What Works for Addiction and Child Welfare

Nikki: Welcome to the Center for Advanced Studies
in Child Welfare module “What works for addiction and child welfare?” This module is presented by Dr. Amy Krentzman
and PhD student Karen Goodenough. My name is Nikki Tillman. I’m an MSW student and will be introducing
your presenters and an overview of the module content. First and foremost, we’d like to extend
our gratitude for the amazing work each and every one of you do every day for children
and families. Your work is appreciated. We hope this module will be beneficial in
your continuing efforts. Our first presenter is Dr. Amy Krentzman,
pictured here on the left in blue. She is an assistant professor at the University
of Minnesota School of Social Work. Dr. K. does research on addiction recovery,
specifically studying the link between recovery and spirituality, gratitude, and forgiveness. She also looks at recovery in the context
of 12 step programs and sober living houses. She is currently doing a study on recovery
in rural Minnesota. In addition to research, Dr. K. teaches a
course in the Masters of Social Work program about substance use disorder. Our second presenter is Karen Goodenough,
MSW and LGSW. Karen is a PhD student, community faculty
member, and research assistant at the University of Minnesota. She is also a principal consultant at Strategic
Consulting and Coaching, a firm located in St Paul, Minnesota, and she works in macro
social work through enhancing non-profit leadership and management, evaluation and data driven
practice and decision making, and consulting on strategic planning, fundraising, budgeting,
and program development. Her research interests focus on addiction,
child welfare, and social workers working in fundraising and philanthropy. As part of her research, Karen has collaborated
with Dr. K. on the study of rural recovery, as well as completed a literature review about
addiction and child welfare, which will be presented at the end of this module as a resource. In 2016 and 2017, Dr. K. and Karen presented
a module on Addiction and Child Welfare, as an overview for child welfare workers. This current module will focus on interventions
and how child welfare workers can work more effectively with addiction and recovery. As a review, let’s look at what the module
in 2016/2017 covered about addiction and child welfare. The addiction and child welfare module concentrated
on the following areas: What is addiction?, The conversation about addiction and child
welfare, brain science of addiction, prevalence of substance use in child welfare involved
families, the impact on families and the child welfare system of addiction, and finally,
What is recovery? For a review of this information, the module
is still available on the Center for Advanced Studies in Child Welfare’s YouTube channel. So, as a review, in 2016/2017, Karen and Dr.
K talked about the problem, addiction and the child welfare system. For this module, they will be talking about
the solution, what works for addiction and child welfare. Therefore, this module for 2017/2018 will
move the conversation further and looks at what works for child welfare and addiction. Let’s take a look at what will be covered
in the following module by Dr. Krentzman and Karen. Dr. K. will begin the module with a discussion
of the different interventions that work well for addiction. The discussion will begin with screening tools
for addiction and then assessment. Following that, Dr. K. will discuss the concept
of harm reduction as an effective intervention, as well as acute stabilization and withdrawal
management. Finally, Dr. K. will cover effective psychosocial
counseling strategies that work well for addiction. The three psychosocial counseling strategies
that Dr. K. will discuss that are effective for addiction are Cognitive Behavioral Therapy,
or CBT, Motivational Interviewing, and 12-Step Facilitation. It should be noted 12-Step Facilitation is
not the same as 12-Step programs such as Alcoholics Anonymous. Finally, Karen will discuss, more specifically,
what works well for addiction in child welfare. She will cover addiction interventions in
child welfare, as well as addiction policies in child welfare that affect your work with
children and families. Karen also completed a comprehensive literature
review on addiction and child welfare. She will present that lit review and the review
is available to everyone as a resource for further information. We will now move into the main content of
the module, beginning with Dr. Krentzman. Amy: We begin with the first section, “What works
for addiction?” I want to start this discussion by telling
you what happened to me at a dinner party I went to recently. I went to a dinner party and there weren’t
that many people there, maybe half a dozen people, but, for whatever reason, because
of the flow of traffic through the living room and the dining room, three different
people asked me what I do for a living. I told them I do research on addiction and
addiction recovery and three separate people at three different points asked me, “what
works for addiction?” And I had to repeat myself three different
times. If they had only asked me once, when everyone
was present, I would have only had to do it once, but I had to repeat myself three times
at this particular dinner party. So what that led to, was it led to a certain
kind of an insight that occurred to me. Which is that, really what works for addiction,
is that the individual with the addiction should completely stop the addictive behavior
and stay stopped for all the days of the rest of their lives. That’s what works for addiction. But, of course, that’s incredibly unrealistic
because doing that, I mean that does describe the nature of addiction recovery, but getting
there is so incredibly difficult that the situation is clearly not that simple to the
point of being comical. So my students when I told them this story
they said to me, how did you answer, when they asked you that three different times,
three different people at that dinner party, how did you answer? And I answered by describing the evidence-based
psychosocial interventions that are used to initiate and support abstinence. That’s the way that I chose to answer the
question. I talked about cognitive behavioral therapy, motivational interviewing, and 12-step
facilitation. Kind of looking at those three approaches
and rooting out their main philosophies and that’s basically how I answered it. Now, don’t worry too much about what I just
rattled off because the main point of this part of the module is for me to explain in
more depth how cognitive behavioral therapy, motivational interviewing, and 12-step facilitation
work for addiction. So that’s coming in this module. But my students pointed out that the real
answer really is “it depends.” So someone asks you “what works for addiction?”
