Welcome to Behavioral Interventions for Substance Use Disorder Improving Outcomes. My name is Stacey Conroy. I'm a licensed independent clinical social worker who also has a master's in public health. I currently work for the Orlando VA healthcare system, though this training is not a VA training. I have no disclosures to report at this time for this training. The overarching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opiate use disorders, particularly in prescribing medications as well as for the prevention and treatment of substance use disorders. At the conclusion of this activity, participants should be able to identify four evidence-based treatments, cognitive behavioral therapy, acceptance and commitment therapy, motivational interviewing, and 12-step facilitation. We'll describe some skills from each of these modalities and evidence-based treatment, and you'll be able to demonstrate an understanding of SUD mutual self-help groups which are different from evidence-based practices. Concurrent treatment for co-occurring disorders is an important aspect of improving outcomes for substance use disorder. According to the Substance Abuse Mental Health Service Administration, the numbers of co-occurring disorders are very high. These numbers displayed here are in the millions, and during 2020, which numbers are a bit higher than the average that was the year of the pandemic, substance use disorders and mental health illnesses increased quite a bit. So we are dealing with a large population of individuals that have co-occurring substance use disorders and behavioral or mental health. Improved outcomes means reduction in substance use, improving functioning, symptom reduction, decreased hospitalizations, increased housing stability, fewer arrests, and most importantly, improved overall quality of life. What are medications for addiction treatment? Well, medications are approved by the Food and Drug Administration, and they represent a whole patient or whole person approach. They are an important aspect in the recovery process for those who struggle with substance use disorder, and they can play a concurrent role in helping stabilize individuals with co-occurring behavioral health concerns. Traditionally, medications have had different connotations attached to them, particularly in recovery communities, so it's very important to discuss these as evidence-based treatments that have gone through rigorous trials and improved outcomes. We want to match the desired outcome of the individuals we work with to the best options, including medication, does that. Common terms used in concurrent treatment. Support of counseling. This can be understood as a kind of psychotherapy, which is more flexible. It offers an opportunity to get to know the individual, what their goals are, what their struggles are before jumping into anything, formal, and. structured such as an evidence-based treatment. It can provide some basic foundational aspects to the therapeutic relationship and help build rapport in the beginning. It can also be used as part of the transition process to discharge from a counseling perspective, where you can do supportive psychotherapy as follow-up sessions and stretch them out maybe one a month or one every three months. to give that final support before ending the behavioral health aspect of treatment. What is evidence-based practice? Evidence-based practice can best be described as the application of research-based treatments. They are tailored by an experienced therapist. Some of these have manualized treatment books or workbooks that you can utilize to offer this to your patients. If you are just learning these evidence-based practices, utilizing the workbooks or the manuals is a good place to start. As you become more comfortable with the material, you'll be able to make subtle adjustments that improve the experience for patients. It's important to realize we're going to present four options in this training for evidence-based practice. You do not need to be proficient at all of them, especially if you're just starting out providing concurrent treatment or doing brief interventions in a medical setting. Pick the one that works best for your practice and focus your skill set there. And then you can add to it becoming more comfortable with a wide range of options for preventing brief behavioral health interventions or providing more structured evidence-based behavioral therapy. Mutual self-help groups. This is an important distinction. Often times, these get used as a treatment modality in and of themselves. And they are not designed for that. They have been shown to be very beneficial in providing social supports, providing basic psychoeducation about the recovery process. Though they have their limits as well. Some examples of mutual self-help groups are 12 step groups, AA, NA, marijuana anonymous cocaine anonymous or some others, smart recovery, and women in recovery. This is not an exclusive list. It is just meant to highlight some of the more popular mutual self-help groups. There are some pros and cons to these self-help groups. Some of the pros are widely recognized and established. They are available in multiple, not only states around the United States, but they are also available in many countries. There is no cost to the participants. I will say that they do pass a round-of-a-back or a hat and ask for a voluntary donation. If this might be a problem or a challenge for an individual, it is good to know that that happens. But it is 100% voluntary. There are no membership dues, no copays or fees for these mutual self-help groups. Some of the cons are they are not a good fit for people who struggle in group settings. If you have someone who maybe has psychosis or severe PTSD and they are not really comfortable in group settings, this might not be part of their recovery plan. It is not led by a licensed therapist. These are for all intensive purposes. Peer-led groups. Other individuals with different levels of recovery who are sharing their experience, strength, and hope and how they achieve their recovery process. They are willing to listen and provide guidance, but it is not an evidence-based treatment. The other aspect of this is it doesn't address the co-occurring disorders. And that's what we're here to talk about today, is how to improve outcomes for those who have co-occurring, SUD, and mental health behavioral health diagnoses. It's important to note that ASAM has some standards that involve co-occurring treatment or. concurrent treatment. Standard for addressing comorbidity states that when it is feasible, concurrent treatment should be offered. Standard 5 involving support networks. Now we often think of support networks as family, and we need to broaden that definition and ask the patient who they want involved in their treatment. It could be a sponsor from a 12-step program. It could be a relative, a significant other, a friend. It doesn't necessarily have to be a family member, a spouse, or a child. Now if you are working with children, you do want to, of course, engage their guardian or parent in that process. But a lot of times we have a narrow definition of who's the social support network for the individual. This is from the DSM, which also acknowledges that substance use disorders have multiple psychosocial aspects. In paired control is one aspect, using more often or more of a substance than intended. Social neglecting responsibilities and giving up on life activities that are meaningful to the individual. This is a big consequence for