Wednesday, August 27, 2014

Barriers to Success

This survey of 100 mental health professionals across the country identified several barriers to addiction treatment success including socioeconomic status, patient resistance to the spiritual elements of 12-Step, and inadequate program resources.  Another point to consider as a barrier to successful treatment is having adequately trained clinicians. Similarly, few medical doctors have training in addiction yet many of them will go on to prescribe addictive pharmacological agents (e.g., Percoset, Klonopin).  It is generally assumed that the clinical skills developed during doctoral or master’s level training are generalizable enough to apply in addiction work. It is simply not the case. As such, many clinicians struggle to engage addicted persons in treatment. In turn, this dilemma, which might reflect deficits in training, plays a critical role in the overall success of treatment.

A program's treatment success depends on a delicate balance between employing well-trained professionals and the delivery of high quality services to its patients.  Services that are evidenced-based and supportive in nature generally do well. Computer-based CBT, motivational interviewing, and community reinforcement models (e.g., Community Reinforcement and Family Training; CRAFT), have demonstrated good efficacy but not all programs utilize these methods or have clinicians trained in them.

In conclusion, the success of treatment programs rests, in part, on the preparedness of its clinical team. In order to address the service delivery side of the equation, appropriate clinical training in addiction treatment is crucial especially since evidence-based models and intervention strategies are all part of a good training and a strong contributor to successful treatment.

Written by Dr. Errol Rodriguez
Assistant Dean and Program Director of the Master’s programs in Psychology and Mental Health Counseling in the Derner Institute of Advanced Psychological Studies.

Thursday, August 14, 2014

After Autism: Are individuals cured or reaching their potential?

Adelphi University has been working for years to raise awareness of and inspire discussion on autism-related issues on Long Island. Our faculty are internationally known experts in autism, and our events, initiatives, and services all reflect their expertise. The following experts offer their opinions in response to the New York Times Magazine article, ‘After Autism’ byRuth Padawer, August 3, 2014.

Stephen M. Shore., Clinical Assistant Professor of Education, Adelphi University

While it is great to read people with autism are doing well – they have not "beaten autism".  

The individuals mentioned in the article are described as having residual effects of autism – usually in the social areas.  The question is... have these individuals recovered from or eliminated characteristics of autism?  Or have they learned how to work with the strengths that come from being on the autism spectrum?  As a person on the autism spectrum, I believe we would be much better served if the focus remains on what can be done with the characteristics autism gives a person rather than having to deny or defeat it.  

Judith H. Cohen, Ph.D., J.D. Professor of Education, Adelphi University, author of “Succeeding with Autism—Hear My Voice

Responding to the recent NY Times article by Padawer,  the outlook about autism is changing dramatically due to the increase in knowledge about the spectrum disorder.  Documented case reports about individuals ‘recovering’ from autism have become more frequent providing greater hope for many families.  

We now know that individuals do change over time and core deficits can be reduced or modified.   There are still no early indicators in childhood behaviors that reliably predict later functioning.  However there are indicators that are associated with better outcomes: early diagnosis, early intervention, consistent and expert intervention, medication to address symptoms, language ability, desire to change, intelligence, and maturity.
I prefer to use the term ‘managing and succeeding’ with autism rather than recovering from autism.

Two, very high functioning adults that I know had severe and classic autistic attributes in early childhood and the recommendation was that both should have been institutionalized.  Instead, their needs were addressed in early childhood through public education and home support.   Today both are independent adults with professional careers and both are still on the autism spectrum. Have they ‘recovered’ or have they learned to manage their areas of deficits and modified aspects of behavior?

Pat Schissel, LMSW , Executive Director, Asperger Syndrome and High Functioning Autism Association(AHA)

These kids are not "beating" autism. Simply put they do not meet the diagnostic criteria at this point. So what.

So what indeed! They still have social issues. They have highly focused interests. They have the past experiences of ASD (bullying and poor self-esteem). Most likely, in my experience, they will need to be supported and encouraged to embrace who they are. Not who the diagnostician in their narrow frame sees. They can do well going forward - as adults when this is acknowledged. I am not a big believer in denial.

Mitch Nagler, MA ’06 Director of the Bridges to Adelphi Program for students on the Autism Spectrum or those who struggle with Social Anxiety or other non-verbal learning disorders

By saying someone is cured of Autism is misleading in my opinion. Two people can present the same at the age of diagnosis [as referenced in the New York Times article], they can be given the same therapies and services, but faced with different individual variables their reaction is bound to be different.

Autism is a developmental disorder, so it makes sense to me​ that as people​ mature, they grows into themselves at a different paces compared to others. As they develop, I have seen many students that have less characteristics of the disorder than when they started in the Bridges to Adelphi Program. We just never know how much someone will progress, or when it will happen. Our approach in the Bridges Program is to support each student’s strengths, with that comes a building of self-esteem and lesser attention on their weaknesses.

Wednesday, August 13, 2014

Endorsing abstinence to treat substance abuse addicts

In a striking example of polar viewpoints, 61% of 100 mental health professionals (psychiatrists, psychologists and social workers) in a national  survey conducted by Wakefield Research on behalf of Adelphi University Center for Health Innovation, endorsed the goal of abstinence in contrast to that of harm reduction for their substance dependent patients.   These very same clinicians believed that the opposite view held true for their patients; namely 61% of their patients would support a treatment goal of harm reduction as opposed to abstinence.  Within this schism lie perhaps the keys to understanding some of the more telling secondary findings of this study: 1) Outpatient treatment programs often fail and 2) a vast majority of mental health professionals (67%) prefer to recommend new approaches including cognitive behavioral therapy, motivational interviewing, self management tools such as SMART recovery (with its roots in CBT), and contingency management reinforcement (with its roots in heightening motivation for change) as opposed to traditional 12-step interventions.