and a better answer almost than the one I gave is “it depends.” What works for addiction depends on the individual. It depends on the individual’s readiness
to change. You might be familiar with stages of change
theory: pre-contemplation, contemplation, preparation, action, and maintenance. What works for addiction depends on the stage
at which an individual is along a continuum of problematic substance use. The person might have some substance use that’s
risky but is not, does not yet meet criteria for an addictive behavior and the way that
you respond to that will vary depending on where they are on that continuum. There’s also a continuum of severity once
the person has crossed that threshold and they meet criteria for an addiction. So depending on their level of severity in
the sphere of addictive behavior, that will dictate what works best for them and that
might mean, for example, outpatient vs inpatient vs residential. So to summarize this slide, what works for
addiction depends on a lot of different criteria and factors related to the individual. What works for addiction also depends on what
is the addictive substance or what is the addictive behavior? For example, for opioid use disorders, there’s
a choice whether to recommend abstinence, 100% abstinence from the addictive substance,
or to recommend a replacement therapy such as methadone or buprenorphine. With alcohol use disorder, the recommendation
would be more abstinence based because there aren’t any replacement therapies yet for
alcohol use disorder. But the person could be prescribed naltrexone,
which could help decrease their craving. So another thing that works for addiction depends
on what is the addictive substance or behavior. Another thing that works for addiction are
policies that influence the larger social environment. So, for example, in Portugal, illegal drugs
have decriminalized, reducing rates of problematic use, harm, and the burden on the criminal
justice system. So, policy change like that would work for
addiction. Also, there’s a lot of research being conducted
that can inform policy changes that can have an impact on addiction for everyone in society. And just two examples of such research. There was a study that showed that exposure
to pro-smoking media led to higher future smoking risk. And another study, just as two examples, that
increases in the price of alcoholic drinks were associated with fewer subsequent alcohol
related deaths in a community and increases in the number of liquor stores in a community
were associated with greater alcohol related deaths in a community. So one other thing that works for addiction
are policies. So in part it depends on what level you’re
looking at, level of the individual or level of all of society. But what we’re going to talk about in this
webinar are these several items: screening, assessment, harm reduction, acute stabilization
and withdrawal management, and then we’re really going to focus in depth on three psychosocial
counseling strategies. These were the ones I mentioned earlier. So we’ll start with screening. You might be familiar with this term that
has emerged from the addiction field in recent years called, pronounced, SBIRT. It stands for screening, brief intervention,
and referral to treatment. The idea behind SBIRT is that in the past
all of the resources devoted to addiction were targeted toward the individuals who became
so severely impaired by addiction that they were, it was recommended for them to enter
treatment. And in this data graphic in this pyramid, it’s
the top four percent of society, those who are most severely addicted, who go into
treatment and all the focus was on them. Now skip down to the blue part of the pyramid,
70 percent of the population are abstainers or low risk drinkers. And for them, there’s no need to worry except
they could be provided with positive reinforcement. But what we were missing as an addiction treatment
field, we were missing the 25 percent of the population who are risky drinkers. These people, research has subsequently shown,
can really benefit from brief interventions and it can help them from becoming alcohol
dependent and entering that four percent. But we weren’t addressing that 25 percent of the
population. So screening to see where people fall in these,
for example in these three categories, is something really helpful that can help with
addiction overall. The World Health Organization recommends that
medical patients should be screened for alcohol problems annually. So, when a person goes for their annual check
up to the doctor, they should receive a one question screening. And that question is, according to research,
“How many times in the past year have you had four or more drinks in one day?” if
you’re a woman, or “five or more drinks in a day?” if you’re a man. If the person says that in the past year,
there was at least one day when they drank four or more drinks in a single day, then they would have
considered getting a positive result to that screen and they’d move on to a screening
that is more involved, such as the Alcohol Use Disorders Test. The Alcohol Use Disorders Test is also called
the AUDIT. It was developed to screen for excessive drinking,
to help identify people who would benefit from reduced or ceasing their drinking, and
it assesses risky or hazardous drinking, alcohol use disorders, and harmful drinking. The AUDIT was developed and evaluated over
two decades. It’s accurate across age, gender, and multiple
cultures worldwide. It was developed and tested in six countries
among 2,000 patients: Norway, Australia, Kenya, Bulgaria, Mexico, and US. To me this is very impressive, that the instrument,
the questionnaire, the audit questionnaire, was normed in several very different cultural
groups to make sure that it was not biased for North Americans. Subsequently, the AUDIT has been translated
into numerous other languages. The AUDIT has been identified as one of the
best screening instruments for the whole range of alcohol problems in primary care and the
total score positively correlates with the severity of the alcohol problem. And the nice thing about the AUDIT is depending
upon what the person scores, there’s a prescription for what the social worker should do. If the person scores between 0 and 7, the
person should get alcohol education. If the person scores between 8 and 15 on the