many of the individuals who have co-occurring disorders. It steals time, energy, motivation, and joy from these social activities. And an inability to complete responsibilities, which also speaks to somebody's ability to. have a high quality of life. Risky use, using in risky settings, continued use despite known problems. We see this all the time. Our patients are not unaware of the consequence of their use. However, it persists due to many factors with substance use disorder. One of the key factors here is time spent. Seeking out a substance, using a substance, and recovering from a substance. Co-occurring disorders can make the time spent in these activities, even more challenging and prolonged, because it interferes with a person's ability to engage and recover while actively using. Physical dependence is something that can happen with any substance. However, in substance use disorder, people go through withdrawal symptoms and they experience craving. An important factor here is talking about craving with our patients. Cravings are natural in early. recovery, and they can even show up in later sustained recovery when someone has a few years or even nine or ten years in sustained recovery from their substance use. Cravings come from stress and they're a biological process. And unfortunately, many people believe that having Cravings, that means they want to use a substance or they're not committed to their recovery process. This just is not true. Cravings are a natural biological process that happens in recovery. And when an individual is stressed, they can have more Cravings to use substances. We need to discuss this and normalize it for the patients we work with. Let them know that it's not the craving itself, that's the challenge. It's how they respond to the craving. If we can change their relationship to that craving and have them respond in a different way, ride the wave of the craving, it will subside and they can continue on in their recovery process. There are several factors that lead to a substance use disorder. The presence of underlining biological deficits, there is a genetic component. We know this from multiple studies and research. If there's a family history of a substance use disorder, the likelihood that someone else in that family, a daughter, a son, a grandchild, will develop a substance use disorder. The repeated engagement in drug use, causes neuroadaptive aspects in the brain and the reward circuitry, certain neurotransmitters such as dopamine and glutamate function differently within the brain. And so this aspect of repeated use can lead to increased symptoms, criteria and consequences of a substance use disorder. Cognitive and affect distortions which impair and compromise the ability to deal with feelings. Emotion regulation is a large component of both substance use disorder and behavioral health challenges. Individuals who can learn to sit with self and regulate their emotions, this does not mean eliminate them, but it means their ability to acknowledge them, feel them, move through them. The concept of this two-shell pass, when things are hard, this two-shell pass, the flip side of that is when things are going well, this two-shell pass, distortions and healthy supports and problems with interpersonal relationships. Many people will start using a substance to deal with relationships, emotions, divorce, breakups, or on the other side, use substances to be able to engage, to reduce social anxiety and be more social go out to social settings to meet people. Exposure to trauma, is a huge risk factor for developing a substance use disorder. Depending on the research, the numbers vary from in the teens 15, 16 percent all the way up to greater than 60 percent of individuals with trauma will develop a substance use disorder. So if someone has a history of trauma, they are more likely to develop a substance use disorder and once they have, having a history of trauma without concurrent treatment can complicate the outcomes and the process of recovery for that individual. And distortions in meaning, purpose, and values, goals, attitudes, thinking, and behavior. This one can manifest in different ways, but one of them, particularly in young people, is a distortion of what is normal drinking or normal substance use. If they come from a family or a social network where there's a lot of drinking, they may think that their drinking is in fact normative. We see this a lot in the perception of college students when asked, "What do you think your peers are drinking weekly?" The numbers are higher than what is actually reported in that population. Distortion in a person's connection with self, oftentimes mental health and SUD conditions lead to isolation. People get frustrated with the behaviors related to these disorders and the world become smaller and smaller. This is one of the benefits of 12-step groups is they reconnect people to who they are and give them a social network to move them forward in the recovery process. And as we've stated many times, the presence of a co-occurring psychiatric disorder, who engaged in substance use, is likely to develop a full-blown SUD and move potentially from mild moderate to severe. Now, locating counseling. We provide medications for the treatment of substance use disorder in a variety of settings. Some are in primary care offices, some may be in standalone practices and some may be in behavioral health clinics. So identifying your resources for locating counseling. So concurrent treatment can be provided, whether it's provided by one individual covering both aspects, or you work as a team with a second provider. National resources include SAMHSA, has a treatment facility locator. Some local resources you might want to have a psychology or social work intern, create a binder of resources as one of their macro projects during their internship or postdoc. In following years, have that social work or intern or even an admin person could do this. You just want to start thinking about your local resources, having them identified, develop, and keeping them current. Share the binder's widely. If you put something together that would help your colleagues, please give that resource to them. We want to be able to identify as much for the patients we provide services for as possible. Now, telehealth. This has really expanded since 2020 and it has increased access exponentially. It definitely has some benefits. It removes some of those barriers. There are no geographical restrictions for ongoing sites for behavioral telehealth services. The individual providing the telehealth service has to be. licensed in that state that they are seeing the patient in. That is one of the requirements. There are benefits and challenges, though there are strong options for referrals. When you're developing that community binder, you want to know if those individuals are able to provide telehealth services. Because then you can offer that to someone who may not drive due to the loss of license or an inability to afford a car at this time. Or they cannot travel because they have child care responsibilities. It really does open up the opportunity for people to access treatment. Some of the benefits as noted reduces barriers, increases access. Decreases unnecessary ER visits for non-urgent care needs. When you can get to your treatment and you know it's coming up tomorrow or in a few days, you may not make that trip to the ER if you're not in crisis. So it can reduce ER visits. An increased patient satisfaction. This is a huge thing. We often