Arizona Families F.I.R.S.T: Engaging Clients Dually-Involved with - - PowerPoint PPT Presentation

Arizona Families F.I.R.S.T:

Engaging Clients Dually-Involved with Child Welfare Services and Treatment of Substance Use Disorders

July 16, 2014 Summer Institute 2014 Center for Applied Behavioral Health Policy

Introduction and Agenda

Presenters

• AFF Co-Investigator: Natasha Mendoza, PhD, LMSW
• Project Coordinator: Marisol Cortez, MSW

 Session Learning Objectives  AFF – Arizona Families F

.I.R.S.T .

 Research and Target Population  Client Engagement

 Trauma-informed and Motivational Approaches

Session Learning Objectives

1.

Participants will be introduced to Arizona Families First programming and be able to articulate its service provision.

2.

Participants will be able to cite current empirical evidence related to families involved in both child welfare and substance abuse service systems.

3.

Participants will be given strategies for client engagement (i.e., trauma-informed and motivational) in settings addressing substance use disorders with child-welfare involved adult caregivers.

AFF - Arizona Families F.I.R.S.T.

Arizona State Legislature

In response to increased involvement of children in Arizona’s welfare system, Arizona legislature passed Senate Bill 1280 in the 2000 Legislative Session which created the Substance Abuse Treatment Fund Partnership. Today it is known as Arizona Revised Statute (ARS) 8-881.

What is AFF?

 Founded in 2001  Partnership result between Arizona Department

• f Economic Security (ADES) and the Division of

Behavioral Health Services (DBHS)

 Program Goals

1.

Child safety

2.

Accessibility to services for guardians/parents with substance use disorder referred in the child welfare system

3.

Substance use disorder recovery for guardians/parents

4.

Permanency through reunification

5.

Guardians/parents self-sufficiency through employment

Involvement in AFF

 Guardians/parents are referred by Child Protective Services

to AFF service providers:

TERROS SEABHS AZPAC Northern

 Referral basis:

• CPS report indicating child unsafety/maltreatment etc.
• Indication of substance use disorder

Service Providers

 Currently there are three AFF providers (TERROS, SEABHS and

AZPAC Northern) as agencies providing services statewide except on tribal reservations.

• TERROS
• TERROS Central: East Maricopa County and Pinal County
• TERROS Southwest: West Maricopa County, La Paz and Yuma
• TERROS Pima: Pima County
• SEABHS: Southeastern regions including Gila, Greenlee, Cochise,

Graham, and Santa Cruz

• AZPAC Northern: Mohave, Yavapai, Coconino, Navajo and Apache

Five Servicing Regions

Child Protective Services and Substance Use Disorder Treatment

 According to the NSDUH, among women of

childrearing age (18-49) who needed substance use treatment, only 10.4% received it.

 As a result, it is often the case that clients

served by Child Protective Services and treatment agencies overlap.

Child Protective Services and Substance Use Disorder Treatment

According to research, it’s important that Substance Use Disorder (SUD) support services aimed at improving treatment outcomes for individuals with SUD include;

Case Management Services Twelve-Step Models Recovery Mentor Advocate Programs Abstinence Monitoring

ASU – Center for Applied Behavioral Health Policy: AFF Evaluating Agency

 Provides program monitoring  Collects and analyze client-level data to produce quarterly and

annual reports

 Technical support for data collection using Data Gateway  Evaluating agency since 2006

Research and Target Population

What is Substance Use?

 In the most recent version of the DSM-5 substance abuse and

dependency have been combined into one single disorder (APA, 2013).

 Prior to the DSM-5, each were classified individually.

• Abuse: improper use of substance and overuse.
• Dependence: habit-forming, reliance and feeling the need to use

the substance.

Why People Become Addicted

There is no one theory or explanation about why people become addicted. Factors contributing to addiction:

• Biological and genetic predisposition have been said to account

for 40-60% of risk addiction

• Social environment and upbringing such as exposure to

substance use

• Risk can also be affected by ethnicity, gender and

developmental stage

Nature and nurture contribute to vulnerability or resiliency to substance abuse.