AUDIT, they should get simple advice focused on reduction of hazardous drinking. If the person scores between 16 and 19 on
the AUDIT, they should get simple advice, brief counseling, and continued monitoring. If they score over 20, then they’re a person
who should get a referral to a specialist for a diagnostic evaluation and probable subsequent
treatment. So, just to summarize the previous section,
one thing that works really well for addiction is adequate and accurate screening and then
appropriate response to a whole range of spectrum of drinking behaviors. Another thing that works for addiction is
accurate and comprehensive assessment. So let’s say someone has scored over a 20
on the AUDIT and they move on to the comprehensive psychosocial assessment. I want to talk about one such assessment that
we call the Rule 25 here in the state of Minnesota and it’s based on the American Society of
Addiction Medicine Dimensions of Assessment. These dimensions are six dimensions, they’re
multidimensional, and their aim is for holistic, biopsychosocial assessment and to be used
for service planning and treatment. So this is when your client scores a 20 or
above on the AUDIT and then they go in for maybe like an hour long conversation with
an expert substance use disorder counselor who will do this comprehensive assessment
across six dimensions of the individual’s life. One, an assessment for acute intoxication,
are they in jeopardy of imminent withdrawal symptoms? Dimension two, their health and medical complications
and concerns beyond addiction. And dimension three, emotional, behavioral,
cognitive conditions and complications such as depression, suicidality, physical violence,
history of abuse, mental health, and historical trauma. Dimension four, the client’s readiness to
change. Dimension five, relapse, continued use, and
continued problem potential. That would be difficulty quitting in the past,
cravings, and history of previous treatment. And finally, dimension six, the person’s
environment, the current life environment and its suitability for sustained recovery. Is the person employed? What are their social connections? Who lives at home? Are they people who use or don’t use substances? What is their housing like and what is the
neighborhood like? So the counselor would sit down with the person
and assess the person for all six of those dimensions and then they would use this really
nice grid where after each, assessing for each dimension, they would rate the person
based on their severity. If you look on the left-hand side of this
grid, you see a severity from zero to four. And they rate the person on each dimension
going across from left to right. And if the person scores a level four with
any of the first three dimensions, then the interview is stopped and the person is referred
immediately for services, either withdrawal services or emergency psychiatric services. That’s if the person is in very, very ill
health and is not well enough to complete the screening. The assessment, rather. If the person scores on dimension four, five,
or six with a severity rating of two, three, or four, then they’re deemed to be eligible
for treatment. So this whole package is a really good way
for the assessment person to do an in-depth and comprehensive assessment and then to get
guidance for what would be the best thing for that person. Harm reduction is also something that works
for addiction. Strategies for harm reduction include outreach
and education, needle exchange programs, and naloxone, which you might be familiar with,
also called Narcan, this is a harm reduction approach when a person has effectively overdosed,
if they can get a dose of this drug, it will reverse the effects of the overdose and the
person will recover and be able to survive and not, you know, be faced with life threatening
overdose. Another thing that works for addiction is
acute stabilization and withdrawal management. This is also called detox. It’s medically stabilized withdrawal from
a substance when medical professionals are observing and also managing the person as
they withdraw. But it’s important to know that by itself,
it’s not effective as treatment. The person should have medically stabilized
withdrawal, if they need it, and then go on for treatment. All by itself, it’s not effective, but it
is an important step in what works for addiction. Now I’m going to move on to really the heart
of this part of the module, which is to go in a little bit of depth on three psychosocial
counseling strategies that work for addiction based on a great deal of research. I’m going to be talking about cognitive
behavioral therapy, motivational interviewing, and 12-step facilitation as three different
psychosocial strategies. We’ll start with cognitive behavioral therapy. You may have been already introduced to CBT
and this might be a review. But, Aaron Beck and Albert Ellis were trained
as psychoanalysts. In their training and in their work as psychoanalysts,
they realized that thinking played a role in a person’s behavior and emotions and
if you could change the person’s thinking, you could change their behavior and their
emotions. So, therefore, they developed a theory focusing
on thoughts and that theory became CBT – cognitive behavioral theory. It’s important to remember that cognitive
behavioral therapy is a giant umbrella under which there are several other kinds of therapies
that are also CBT therapies. You might have heard of coping skills therapy
or dialectical behavior therapy, these are parts of, these are forms of CBT. It’s important when you consider what is
CBT to remember that thinking is really essential. A person’s thinking and thought processes
are essential and you can think of thinking as a mediator. A mediator of the effect of an event in the
world on a person’s behavior and emotion. So the little guy moving his hand that represents
action or behavior and the heart represents emotion. And the effect of the event on how the person
will act and respond to it or feel and respond to the event is mediated by what they think
about the event. They might have irrational thoughts related
to the event which would lead to behaviors that are not helpful or emotions that are
not helpful. They might have automatic thoughts in relationship
to the event or negative self talk in relationship to the event. These things would skew the subsequent behaviors
and emotions. You might have heard the expression life is