say people vote with their feet, but sometimes it's not about not wanting to be there. It's about an inability to access services. Some of the challenges is a lack of multi-state telehealth licensure. Some states have identified telehealth only providers as part of their licensing process or behavioral health. This may be different for medical providers and prescribers. You want to ensure that if you're providing telehealth, that you have addressed the issue of licensing and make sure that you're practicing appropriately. Patient privacy and confidentiality. You want to make sure that you have a platform that is HIPAA compliant and you're not just providing it on an open. platform such as Facebook Live or a non-HIPA compliant Zoom or other commercially available product. Establishing a provider patient relationship can also be a challenge. Many people are used to face to face care, but I think this is dissipating even more since 2020. And we're now clearly identifying. telehealth as an way to increase access. And I think fewer and fewer patients are challenged by not being in the same room. So prescribing controlled substances, specific medications such as Suboxone or Methadone, you really want to make sure you're following the guidelines as they develop and potentially change. Always keep current for that if you are a prescribing provider. SAMHSA has a resource page for evidence-based treatment and the link is here. This will allow you. to learn more about each of the evidence-based treatments that we will be providing here today. We're going to introduce them, go over some basic concepts that can be used in brief interventions. And if you want to learn more, this is one aspect. We also have a resource page at the end of this presentation where you can learn more about each of the four that we will be covering. And these are not exclusive EBPs. There are many more, but we will be covering these today as they lend themselves well to multi-site interventions and both brief and prolonged interventions. Okay, motivational interviewing. This is a collaborative goal-setting way of eliciting change talk from the individuals you are working with. Why would somebody go through all the hard work of putting down a substance or engaging in an evidence-based treatment for their post-traumatic stress disorder? We need to build the why of change before we can begin to help facilitate that change. Am I as a guiding style of communication that sits between the following, good listening, and directive, giving information and advice? It is not an either/or. Sometimes people feel like you cannot give any direction or psychoeducation while utilizing motivational interviewing. This is not true. You just don't want to lean too far towards the directing or too far towards the following. You want to find that balance in between that elicits that change talk. Why am I willing to do this work? Am I as designed to empower individuals? It's not why I think you should change. It's why you as the individual or patient want to change. Am I as based on respect and curiosity about what is going on with that individual? As we often know the respect aspect for those who are dealing with mental health and substance use disorder is missing far too often. There's a great deal of stigma around. the behavior, the disorders that they carry into our offices. We don't want to perpetuate that. So we really want to use motivational interviewing to understand what is it like for you and what's going to motivate you to make these changes. Am I as a practice with an underlining spirit away of being with people? Again, it's non-judgmental. It does have direction and psychoeducation, but it's based off what the individual is sharing with you. It's a partnership. And the patient is the expert on them. We are the expert on behavioral health tools and medications. We can share with them their knowledge why they are sharing with us their knowledge of themselves and what would work best for them. And evoking, you want to evoke change talk. Find out what skills are needed for their change, what motivates them and what will help support their success. Acceptance of the individual, being non-judgment. So understanding the person's perspective and experience. You might have someone who's come in and you're their first doctor who's helped them or their first therapist that they've ever seen. However, you might be their 50th provider. And they have a lot of experience. They know what has worked and what hasn't worked, accepting them for who they are and where they're at and what they're coming to you for. Now, that does not mean you have to agree and offer them everything they want. There is some professional judgment here, particularly with prescribing. However, it's the acceptance that lets them know that this is a safe place where they will not be judged, they will be treated as a patient. And that feeds right into compassion, which is the last item mentioned here. Compassion is a skill for both the provider and the client. Learning some self compassion is actually a tool that can help an individual move closer into a change process. Skills with motivational interviewing. One of the acronyms is ORS, O-A-R-S. The first part of that is open questions. We want to ask questions that cannot be answered with a yes or a no. An example of this is how much do you drink? That's a very close-ended question. It might not be answered with a yes or no, but it's answered with a number. Two beers, five beers, 10 beers a day. Instead, you may want to ask somebody, tell me what it's like for you when you drink. How has alcohol impacted your life? These are different types of questions they can't be answered with a simple one-word answer. Information of strengths, efforts, and past successes. I love this one. When someone comes to me and I know they've been in treatment before, I will ask them, "What has worked for you? And what hasn't worked for you? What do you think your barriers change and recovery are?" I find most people can identify their barriers and their relapse triggers. What they want is an opportunity to find a different way of addressing them. If you go back to the conversation on an earlier slide about cravings, changing how someone thinks and experiences, cravings can be one of those things that moves them forward in a very different way. And it's not a difficult conversation to have. It's just one that often has not happened in their recovery process. Reflections are based on careful listening. You want to reflect back to the person what they are saying. And again, we go to summarizing. Summarizing everything they've shared and ask them. If I'm understanding you correctly, you're saying the following. Do I have this right? You'd like to make these changes, but these are your barriers. And we're utilizing their words as much as we can. Attending to language, when somebody starts talking about change, they'll use particular language. I would like to change my substance use because I want to be able to keep my job, be in recovery, be with family, go to school, whatever it is. But the changed talk will come out. And when it does, we want to highlight and encourage them to focus in on that aspect. Exchange of information. This is what I said earlier in terms of we are the expert in the medicine and behavioral evidence-based practices. They are the experts on themselves. And what they need. to make recovery achievable. This is one of the tool sets from motivational interviewing that can be used in any setting. It's called the readiness