Foundation
Pakistan
Dato Zainuddin A. Bahari
Consulting Trainer
Malaysia
Tapasi Bandyopahyay
Consulting Trainer
India
Tay Bian How
Consultant
The Colombo Plan ACCE
Sri Lanka
Prof. Sun Min Kim
Research Professor
Seoul National University
South Korea
Winona A. Pandan
Guidance Counselor
LaSalle College Victorias
Philippines
Dr. V. Thirumagal
Consultant
TTK Hospital
India
Susmita Banerjee
Trainer
Sri Lanka
Ma. Elena (Malyn) Cristobal
Family Therapist, Private Practice
Living Free Foundation
Philippines
Aditi Ghanerar
Counselor and Training Coordinator
TTK Hospital
India
Mohammed Sharif Abdul Hamid
Clinical Supervisor
Kasih Mulia Foundation
Indonesia
Fadilan Abdul Kayong
Senior Advisor
The Colombo Plan Afghanistan Ofce
Afghanistan
Ibrahim Salim
Trainer
Sri Lanka
Dr. Shanthi Ranganathan
Hon. Secretary
TTK Hospital
India
APPENDIX FSPECIAL
ACKNOWLEDGMENTS
A special thank you to the following individuals who participated in pilot testing this
curriculum and created client case studies for the curriculum series. Their input was
invaluable.

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) reduces or eliminates withdrawal symptoms associated

to avoid this potential problem.

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