10 percent what happens and 90 percent what you make of it. This idea is essential to CBT. That the 90 percent of what you make of what happens
can influence your behavior and your emotions. And this illustration suggests that it’s
not the event, but the perception of the event that is problematic for people. And problematic thinking is often not reality
based and not helpful. These last two slides I credit to Kerry Beldin,
PhD at the University of Nebraska. So if you’re treating someone with CBT,
you might have them keep a log of what happens, that is, the event, and how they respond to
it. For example, suppose a store clerk doesn’t
smile at the person when they pay for their purchase. That’s the event. And if the person has some negative self talk
or some dysfunctional thoughts, they could make that mean that nobody likes them, that
they look awful, that they’re a bad person or that they’ll never improve, nothing will
ever get better for them. But if they can use CBT, they can think
of alternative pathways like maybe the clerk was having a bad day or maybe she never smiles
at customers. And this can help them feel better and respond
to events in a different way. So the question is what does CBT look like
when it’s applied to addiction treatment? One way that CBT is very relevant for addictions
is this idea of high risk situations. These will vary from person to person, but
if a person is in a treatment setting for addiction, they are going to, if CBT is used
and this is what’s recommended, they’re going to be helped to identify for them what
constitutes a high risk situation in the environment that going to be a very strong trigger for
them to use the substance or to relapse. And, in summary, that could be people, places,
or things. So the counselor helps the person to identify
who are the people, what are the places or settings, and what are the things that you
associate so strongly with using substance that these things could effectively
trigger a relapse. And the person identifies these and comes up with
strategies for dealing with them in the environment. Another aspect of CBT in addiction is the
idea of role play, practice, and homework. So the counselor will rehearse strategies
for coping with high risk situations with the client. Maybe the counselor will play the role of
the client first in one of these high risk settings and then the roles switch and in
the therapy session, the client will then practice what will happen when they see these people who are high risk for them, or when they’re in the environment
that are high risk. How do you avoid these environments all together? Another aspect of CBT in addictions is this
idea of cravings. So craving for addiction can lead to relapse,
craving for the substance. And there’s a CBT strategy called “urge
surfing,” which invites the person to observe the craving and not react to it. And to ride the wave of the craving until
it passes. Another thing that happens in CBT and addictions
is the idea of challenging negative thinking. For example, quote “I need cocaine to get
through the day,” “I need to be intoxicated or I won’t be attractive,” “smoking
makes me look cool,” these are negative cognitions that can be challenged using CBT. Another thing that works for CBT and addictions
is this idea of positive incentives. This is also called the community reinforcement
approach. And the idea is that the client might win
a prize for “clean urines,” maybe they spin a wheel and they get a small prize if
they have presented a urine test that has come out clean for drugs. And this has shown to really help support
people in early recovery and help them build and put together days of abstinence. Another thing that happens with CBT and addictions
is attention to life skills that will help the person’s life be better and more functional
and so they don’t use drugs and alcohol as coping mechanisms. So there might be class sessions where skills
are learned about starting conversations with strangers, nonverbal communication, assertiveness,
what to do if someone criticizes you, and anger management. So in summary, CBT for addiction includes
things like attention and focus on high risk situations and how to cope with them, role
playing, practice, and homework, urge surfing for cravings for using the substance, challenging
dysfunctional behaviors and thoughts related to substance use, positive incentives, and
learning additional life skills. We’ll move on now from CBT to motivational
interviewing. I recommend this text, the third edition of
Motivational Interviewing: Helping People Change. It’s really well written, it’s clear,
and it really describes motivational interviewing extremely well. Motivational interviewing started in Norway
in 1982. Bill Miller was in Norway and his students
asked him, “what are you doing with clients, can you describe it?” He was teaching and working in a substance
abuse treatment program. And he answered, he was using a Rogerian approach,
but with a twist. And the twist was motivational interviewing. To understand motivational interviewing, one
thing that’s important to understand is the word ambivalence. Someone shows ambivalence when they have conflicting
feelings about something. Ambivalence is very common in addiction. That’s when someone really, really wants
to stop smoking cigarettes and they really, really don’t want to stop smoking cigarettes. Originally a psychological term, ambivalence
was borrowed from the German word which meant in two ways and vigor and strength. It means you feel two opposite ways at the
same time. You use motivational interviewing when two
things are present. One, when there’s ambivalence about change. When the person really wants to change, but
they also really don’t want to change. And second, when there’s a targeted behavior
change that has been identified. For example, reduction of use of social media,
drinking less coffee, cutting down on sweets, or exercising more. When you have a targeted behavior change that
the person feels ambivalent about, you can roll out the motivational interviewing. And when you think about it, addiction recovery
is all about ambivalence and it’s all about behavior change. So, therefore the fit with motivational interviewing. A definition of motivational interviewing is that it is a collaborate conversation
style for strengthening a person’s own motivation and commitment to change. One core of motivational interviewing is the