ruler. And what you ask here is how important is it for you to make the change? How important is it for you to stop using substances? I often get responses eight, nine or ten is very important. People come in with the motivation. The second aspect of this is asking how confident are you that you can make this change? And there I often get two, three, or four. So they want to make the change. They're ready to try and make the change, but they lack the confidence. Now here's an important aspect when somebody says four, I don't say, wow, that's really low. I say, wow, four, that's great. It's not zero. And it's not one or two. So you have some confidence. Where does that come from? Have you had previous successes that lead you to know that this can be done. even if it was for a short time? And then we move to what would you need to move the confidence from a four to a six? Now notice I'm not trying to move it from a four to a nine because that's a huge leap. Let's get it from a four to a six. And once it's out of six, what do we need to put in place for it to move from a six to an eight? And we can slowly use motivational interviewing and the change talk. to raise that confidence. Cognitive behavioral therapy is the next evidence-based practice we're going. to talk about. This has many aspects and can be used in so many behavioral health or SUD treatments. There is cognitive behavioral for substance use disorder for PTSD, for anxiety, for depression. It's very universal in this application and one of the reasons we picked it for this training. So it is a term used for a lot of treatments and is based on scientific evidence, which is why it's evidence-based treatment. Traditionally it's often six to 20 treatments for a course of CBT, but that's not written in stone. It can be shorter. It can be longer. And it can be adapted. based on the individual's needs. You might start off providing CBT focused on one area and then transition into CBT focused on another area. Or you might do CBT concurrently in both areas. It really is tailored to what the person is ready for and what options you have available to you in your skill set. CBT has definitely shown efficacy, whether used with medications or without. Again, just like motivational interviewing, the therapists and client work together on a mutual understanding that the therapist has the theoretical and technical expertise, but the client is. the expert in themselves. So these two therapies, although they are slightly different, motivational interviewing builds the why for change, cognitive behavioral therapy is more of a skills-based approach to give the tools for change. Therapist helps seek the patient discover that they have the capability of choosing positive thoughts and behaviors. We're going to go over some of those changing thoughts and behaviors. This does not mean that you stop a thought, because if I tell you not to think about a pink bunny rabbit, chances are you just thought about a pink bunny rabbit. But there are some specific skill sets that help people change how they view the world. And we'll talk about both shortly. Treatment is goal-oriented, to resolve a problem. So CBT is focused on symptom reduction, and it is a step-wise process of building skill sets. Some of the core components of CBT specific for substance use disorder involve. skills for triggers and urges or cravings. So they're common, they're predictable. When you get stressed, chances are you're going to have cravings. If you go into a place with alcohol or you walk by a neighborhood where you're used or you run into someone that you've, you know, used substances with, chances are you're going to get triggered for a craving. They're time-limited, as I said, changing your relationship with the craving rather than saying, because I'm having a craving that obviously means I want to use. Some of the aspects of teaching people about craving is that they will come and go. They'll have a peak, a high point, and a fade. If you think of a bell curve in research, the craving will come, it will go up, it will reach a peak, and then it will start to dissipate. Teaching these skill sets and talking about what cravings are and what they are not is one conversation within the CBT that can be very beneficial. Coping with cravings and urges, cognitive restructuring, avoid escape, distract. Don't go to the bar. If someone starts drinking at a family gathering and that is two triggering for you, leave. If you go somewhere and someone pulls out a substance, you can leave. And if you're having a craving, you can use distraction. Distraction is a tool talked about a lot in emotional regulation. And we use distraction to ride the wave and get through the most distressing aspects of the unwanted emotion or thought. And then as it starts to dissipate, we can go back to. other life activities. But in doing these steps of avoid escape or distract, we've maintained the recovery process despite having the craving. Refusal skills, where are your social pressures coming from? Are they coming from friends, people you've used with, people who are selling substances, family who say, oh, drinking's no big deal, identifying where those social pressures are coming from are a key component to then being able to develop the skills to refuse to engage in those activities, to make different choices, to escape. Say, no, I need to go home or I need to get away and then engage in some healthier practice. Identifying situations that call for a sort of communication and practice is basically what I was just talking about as well. But you may want to role play these and really have the individual think out how they would do this specifically in each situation where they've identified social pressure to continue to use drink or engage in unhealthy behaviors related to their behavioral health diagnoses. Because when we do concurrent treatment, we are addressing both the substance use disorder and the behavioral health aspect. So there might be some things that are triggering to their anxiety, depression or PTSD. And they need to use those same avoid escape and distract skills for that and identify where social pressures are asking them to engage in activities that trigger their PTSD. One that comes up every year, particularly for veterans, is both a July fireworks. Many individuals who have served in combat do not want to be around large booms of fireworks. This can be a very triggering event for them. Finding that as a social pressure, from their family or friends who want to engage in for the July activities can help someone avoid relapsing on a substance. Especially if they're going to use that substance to try to make themselves more comfortable with that activity. Okay, as I said earlier, we were going to talk about some specific. cognitive thought processes. These are 10 common cognitive distortions, also referred to as thinking errors. And these are what get people stuck in a negative mindset. And those who have more negative perceptions of the world around them are more likely to engage in substance use disorder. They're more likely to have their depression and anxiety symptoms remain high. So going through these and learning these and making them more aware of them is a great tool to use when providing concurrent treatment. I won't go through all of them, but we will go over some of the larger ones that happen all the time. All or nothing thinking. The individual sees the world as black or white. I'm either 100% recovery or I'm not recovery at all. I either have no anxiety or my