One does not need to go further then to understand that the perception of treatment failure might be closely linked to the disagreement between the mental health professional and their patient with respect to desired treatment outcome.  This would be true for any helper-helpee relationship in which there was a lack of consensus with respect to course of treatment. In fact, our survey revealed that only 28% of mental health professionals think traditional outpatient programs are effective for a majority of their patients.  Often, these programs are driven by abstinence-based mission statements upon which utilization reviews of treatment outcome and funding sources (insurance included) are predicated.

Patients seeking treatment on an outpatient basis, particularly within younger populations such as adolescents and young adults, where the line between abuse and addictive disorder is less delineated, may not be seeking abstinence as an initial goal of treatment. Perhaps their drugs of abuse are alcohol and/or marijuana and they would like to begin an exploration of harm reduction.  In fact, they may not even be motivated for treatment at all, let alone seeking abstinence, instead having arrived at the doors of outpatient treatment through the leverage of others, courts, schools or parents. Naturally, treatment as measured by abstinence goals will fail, although if measured by reduction in use, or decrease in risk-taking behaviors, may be seen as successful outcomes. Implicit in the survey findings is the curious contradiction of these very same professionals to overwhelmingly “prefer” (67%) and be “open to” (93%) using newer approaches that often “begin where the patient is” (this does suggest tolerance of harm reduction) as opposed to traditional approaches such as that of the 12-Steps that foster spiritual surrender to goals of abstinence as the basis of recovery.

In the case where drug use shifts to that of opiates, methamphetamine, cocaine, alcohol dependence, or  when addictive disorder becomes life threatening, or marked by repeated failed attempts to curtail use,  then abstinence goals are certainly more appropriate. Our survey results reveal that 63% of mental health professionals think a person who has been treated for substance dependence cannot use that substance again responsibly.  Perhaps their patients might ultimately come to share this point of view.

Written by Audrey Freshman, PhD, LCSW. CASAC
Adelphi University School of Social Work
Director of Continuing Education and Professional Development
Director of Postgraduate Certificate Program in Addiction

Tuesday, August 5, 2014

Abstinence vs. Harm Reduction - What works for addicts?

It’s interesting to speculate about the Center for Health Innovation Poll result that a large majority of mental health professionals endorse the treatment goal of abstinence over harm reduction.   It is often the case that those addicts who end up seeking professional help are a particularly distressed and difficult to treat group.  How do we know that?  Ann Fletcher who wrote “Sober for Good,” learned from speaking with addicts themselves, that as many as 50% find their way to abstinence on their own, without ever seeking professional help, and without ever attending a 12-step program.   We also know that a small number of alcoholics can actually drink on occasion without lapsing into more problematic use.  This suggests that professionals in our survey may be reporting on their experiences with addicts who have not been able to help themselves, whose behavior is already more engrained and resistant to the tools and approaches at the disposal of our professionals, when compared with addicts who manage to get sober on their own.  Hence, the professionals surveyed might advocate a tougher and more demanding abstinence approach with the people they treat.

It’s also likely that when asked to choose between treatment goals of abstinence versus harm reduction, professionals in our survey understandably report the more conservative and consensually endorsed one, abstinence.  But in practice, the dichotomy may be somewhat misleading.  Many professionals will begin, quite correctly, where their patient is at, so to speak, working initially with an addict’s stated preference for harm reduction, knowing that, to abrogate a patient’s treatment goal right off the bat, can be a recipe for failure.  And for many addicts with years of use and a lifestyle to go with it, abstinence is an unfathomable leap.  Harm reduction offers a way forward, but one that is stepwise, and for many subjectively more manageable.  As a result, our wise and experienced professional might say, in effect, “Let’s try harm reduction and see how far we get.  If this approach to moderation of your substance use works, then great.  If not, we’ll reassess and go from there.”

The survey also provides hints about some very important principles in working with addictions.  For one, recovery should address an array of often co-occurring and related problems, some of which are as important in addictive disorders as the substance use itself.  Many addicts may have psychological problems underlying the addiction, including major depression, bi-polar disorder, anxiety, eating and personality disorders (lifelong maladaptive behavior patterns that interfere with work and relationships).  If these co-occurring problems are not addressed, then detox and short term outpatient treatment, no matter how intensive, may afford the patient only temporary relief from the addictive pattern.  That may be why, in their estimation, professionals feel that medical insurance to support treatment of addictions is less than adequate; the range of associated problems that may underlie the addictive disorder requires extensive rehabilitative resources.   For an addict to remain well, he/she will often need not only to stop using drugs, but also to forge a new life that offers a compelling alternative to drugs and requires resources that may never have been available before the addictive cycle dominated their lives.

And on this last point, the involvement of family and friends is critical.  An approach gaining in popularity, CRAFT (community reinforcement approach and family training), helps people learn to reduce the power of their addictions, and also equips family and friends with supportive techniques to encourage loved ones to begin and continue treatment.   The approach also implicitly acknowledges that just as one addict can negatively affect the lives of so many others, so may others positively affect the life of the addict.

Written by
Jonathan Jackson, Ph.D.
Director, Center for Psychological Services
Derner Institute
Adelphi University