idea of motivational interviewing spirit, which is rooted in the work of Carl Rogers,
who is the psychologist who said that unconditional positive regard, empathy, and genuineness
is all that’s needed to be helpful to another human being. In motivational interviewing, they’ve changed
some of the language slightly. They talk about acceptance, collaboration,
evocation, and compassion. Motivational interviewing’s core skills
are called OARS. “O” for open-ended questions, “A”
for affirmations, “R” for reflective listening, and “S” for summaries. And I would add that a core skill in motivational
interviewing is asking permission of the client. There are four processes of motivational interviewing
that basically follow the basic problem solving model, engagement, focusing, evoking, and
planning. The novel step here is evoking. That you evoke from the client their own innate
reasons for change. The main heart of motivational interviewing
is the idea that you’re navigating the landscape of client dialogue. And it’s client talk along the lines of
change talk and sustain talk and you as the counselor are navigating the client’s change
talk and sustain talk and that is motivational interviewing. Change talk and sustain talk can be identified
along, sort of, this two by two table presented here on the slide. Good things related to making the change,
good things related to staying the same, bad things related to making the change, and bad
things related to staying the same. An individual could probably come up with
a list under all four of these categories if they are considering a behavior change. Especially one they feel ambivalent about. Let’s look at an example. Let’s say that the target behavior is exercise. Good things related to making the change would
be I like how it feels to exercise, my clothes will fit better, I will feel more confident. Good things related to staying the same are,
well, I could rest and relax, I could do what I want when I want to, and I could use the
valuable time I’d spend at the gym doing other important things. Bad things related to making the change include
the gym is expensive, exercise hurts, and the whole thing is a hassle. Bad things related to staying the same include
lack of exercise could turn into a bad health issue and I get winded when I climb the stairs
and I don’t like that. So a client who’s considering change, in
this case exercising, in talking to you, the counselor, they could have things that they
say that fall into all four of these boxes. And the thing with motivational interviewing
is to remember that when people talk about good things related to making the change or
bad things related to staying the same, that that kind of language, is called change talk. And when the client talks about good things
related to staying the same or bad things related to making the change, that kind of
language is called sustain talk. Sustain talk is any client speech that favors
the status quo, no change, specific to a target behavior. And one of your tasks as a clinician doing
motivational interviewing is being able to discern change talk from sustain talk and then
doing different things in the face of it. Traversing the landscape of sustain talk and
change talk are the heart of the craft of motivational interviewing. Basically, as the counselor, you want to evoke
change talk, maximize it, and de-emphasize sustain talk. How does motivational interviewing work? People who are ambivalent have within them
the reasons, arguments, and motivations for change. It’s already in there within them. It is better to draw the innate motivation
for change out of the person than impose it on them from the outside. Motivational interviewing uses a conversational
strategy which draws out a person’s innate motivation for change. It does this by interacting with a type of
naturally occurring speech called “change talk.” What is change talk? We talked about that actually earlier in the
slide. It’s the reasons they would articulate that
favor change. And as the counselor you would intentionally
evoke or bring forward change talk. How would you do that? First, you would learn to recognize it when
it naturally occurs. And then you’d encourage it. You’d become very interested in it. You’d ask the person to elaborate on it. You’d ask the person to provide examples
of it. And you’d put your OARS into it. You’d ask open-ended questions to elicit
more change talk, you’d affirm the change talk, you’d reflect it, and you’d summarize
it. Basically you’d pour Miracle-Gro on the
change talk that the client offers. You’d pour the warm sunlight of your attention
on to the change talk. But what do you do when you hear sustain talk? You honor it, but you don’t reflect it by
itself. And you don’t elicit it. So you don’t say to someone, “what’s
good about lying on the couch all day and eating as much of whatever you want?” You wouldn’t say that. That would not be motivational interviewing. You wouldn’t say to the client, “what
do you love most about smoking?” You could use a skill called a double sided
reflection where you reflect the sustain talk first and then reflect change talk. You could use an amplified reflection where you reflect the sustain talk, but in an exaggerated way. And you emphasize that the person is ultimately
responsible for whatever choice they make about their lives. So you’d emphasize their control and personal
choice. So, in the previous slides, I listed, actually
rather quickly, a set of skills that the counselor uses to elicit change talk and de-emphasize
sustain talk. And those are learned more slowly as someone
is trained in motivational interviewing. So what makes motivational interviewing especially
good for addiction? Here I’m going to quote from my notes from
a lecture I heard recently from an expert in addiction named John Renner. He said, “people with addictions have had
their self esteem destroyed. They feel defeated. Don’t give up on them.” He says, “when meeting a client with addiction
assume the person is depressed, assume their self-esteem is zero, and be very gentle with
them.” And I feel that these comments from my notes
from hearing this lecture by John Renner really suggest that motivational interviewing would
be a way that would be a very gentle and affirming way to work with people who feel very sensitive
and very damaged by their experience with substances. Summary of motivational interviewing for addiction. Use motivational interviewing when two things