anxiety is overtaking me. If my boss gives me any negative feedback, then I'm horrible at my job. It's all or nothing black and white thinking. It's two ends of a spectrum and never really being in the middle. This is very common in early recovery as people are having a lot of stress and emotional reactions and they have stopped engaging in substances which was their primary method for numbing those feelings. So disqualifying the positive. This one comes up a lot as well. People don't give themselves credit for the work they have done. If you have someone come into your office who feels that they have had a lapse or a relapse on substances or in other behaviors related to their behavioral health diagnosis, they will not give themselves credit for all the work that they have done thus far. They will focus in on I used marijuana or I drank last night or I engaged in self-injurious behavior and they disqualify all of the days of success that have been part of their recovery process. Now interestingly enough, 12 step programs, especially in the first year, have a traditional handing out markers of recovery in AA, alcoholics, anonymous, they referred to as chips and in NA, traditionally they have been key chains and these keychains have different colors. If you have a lapse or a relapse, the tradition is you go back to the beginning and you pick up a white chip or a white keychain. Now I'm not saying. this tradition is good or bad, however, it can have the unintended consequence of disqualifying the positive if somebody's had some time in recovery. So they're utilizing a mutual self-help group that may unintentionally feed into some of these cognitive distortions. So we want to be aware of the benefits and challenges that come from some of the resources that our patients are utilizing in their recovery process. Magnification or catastrophizing, this can be a big one. If I don't get this job, then I'm going to lose my house, lose my car, lose my recovery, lose everything I have, and you know what, there might be some truth in some of that because if you don't have a job and not have an income, you could lose your housing, but it does not necessarily mean that you'll lose your recovery, your friends, your family, and everything will go down the tubes, so to speak. So it can be that people catastrophize even small things, like thinking about using. I've worked with people who catastrophize if they have a thought about alcohol, then that means they're not committed to their recovery, that all their work is going to be for nothing, and they should just, you know, roll in the towel now. So that's an example of catastrophizing, and it is a way of thinking that keeps people stuck in their illness and takes them away from the recovery process. Okay, should statements? Now, this could be should or shouldn't. I should have been able to stop drinking years ago. No judgment there. I shouldn't have any cravings for substances. You know, it can also use other words like, I must go to 90 meetings and 90 days, or I ought to have known that that was going to be triggering for me. These statements keep people stuck, and should, shouldn't, must, and ought. Our words, we want to teach people to be on the lookout for, so they can identify when they're getting caught in these cognitive distortions. And as treatment providers, whenever we hear these words, we should stop and say, hold on, did you hear what word you just used? Let's take a moment and think about this. That can be done in a doctor's office, in a therapist's office, in any setting that we provide care in. So if you understand even a few of these cognitive distortions and be on the lookout for them, you can do a brief intervention that will be highly effective. Labeling and mislabeling, this represents an exaggerated form of overgeneralization. Instead of acknowledging a mistake, you become the mistake. I am a loser. We see this a lot again in people identifying themselves as an addict, or a drunk, or. alky. The negative language our patients use to identify themselves, fell in. No, you have a felony. That's what you have. It's not who you are. Just as you have the disease of alcohol use disorder, or opiate use disorder. It's what you have. It's not who you are. And again, changing these labels. If you ever want to have fun and you have the opportunity to run a group for people in recovery, go into the group and ask them to introduce themselves as anything except an alcoholic or addict. Watch what happens. A lot of individuals in the group will struggle with identifying themselves as a mother, a father, an employee, a friend. These are not the labels they move towards. All right. The next evidence-based treatment we're going to talk about is acceptance and commitment therapy. This is a form of cognitive behavioral therapy. However, it uses very different language and tools in skill set. And it doesn't have the same goal of symptom reduction. Acceptance and commitment therapy has six core principles that helps people move towards their values in a valued life direction. This creates the motivation for change. So, it incorporates aspect of motivational interviewing. What is important to you? Why are we going to make this change? And it asks you to be flexible in your thought process. Not have that all or nothing thinking. Not have that catastrophizing, that mislabeling. See yourself as more and move within different aspects. There's no all or nothing in acceptance and commitment therapy throughout the six core principles. And as I said before, the goal of act is not explicitly stated as symptom reduction. Act season is a happy byproduct of moving towards your values in life. One of the goals here is helping our patients identify their values and what is important to them. Some come through the door knowing these, but they've lost connection to them. And some have lost the connection to the point where they can no longer identify what they value, how to move towards that. And in some cases, the thing they value most is what they have lost. I've worked with a number of women who value being a mother or a parent. And even work with men who have lost their parental rights due to their substance use. And so we need to help them identify the other values in their life that help them continue to do the hard work that is early recovery. So core principles of act can be divided into two subgroups, acceptance and willingness and commitment and behavior change. So here you see acceptance and willingness, male line with motivational interviewing concepts and commitment and behavior change, male line more with cognitive behavioral therapy skill sets. So if you're more knowledgeable or comfortable with MI and CBT when you're learning acceptance and commitment therapy, this is a way to separate the six core principles into concepts that you may already be familiar with. So under acceptance and willingness, we have open up. There is language about acceptance in almost every type of therapy and even in 12 step books, there is a page completely about acceptance. Be willing to sit with your emotions, open up to them. Do not try to hide them, eliminate them, or push them away. When you can increase your acceptance and willingness, it is part of the recovery process. Diffusion, watch your thinking. What are the thoughts that get you stuck? When you are fused to something, you hold on to it tightly. You cannot walk away from it. It's one of those thoughts that sticks with you, such as a rumination or an obsession. When you get very over focused on one. negative