Substance Use and Parenthood

According to a national survey in 2007, 8.3 million children lived with at least one parent who abused or was dependent

• n alcohol or an illicit drug

(Office on Child Abuse and Neglect, 2009).

Age Range Percentage

0-2 years 13.9% 3-5 years 13.6% 6-11 years 12.0% 12-17 years 9.9%

Substance Abuse and Parenthood cont.

According to the Office on Child Abuse and Neglect (2009),

• Children of parents with substance use problems are

 at higher risk of abuse and neglect.  likelier to experience physical, academic, social, and emotional

problems.

three times likelier to be involved in substance use them selves

later in life.

https://www.youtube.com/watch?v=n5XakEKSIaM

Client Engagement

A Motivational and Trauma-Informed Approach

Overview

What this presentation is NOT

…and what it IS

Trauma-Informed Approach Motivational Enhancement Skill Development

Introductions

Who am I? Who are you? Trauma-informed? Motivational Interventions?

What this Presentation is NOT

NOT therapeutic training NOT a therapeutic intervention

What this Presentation IS

A way to diminish client resistance Enhance treatment engagement

Trauma-Informed Approach

Changes the question from…

“What’s wrong with you?” to “What happened to you?”

Trauma-Informed Approach

“When a human service program takes the step to become trauma-informed, every part of its organization, management, and service delivery system is assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking services. Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization.”

• The National Center for Trauma Informed Care

What is Trauma

 Trauma is the “direct personal experience“ of an event involving:  actual or threatened death  serious injury  other threat to one’s physical integrity  Trauma is “witnessing” an event that involves the above 3 factors as related to

another person.

 Trauma is “learning about unexpected or violent” death, injury, or threat thereof

as experienced by a significant other.

 Trauma can be:  A single event  A connected series of events  Chronic lasting stress

“…In short, trauma is the sum of the event, the experience, and the effect.” SAMHSA

Trauma

“Individual trauma occurs in a context of community, whether the community is defined geographically as in neighborhoods; virtually as in a shared identity, ethnicity, or experience;

• r organizationally, as in a place of work,

learning, or worship.”

– SAMHSA, 2012

Trauma Triggers

 Triggers  Seeing, feeling, hearing, smelling

something that reminds us of past trauma

Activate the alarm system The response is as if there is

current danger

Thinking brain shuts off in the

face of trigger... It’s time to survive

Past and present danger

become confused

Triggers

What triggers you?

…to become angry, fearful, worried, or stressed?

What triggers clients?

…to become angry, fearful, worried, or stressed?

“What makes you feel scared or upset or angry and could cause you to go into crisis?”

 Not being listened to  Lack of privacy  Feeling lonely  Darkness  Being teased or picked on  Feeling pressured  People yelling  Arguments  Being isolated  Being touched  Loud noises  Not having control  Being stared at  Room checks  Contact with family  Time of year/time of day

Clients have unique histories with uniquely specific triggers – it’s essential to ask & incorporate triggers in to treatment

Trauma-informed Staff Responsiveness

Greet everyone as if they have a trauma

history.

Be knowledgeable about potential triggers

and adjust your body language and voice accordingly.

Understand that everyone is subject to

their own reality which is different from yours.

Using Motivational Enhancement

Beliefs About Motivation

(True or False?)

1.

Until a person is motivated to change, there is not much we can do.

2.

It usually takes a significant crisis (“hitting bottom”) to motivate a person to change.

3.

Motivation is influenced by human connections.

4.

Resistance to change arises from deep-seated defense mechanisms.

Beliefs About Motivation

(True or False?)

5.

People choose whether or not they will change.

6.

Readiness for change involves a balancing of “pros” and “cons.”

7.

Creating motivation for change usually requires confrontation.

8.

Denial is not a client problem, it is a therapist skill problem.

Motivational Basics

 Theoretical Foundation- Stages of

Change

 Clinical Foundation- Person Centered

Therapy

 Carl Rogers  Everyone is doing the best they

can at any moment?

Relevance?

Motivation can be influenced from the moment

someone walks through the door.

Disarming resistance can happen early and

carry over to Tx.

Focusing on client achievement- even in a small

way- can enhance motivation.