are present, ambivalence about change and an identified change behavior. Motivational interviewing spirit is rooted
in the work of Carl Rogers. It has to do with eliciting the client’s
innate motivation for change. And you navigate the landscape of speech related
to change talk and sustain talk offered by the client. This is the third psychosocial intervention
I will describe in this module. It is 12-step facilitation. The first thing I want to emphasize is that
there’s a difference between 12-step facilitation as a professional counseling technique and
Alcoholics Anonymous, or 12-step programs that exist in the community. Maybe the first thing to do is to introduce
what is Alcoholics Anonymous, and then, what is 12-step facilitation in contrast to it. Alcoholics Anonymous is a voluntary, worldwide
organization of individuals who meet to attain and maintain sobriety. The only requirement is the desire to stop
drinking. It is free of charge. It emphasizes total abstinence rather than
reducing drinking. The meetings are run, not by professionals,
but by recovering individuals. It’s extremely widespread and accessible
with thousands and thousands of groups and over two million members in 170 countries
worldwide. 86.7 percent of countries on Earth have AA meetings. There’s been in research a very robust relationship
found between the effect of AA on drinking. And that’s any way that AA is measured – AA
attendance, AA involvement. And any way that drinking is measured – percent
days abstinent, drinks per drinking day. And any time lapse, whether it’s a month
or six months or eight years, Alcoholics Anonymous has an affect on reducing drinking. So 12-step programs such as Alcoholics Anonymous
exist in the community and have nothing to do with professional treatment. But 12-step facilitation is something different. 12-step facilitation is a professional treatment
approach. Twelve-step facilitation happens in the context
of substance use disorder treatment settings. Again, it’s not part of Alcoholics Anonymous. It varies widely, but what does not vary about
it is that 12-step facilitation builds a bridge from professional treatment settings to 12-step
meetings in the community, so that the client can easily walk over that bridge. It actively prescribes and recommends AA meetings
while the person is undergoing professional treatment. It may also help the person actually do some
of their step work. So 12-step programs have twelve suggested
behavioral and attitudinal steps and with your professional counselor in treatment,
the client may work step one, step two, step three, step four, or step five. 12-step facilitation may look a little bit
differently. For example, an approach called MAAEZ, which
stands for Making Alcoholics Anonymous Easier. A set of researchers developed a manual guided
intervention, which is a 12-step facilitation approach, with four core sessions that focus
on spirituality, principles not personalities, sponsorship, and living sober. Which are accompanied by weekly homework assignments. Some of the homework assignments include talking
to someone else at a meeting, getting someone’s phone number, socializing with someone from
a meeting, or seeking advice of someone who has more sober time, including getting
a temporary sponsor. There are some treatment programs that primarily
use a 12-step facilitation approach. For example, Dawn Farm, which is a treatment
program in Ypsilanti, Michigan, as its motto, there in the smaller type, they identify and
remove barriers that prevent addicts and alcoholics from joining the recovery community. So, basically they’re all about helping
people to bridge with that recovery community, recovery support group, that will help support
them for all the rest of their lives, really. Here in Minnesota there’s a similar treatment
program called The Retreat. Which similarly uses a model where they don’t
employ professional counselors, but they employ individuals in the community who are already
successfully sober to come in and work with the people who are seeking recovery in the
treatment program. And even for addictions outside of alcohol
and drugs, this idea of 12-step facilitation has been used. For example, again in Minnesota, there’s
something called COR Retreat, which is for food recovery. And this is one where people are invited to
consider successful strategies that will work after they complete the five day retreat where
they affiliate with Overeaters Anonymous in the community. So a summary of 12-step facilitation. 12-step facilitation strategies are not the
same as 12-step programs like AA. Treatment programs that use 12-step facilitation
approaches are not part of AA or other 12-step programs. 12-step facilitation approaches help people
transition to 12-step programs in the community. And sometimes whole treatment programs use
12-step facilitation as their primary approach. Karen : We’ll now switch in to covering some of
what works for addiction specifically as interventions in child welfare. Just to ground us a little bit, I want to go back
to some slides from an earlier module that we presented that talks about the prevalence
of substance abuse in child welfare. We know from the research that the statistics
vary widely and there’s no standardized national data collection on this topic at this
point. But what we have found is that an estimated one-third
to two-thirds of all maltreatment cases are affected to some degree. So one-third to two-thirds of those cases that you are
working with in child welfare are being affected by substance abuse. Others estimate that substance abuse is a
factor in about 15 percent of investigations of child welfare and about 25 percent of substantiated cases. So you could find that, if you’re an ongoing
child welfare worker, that anywhere from one-third to two-thirds or around 25 percent of those that you’re
serving are affected by substance abuse. Of those children who are in out of home care,
we’ve found that 61 percent of infants and about 41 percent of older children are from families affected
by substance abuse. Now continuing the discussion of what works
for addiction, and now talking about addiction and child welfare, I want to start with child
welfare casework practices. So these are things that work for addiction
that are specifically how you work with families that are struggling with addiction. So the first thing you can do is understand