thought or one, maybe traumatic memory that keeps tripping you up in your recovery process. Hey, self-ass context in terms of pure awareness, what is the story of you? Is the story of you one of mental health and substance use and all of the things that have gone wrong? Or is the story of you someone who is working really hard to move in a value direction that you know why you want to change? You just need the skill sets to achieve those goals. Self-ass context is just understanding who you are. It goes back to the concept of substance use disorder, opiate disorder, alcohol use disorder, PTSD, general anxiety disorder, those are things you got, they are not who you are. Commitment and behavior change, values, do what matters. If you can do those things that move you towards your values, you will strengthen your recovery. I'll give you an example. I had an individual who really wanted to be able to travel around the country, to go to the Grand Canyon, maybe to visit Disneyland, but they were terrifying of flying. So we did some work to move them towards their values and taught them some skills for flying, brought them to an airport, got them into a fear of flying program that was actually run by an airline. So what is it that we can do to help you move towards your values? Their desire to go see the Grand Canyon was the factor that pushed them through all that therapy for their fear of flying. And one of the things we also worked on was opening up when that anxiety came. And when they were boarding the plane, they started to cry, not hysterically, just anxiety driven tears. And when they were asked by the flight attendant, "Are you okay?" And they said, "Yes, I'm going to the Grand Canyon. I'm just really nervous." And they were able to get additional support from the flight attendant, and they went. So identifying what the values are. And they are as diverse as the individuals we work with. So I can't give you specific values, although there are lists of different values. If you need a starting place with an individual, Google a list of values, and you can have them identify ones they think. We also have a worksheet that might help with that a little further on. So connecting to the moment, be present, be where you are. Anxiety particularly often lives in experiences of our past, or concerns about our future. The more present and mindful an individual can be, the more likely they are, to be able to engage in behavior change. I even went as far as having one of the individuals I work with. He wore converse sneakers, and they have those great little wiped toes. He took a marker and said, "Be here. You wrote B on the left foot, and here on the right foot." And every time you. decided he wanted to be someplace else, he looked down and remind himself to be present. So you can be very creative with how these skills are applied. And committed action, do what it takes. Recovery from PTSD, anxiety, depression, obsessive, compulsive disorder is not easy. Recovery from SUD takes time, energy, and effort. So you need to have committed action and do what matters, even when it's hard, which brings us back to the values. The six core principles of act went over some of these already in the last slide, but there's a little bit more room here. So opening out, making room for painful feelings, sensations, urges, or cravings, and emotions, and realizing they are not your enemy. It's the response to them that is usually the problem. Diffusion, watch your thinking, learn to step back and. detach from our thoughts, images, and memories. Contacting the present moment, be here now, means being psychologically present, consistently connecting with and engaging with it, ever is happening in the moment. This is one that substances often steal, as does depression and anxiety, when you're so anxious that you can engage with the activity, whether it's a movie, a cookout, an AA meeting, a therapy session. That's a problem, when all you can think about is your future substance use, like I need to get more of whatever substance you're struggling with, you're not in the present moment. And sometimes being in the present moment is uncomfortable. That's another important thing. I wish there are a lot of nice activities, but being present also means being present for the difficult emotions, dealing with grief, attending a funeral, losing a job, and being able to process those in state in the moment. Self as context, pure awareness in everyday language we talk about the mind, without recognizing there are two distinct elements of thinking, self and the observing self. What you do and how you view that. We all have that inner dialogue where we talk about, oh, if I move again, does that mean I don't have stability in my life? All my family has lived in one state, they're entire, and I'm moving to my fourth state. What does this say about me? So we have both ourselves and our minds, M-I-N-D. And one aspect of that is to be aware that the observing self doesn't always tell the truth. Our minds can lie to us and give us false information. Values know what matters. These being your heart, what do you want your life to be about? What do you want it to stand for? An interesting activity here that can clarify values is writing one's own obituary. What is it that you would want people to remember about you? What would you want said about you at the end of your life? This can be a very challenging exercise, so make sure that the individual is ready and has done some values, clarification, some motivational interviewing, but it also can clarify what exactly the person would like to do, what's important to them, which can benefit them to then choose committed action. And that is do what it takes. This means taking effective action, guided by our values, engaging in therapy, taking medications, going to whatever support structure you choose, mutual self-help group, a structured therapy group, but taking those steps and doing the work, engaging in behavioral health components. If you have PTSD, are you willing to do cognitive processing therapy, which is a different evidence-based practice? We're not going over here, but it is a common one for PTSD and it's more structured. Also things like prolonged exposure for PTSD or exposure response prevention for OCD. Again, those are outside the scope of this particular training, but as people move through the recovery process, if they need a more structured aspect, committed action can be built upon, and people can be ready for those challenging behavioral health interventions through identifying their values and becoming willing and practicing mindfulness. So when the therapy stresses them out and raises their anxiety, they can choose to be in the present moment. Okay, this is the values clarification and committed action form I was telling you about. Where do you want to put your energy? Because we can't do everything. Although many of us try, we can't. So where do you want to put your energy for your committed action? This helps visualize and break things down. It also identifies different realms of values. So if you're working with somebody who's not sure what their values are, these different realms here in these battery boxes can help people understand. Is it their intimate relationships? Family, spirituality, their education, their career. What is valued by them? Where do they want to put their energies? Okay, acceptance and commitment therapy marks a journey. Mark is a 24 year old male on medications for alcohol use disorder. He's facing multiple legal issues due to