Motivational Interviewing

Ambivalence is normal and important. Ambivalence can be resolved by working

with the client’s intrinsic motivations and values.

Empathetic, supportive, directive NOT argumentative or aggressive

confrontation

A Successful Motivator will….

• Express empathy through reflective listening
• Communicate respect and acceptance
• Be non-judgmental
• Be supportive and knowledgeable
• Compliment rather than denigrate
• Listen rather than tell
• Gently persuade
• Support through the process
• Develop a discrepancy between clients’ goals or values and current

behavior, helping clients recognize the discrepancies between where they are and where they hope to be.

And will…

 Avoid power struggles  Adjust to, rather than oppose client resistance  Support self-efficacy and optimism

Motivational Interviewing Strategies

OARS

• Open-ended Questions
• Affirm
• Reflective Listening
• Summarizing

Staff Interactions

 Focus on O. A. R.

4 Principles of Motivational Interviewing

 Clinical Components that Work  Express Empathy  Develop Discrepancy  Roll with Resistance  Support Self Efficacy  Staff Take-away  Don’t underestimate empathetic response  Opportunities to identify discrepancy will show themselves  Don’t get “pulled in” to resistance. Reflect and watch it

diminish

 Don’t underestimate the kudos

Open-ended Questions

 Gather descriptive information  Facilitate dialogue  Starts with words like “how” “what” “tell me about”

“describe”

 Relay that our agenda is about the consumer

Affirm

 Must be sincere  Promotes self-efficacy  Acknowledges client

challenges

 Validates the client’s

experiences

 Emphasizes strengths/success

Reflective Listening

 Begins with an interest in what

the person has to say and a desire to truly understand how the person sees things.

 Repeating  Rephrasing  Paraphrasing (May be directive

• r over-emphasized)

 Reflection of feeling

Summarize

Reinforce what’s been said Link together clients feelings of

ambivalence and promote perception of discrepancy ….but back to reflection…

Reflections Are Statements

Question: You’re thinking about stopping? (inflection goes up) Versus a statement: You’re thinking about stopping. (inflection goes down)

Thank YOU!

Comments? Questions?

References

 APA-American Psychiatric Association. (2013). Substance-Related and

Addictive Disorders. American Psychiatric Publishing. Retrieved from http://www.dsm5.org/Documents/Substance%20Use%20Disorder%20Fact%20 Sheet.pdf

 Florida Department of Juvenile Justice. (2010, July). Statewide TIC

presentation (DJJ) . Retrieved from http://www.djj.state.fl.us/docs/partners-providers-staff/trauma- informed-djj-wfsu-webcast-july-2010.pdf?sfvrsn=0

 “How To Make Your Agency Trauma Informed” by Jennifer Barr, LCSW,

Apalachee Center, Inc. & Aimee Griffith, LCSW DISC Village, Inc. in Tallahassee, Florida.

References cont.

 Miller, W.R. (2004) Toward a Theory of Motivational Interviewing.

motivationalinterviewing.org

 NCTIC - The National Center for Trauma Informed Care. Website:

http://www.nasmhpd.org/TA/nctic.aspx

 Office on Child Abuse and Neglect. (2009). Chapter 2: The Nature of Substance Use

• Disorder. U.S. Department of Health and Human Services. Retrieved from

https://www.childwelfare.gov/pubs/usermanuals/substanceuse/chaptertwo.cfm#why

References cont.

 Office on Child Abuse and Neglect. (2009). Chapter 3: How Parental Substance Use

Disorders Affect Children. U.S. Department of Health and Human Services. Retrieved from https://www.childwelfare.gov/pubs/usermanuals/substanceuse/chapterthree.cfm

 Office on Child Abuse and Neglect. (2009). Chapter 6: The Role of Child Protective

Services When Substance Use Disorders Are Identified. U.S. Department of Health and Human Services. Retrieved from https://www.childwelfare.gov/pubs/usermanuals/substanceuse/chapterthree.cfm

 SAMHSA – Substance Abuse and Mental Health Services Administration. (2012,

December 10). Part One: Defining Trauma. Retrieved from http://www.samhsa.gov/traumajustice/traumadefinition/definition.aspx