substance abuse, the signs, effects on parenting, and what to expect during treatment and recovery,
which is what these modules have been about. Another has to do with family engagement. And this is helping to motivate families to
enter and remain in substance abuse services and address their individual needs including
previous trauma history and family needs such as childcare and transportation. Things that could affect their ability to
do well in substance abuse treatment and recovery. Others include routine screening and assessment. So using brief, validated, culturally appropriate
tools to identify problems and help connect people to appropriate substance abuse services. Another is individualized treatment and case
plans. So really looking at the individual needs
of each person that you’re serving. Another thing that works in casework practices
is supporting parents. So helping parents to build coping and parenting
skills and learn to pay attention to their own triggers for substance abusing behaviors. In 2009, a research study by Lewandowski and
Hill, found that child welfare support impacted women’s treatment completion. So your work in supporting parents can really
impact their ability to complete treatment and get those support in recovery that they
need. Another is supporting children. So we know that the effects on children are
significant and engaging children with behavioral and mental health professionals to meet their
individual needs and potential risk for substance abuse themselves are really important pieces
of casework practice. Another is concurrent permanency planning. So to achieve timely permanency, planning
concurrently for both reunification as well as an alternative plan in case reunification
is not possible. We’ll talk a bit later about a more extensive
literature review that will describe a large section of research devoted to many of these
practices if you’d like read more about the outcomes of each of these specific interventions. Another part of what works for addiction in
child welfare is prevention and treatment approaches. So, there’s many approaches that have been
shown to be successful in child welfare. One is promoting protective factors, the social
connections, supports, and parenting knowledge that helps people do well in their addiction
recovery. Another is identifying early, those screening
efforts to get services to families quickly. Timely access to treatment and whenever possible,
getting priority access for mothers in the child welfare system. Gender sensitive treatment, specifically to
meet the needs of mothers and potential co-occurring issues that people of different genders face. And family centered treatment, where mothers
can have their children with them in treatment and where services are provided to all of
the family members, not just the mother, but the children as well. Another approach that works is recovery coaches
and mentoring and that’s to support treatment and recovery and parenting. And having folks who people can look to as
guides and examples of folks who’ve done well in treatment and recovery. And another is shared family care and that
is, placing families with a host family for support and mentoring. Many large scale efforts have also been made
across the country and around the world towards systems change and collaboration between child
welfare and substance abuse treatment and recovery systems. One of these is family treatment drug courts. This is a cross system approach that has shown
great success in treatment access, completion, and family reunification. Another is cross-training. So having both substance abuse and child welfare
professionals understand the needs and services in each of those systems. Another is co-location, or having substance
abuse professionals on site in child welfare agencies. There’s also information sharing, which
many of us do in our work every day, but making sure that we have signed agreements with families
to ensure there’s communications between their systems to best meet the needs of children
and families in a timely way and some areas are even using linked data systems to track
progress and shared goals of the families that they’re working with across these systems. Another is joint planning and case management
to help families not get overwhelmed with their multiple goals and our multiple systems
that are disconnected. And another is wraparound services or meeting
the needs of multiple needs, meeting the multiple needs of parents and children including their
mental health, substance abuse, parenting, housing, employment, education, childcare,
and domestic violence. And having all of these services in place
and connected and talking to each other whenever possible. So another area of what works for addiction
in child welfare are policies related to addiction and child welfare. So, 47 states and the District of Columbia
address aspects of parental substance abuse in their child protection laws. The Adoption and Safe Families Act of 1997
limited the time until a permanency decision is made. And this really got our child welfare system
moving rather quickly in terms of finding permanent homes for children. A study of pre/post child welfare outcomes,
so pre the Adoption and Safe Families Act and post, found that there’s less time in
foster care, quicker permanent placement, and children are more likely to be adopted
than remain in long term foster care. However, rates of reunification pre and post
this act stayed the same. Termination of parental rights appeals, however,
after the Adoption and Safe Families Act were more likely to be to be upheld after, after
the Adoptions and Safe Families Act for parents with alcohol or other drug problems. And, generally, this act has made it so that
timely treatment of substance abuse is even more critical for families as the time that
they have to get treatment and recover is much more limited and they have to prove more
quickly that they are ready to have their children. There are also many policies affecting newborns. So the Child Abuse Prevention and Treatment
Act, or CAPTA, of 2010 requires that states have policies and procedures for child protective
services notification and services for substance abuse, substance exposed newborns. So fourteen states and the District of Columbia
include this work for notification and services in their definition of child abuse or neglect. And seven states, including Minnesota, require