his drinking. It's court ordered to treatment and starts the first session with I don't do AA. Mark agreed to treatment with acceptance and commitment therapy act, utilizing the workbook, the wisdom to know the difference, and that is a resource listed further down in this training on the resource page. Mark worked through values clarification, diffusion, acceptance to include a willingness to sit with difficult emotions without using alcohol and identified committed actions he'd engage in. Mark was taught a few act metaphors, passengers on a bus. Passengers on a bus says that you are your bus driver. You drive your bus in a value direction. There are passengers who may come on your bus for a little while and then they may get off. And then there are passengers who may stay on your bus for the entire journey. Sometimes they'll sit in the front. Sometimes they'll sit in the back. But what these passengers do is they yell at the driver. Sometimes they yell at the driver to turn their bus around and take it back to the bar or to the neighborhood where they use or to, you know, avoidance. Go back home, walk the doors, be safe. Don't drive in that value direction. So this metaphor really helps people contextualize what it means to move in a value direction, to have that acceptance and to make room for these passengers. But still drive your bus where you want to go. There's also a two mountains metaphor. Acceptance and help. The two mountains metaphor says we both have a particular view. And if you've ever climbed a rock face or a mountain and you look straight up, you realize you might not be able to see the clearest path. But if I'm across the room or across the way on my mountain, I might be able to tell you, hey, it looks like you'll have a lot of success if you go to the left or to the right or if you take a step back and change your path. So it's not saying I'm an expert at saying I'm seeing things from. a different perspective. Mark completed 10 sessions and 12 weeks of group therapy for recovery support. Mark had two instances of drinking in early therapy and was sober for the last 14 weeks of his intervention with acceptance and commitment therapy. We've got to move on now to 12 step facilitation. Many of you who work in this field will be familiar with 12 step meetings, AA and NA. The trick here, and it's not a trick, but the aspect here that's important is 12 step facilitation is more structured. It helps people develop those tools that 12 step meetings give them. Remember, it's a 12 step program, which actually means there are steps along the way that people work through and 12 step meetings and the 12 steps really actually follow a cognitive behavioral framework. First, you decide you have a problem and then you decide what you're going to do about it. And it goes back and forth throughout the steps. If you get up to later steps, one says, I made a list of people who I had harmed. And the next step says, I made amends wherever possible, except when to do so would harm me or others. So 12 steps really still do follow a cognitive behavioral type model in addition to providing the shared stories, experience, strength, and hope and the social aspects of the 12 step program. So TSF 12 step facilitation is generally 12 to 15 sessions. That's guidance. It's not written in stone. And it's based on the behavior and cognitive principles of 12 steps. So you may go through the big book with somebody. You may read the basic text. You may help them do their first step, their second step. There are multiple workbooks and other tools to help. you go through each step. There's even a book called the 12 by 12 and it's the step process. We have some books that are recommended. Again, I have no disclosures. I'm not connected to them. They're just really helpful in this process of 12 step facilitation. They are gender specific and trauma informed. Now, I will say it is a binary gender split. There's one for women and one for men. We do not yet have a book for gender floor non binary individuals. Someone wants to write that. I would love to read it. But for now, we have these updated versions that are gender specific and trauma informed. They'll be shared later. The therapy focus has two general goals. Oh, look at that acceptance just as with at 12 step facilitation has an aspect of acceptance. Here, it's the acceptance to abstain from alcohol or other substances and to realize that your powerless only over the substances, you're not powerless over your entire life. Just the drugs and alcohol and surrender the willingness to participate in the fellowship of the 12 step programs to go to meetings to say, I do need to help. One of the bravest things anybody can say is help. We all need help at some aspect, but it's one of the most challenging and difficult things to say. So when somebody says help, I want to make sure that I can give them the tools to move forward. But they have to surrender to win. You need to be able to sit with those negative emotions and accept the help. And that's where that surrender aspect comes in. So you'll go over and explain. One of the things I hear a lot from patients I've worked with is I grow to meetings. They're not helping. What are they reading the text? Are they going through the 12 steps? Do they understand what a sponsor is? So in 12 step facilitation, you actually walk them through this in a process similar to cognitive behavioral therapy where I'm giving you skills. I'm explaining, I'm actually doing the psycho education from the written materials of these programs. You can do a similar process to this for smart recovery or women in recovery. Both have some basic text and common handouts that they provide to their members. It's just that this 12 step facilitation is an evidence based process. It has been shown to improve outcomes when utilized as a structured, skill building intervention. It has been researched again and again. 12 step facilitation is different than just sending your individual two meetings. It is structurally going through and helping them understand the concepts and applying them to the different areas of their life. So we have randomized controlled studies and a few that were not, but all of them had good outcomes. It performed at least as well as other established treatments such as cognitive behavioral therapy. So when it comes down to a lot, if you have someone who's very hopeful and engaged and wants to use 12 steps, you can still improve outcomes beyond the social, mutual self-help aspect and engage them in this process that is a skills-based process. And it saves money. I mean, we do this to help our clients, but also it does reduce overall healthcare costs. So engaging in these training staff in these, sending your staff to training or being a trainer in, is a cost. But overall, it's a cost benefit if people can maintain the recovery. Okay, recovery for individuals who have engaged in AA, this particular was an AA study. So the longer people went to meetings, the more they were able to hold on to their recovery. This is not to say that AA is the only way. However, it has been shown that if you are engaging in meetings, post treatment, whether it's residential or detox, the odds of your recovery process increase with commitment, the committed action to engage in the 12-step process. Or though this study talks particularly about AA, women for sobriety, smart recovery, whatever is that the person has identified as their recovery support, the more they engage in it, better the outcome. Having someone be able to walk through