a needs assessment for the newborn and their family and referral to services. Two states, Minnesota and Illinois, require
mandated reporters to report when they suspect a pregnant woman is a substance abuser. Now children exposed to illegal drug activity
is another area of policy that affects our work in child welfare. We know that negative effects of substance
abuse on children is a growing concern and thus there have been many new laws. Considered neglect in Minnesota is prenatal
exposure to substances and subsequent Fetal Alcohol Spectrum Disorder. So children who’ve been prenatally exposed
or then have FASD are considered in our neglect statutes. Using a controlled substance that impairs
a caregiver’s ability to adequately care for the child’s basic needs and safety is
also considered neglect in Minnesota. Considered abuse, however, is giving a child
alcohol or other non-prescribed substances to control or punish, or resulting in otherwise
unnecessary medical procedures. Considered abuse or neglect in other states,
so not Minnesota, are things like manufacturing a controlled substance in the presence of
a child or on premises occupied by a child; exposing a child to, or allowing a child to
be present where, chemicals or equipment for the manufacture of controlled substances are
used or stored; and exposing a child to the criminal sale or distribution of drugs. Now several of these things are, however,
included in criminal statutes. So in Minnesota, while they’re not in the
child welfare statutes, several of these things are criminal. So Minnesota and 33 other states and the US
Virgin Islands include exposure of children to illegal drug activity in their criminal
statutes. In Minnesota and ten other states, it’s
considered child endangerment to expose children to the manufacture, possession, or distribution
of illegal drugs. And in nine states, there are even stricter
penalties related to methamphetamines. So now we’ll go into what works for addiction,
a comprehensive literature review. So a comprehensive literature review through
July 2017 looked at Social Work Abstracts and PsycINFO, so two of the search engines that
we use to look for what does the literature say. So what research has been done, what have
people published? And we looked at alcohol, drug, and addict,
and other extensions of these words, so alcohol with a star would include alcoholics or alcoholism,
addict with a star would be addiction, addicts, that sort of thing. And substance in the title of those articles. And then we looked at the keyword or subject
heading search for child welfare and combined the two. And we found 264 publications, not including
book reviews or dissertations. So looking at those by topic, we’ve taken
this large chunk of literature and brought it to our child welfare workforce. We know you’re busy, we know that you don’t
have time to look at all of this depth of the literature. We sorted it by topic to help you, sort of, dig
deeper into the things that are most interesting to you. So by topic here are some of the areas that
we’ve covered: screening, interventions, both related to child welfare and substance
abuse, understanding the link between substance abuse and child welfare, and there are many
resources related to this, sort of helping you understand why do people who abuse substances
end up in the child welfare system, or how the child welfare system treats people who
are substance users, that sort of thing. Then there are many areas of special populations
covered in the literature. So things related to fathers, indigenous peoples
and American Indians, people of color, meth users, and infants. Parenting and motherhood and specific interventions
and ways that our child welfare system thinks about parenting and motherhood related to
substance use. Trauma and the effects of trauma, both for
the parents and for children. Training and options for training staff, graduate
students, and foster parents related to substance abuse. And then outcomes. And outcomes is a huge section of the literature
and it’s broken down a little bit more deeply for you, but to help you understand what are
the outcomes for children, for parents, for the long term effects on children, the outcomes
in the child welfare system. There are many sections in the outcomes area
for you to look at. And another is collaborative practice between
child welfare and substance abuse. And many researchers have looked at this relationship
between child welfare and substance abuse systems. And then youth and adolescent substance abuse
in the child welfare system. Many researchers have looked at the number
and effects on adolescents who are also substance abusers themselves. Amy: So here in this next slide, I’ll just summarize
what I feel are the core takeaway messages from this idea of what works for addiction. And the first takeaway is that what helps
with addiction really depends, it really depends on factors related to the individual, the
substance, and the social environment. But there are three primary psychosocial treatments
that I focused on in the webinar. One is that cognitive behavioral strategies
are used to change maladaptive thoughts and behaviors related to substance use and relapse. Motivational interviewing is used to enhance
innate motivation of the individual. 12-step facilitation is used to help individuals
connect with 12-step programs in the community that can support them throughout the rest
of their lives as they remain in recovery, optimally. Karen: And Karen Goodenough’s takeaways are policy
and practice interventions have been plentiful over the past 20 years in an attempt to positively
impact the children and families affected by substance abuse and the child welfare system. And ensuring that all child welfare workers
have knowledge of substance abuse and recovery and the effects on both parents and children
is key to effectively helping families through the process of addiction and recovery. Thank you very much for your kind attention
to this series of modules and we thank you for all of the hard work you do on behalf
of children and families. And the bibliography will be available to
you. As well as the summary of the research that
I described, that will also be available to you. So what follows on the following slides are
the bibliography for this series of webinars. Thank you again.

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