the core principles of that aspect, take it from a solely social endeavor to a skill building endeavor is what will improve the outcomes and is the concept behind 12-step facilitation. Okay, Bob's step facilitation, Kim's journey. Kim is a 35-year-old female who utilizes AA as a sponsor, though relapsed on cocaine and alcohol. Kim has been on buprenorphine, now, Lexon's sub-wing will film for two years and has not used opiates since. Kim agreed to an adaptive form of 12-step facilitation using a woman's ways for the 12-steps. Four concepts of 12-step facilitation were incorporated such as goals for surrender and acceptance, along with objectives around behavioral, cognitive, spiritual, and social aspects of 12-step programs. Over 14-session, Kim increased her understanding of 12-steps from a trauma-informed gender-specific. framework and committed to great 12-step meeting attendance. Kim reported decreased anxiety and improved engagement with AA. Kim's GAD 7, which is a measurement-based tool for measuring anxiety, score reduced from 12-3 over the 14 weeks, confirming her lived experience. Kim had no positive UDSs during the time in therapy. So here, Kim was engaged already and really committed to the 12-step process. So utilizing this modified 12-step facilitation, which was gender-specific and trauma-informed, had very positive outcomes. Okay, here we just look at some of the various settings that we provide, Carin, opiate treatment programs. Some of them have licensed mental health providers on site, most do, so they can incorporate any of these aspects that we've reviewed today. They can do them short-term and longer-term. Bupin orphyne providers only, PCP or psychiatry. They may provide interventions, use community referrals, psychiatrists may also provide therapy. People use different models, but you would be able to utilize aspects of motivational interviewing, the cognitive distortion list, the 12-step facilitation, really helping people engage and understand the concepts, or identifying value and what matters, committed action. And Bupin orphyne are in care management model. With any program, can have access to primary care mental health integration in some settings, or can utilize community referrals. But one of the nice things about motivational interviewing and some of the 12-step facilitation is it doesn't have to be provided by an LIP. You can talk to somebody about why they want to change, what is their experience like, and you can help them better understand some of the concepts presented in 12 steps. You could explain to them the role of a sponsor what they are and what they're not. Sponsors are not therapists, but they are really good supports because they're a peer that has maintained their recovery over time. And in private practice, MDs or nurse practitioners, we can engage in all of these. options for evidence-based brief interventions or use community referrals. This slide is really saying that you have a menu from which to choose. And as I stated in the beginning, you don't have to be good at all of them. Pick the ones that work within your practice how it is set up, whether you're a solo provider or you work in a team or a clinic or a specific treatment facility. These are aspects you can incorporate to provide concurrent treatment and improve outcomes. Medications and treatment challenges. Obit treatment programs usually have mental health. That on site, but they might need training in specific EBPs. Bupinorphine specific programs may or may not have mental health treatment projects on site. So you have to go back to that developing that community referral model. And if you know other individual or solo practitioners once you develop it, you could share it with them and then find a way to keep it current. And primary care prescribers, yeah, same as above, you may or may not have them. Some places have mental health, primary care integration, so they have behavioral health providers right there in the primary care setting. Others do not. You have to find what works for your practice. But hopefully we've given some tools here. This is just an example of the 12 steps of AA. You can read through this at your leisure and it lists some of the things, aspects of this. They don't have any affiliations or endorsements. Different groups have different characteristics. One of the things is in the online or in a book meeting list, there's usually a guide or a legend in the front that tells you sort of the codes. So you might have something that says, oh, that's an open meeting. Anybody can go. Use a provider who does not have a substance use disorder. It can go to an open meeting, sit down and listen and see what it's like for individuals to go to a meeting. If it's see that's a closed meeting that's only available for people who are struggling with substances. Family, friends, and providers are not welcome at that meeting. Then you can have a YP. That's young people. Traditionally, people under 25. One of the aspects here is the people under 25 get older and stay in the same meetings of not always, but that's the intent. Then you might have. a G. This is a gay meeting. This is a meeting for the LGBTQI+ community. So it's a safe place to be yourself and seek recovery. There are so many meetings. There's women's meetings, men's meetings. So knowing the different types of meetings can also be a component of getting people to engage and to utilize 12-step facilitation. Somebody might feel much more comfortable. at a meeting for LGBTQI or a women's only meeting, particularly if the woman has a trauma history. That might be the change and the aspect that gets her into 12-step meetings combined with a women's way through 12-step. You've changed the potential outcome of her recovery process. This is the additional resources and learning. I've put information in here for each aspect, cognitive behavioral and motivational interviewing, 12-step facilitation act, and the links for developing your resources in the community are also present here. Then we have the references which you are welcome to go through at your leisure if you want to follow along with more information as to how this particular program was developed. We'd like to wrap up. So first, we'd like to tell you about PCSS mentor program is designed to offer mentoring assistance to those in need of more one-on-one interactions with one of our colleagues to address clinical questions. You can request a mentor from our mentor directory or we are happy to pair you with one. To find out more information, please visit our website using the web link noted on this slide. Have a clinical question? Second, PCSS offers a discussion forum which is comprised of our PCSS mentors and other experts in the field who help providers prompt responses to clinical cases questions. We have a mentor on call each month. This person is available to address any submitted questions through the discussion forum. You can create a new log-on account by clicking the image on the slide to access the registration page. This slide simply notes the consortium of lead partner organizations that are part of the PCSS project. Finally, please reference this slide or our contact information website and Twitter and Facebook handles to find out more about

Substance Use Disorder

Evidence-based practices

Stacey Conroy

PCSS

Cognitive behavioral therapy

Acceptance and commitment therapy

Motivational interviewing

12-step facilitation

Co-occurring disorders

Medications for addiction treatment

Mutual self-help groups

Intervention settings