Effective Treatment: Doing the
Right Thing in the Right Way
Terrence D Walton, MSW, ICADC
Morality
Modal
Alcoholics
Anonymous
Treatment
Disease
Concept
Temperance
Model
Manuals
Science
EBT
Outcomes
Best
Practice
OUT
IN
Process
Effective
Treatment
Practice
Process
Full Continuum of Care
Adequate Duration
Sufficient Intensity
Stage of Recoverybased Design
 Policies & Procedures
 Team Interactions
 Evaluation




Practice
 Culturally-appropriate
evidenced based
treatment practices
 Practitioners trained and
coached in manual-guided
delivery
 Services dominated by
those that have been
rigorously tested
Sources of Information
Sources of Information
Four Big Alcohol Studies
•
•
•
•
•
Randomized Controlled
Trials
Project MATCH
COMBINE Study
UK Alcohol Treatment Trials
Mesa Grande Project (361
clinical trials analyzed)
A Big Resource
National Registry of Evidencedbased Programs and Practices:
www.nrepp.samhsa.gov.
Other Evidence Based Practices
1. Behavioral Couples Therapy (BCT)
–
Not well tested in an offender population
2. Brief Interventions (5 or fewer sessions)
–
Not appropriate for an addicted DUI offender
Not Evidence Based
1.
2.
3.
4.
5.
6.
7.
Generic Counseling
AOD Education
Confrontational
Interventions
Psychodynamic Therapy
Solution-focused
Therapy
Mindfulness-based
Stress Reduction
Acupuncture
Goals of Cognitive Behavioral
Therapy (CBT) Approaches
1. Analyzes thoughts, feelings,
and actions (behavior)
2. Thoughts drive emotions
3. Emotions drive behavior
4. Identify thinking patterns and
stop thinking “errors” from
leading to emotional
reactions that produce
problem behaviors.
Key Question
Be Skeptical
•
•
Nearly every
evidenced based
intervention is
manual-based.
However not every
intervention that is
manual-based is
evidenced based.
Motivational Approaches
1. To increase and maintain the
person’s motivation to change his or
her life
2. Motivate those who don’t want to
change
3. Help increase the motivation of the
people who aren’t sure
4. Help the motivated maintain their
readiness to change
1. Motivational Interviewing:
Preparing People for
Change
–
William Miller & Stephen
Rollnick (2002)
2. Addiction and Change:
How Addictions Develop
and Addicted People
Recover
–
Carlo C. DiClemente (2003)
Assessing Readiness to Change
Pre-Contemplation
Contemplation
Preparation
Action
Maintenance
Medication-Assisted
Treatment
1. To provide relief from withdrawal
symptoms
2. To prevent drugs from working
(antagonist)
3. To reduce craving
4. To provide replacement (agonist)
5. To provide aversive reactions
Medication-Assisted
Treatment
•
•
•
Naltrexone – Interrupts
actions of alcohol and
opiates; reduces
cravings (Vivitrol)
Acamprosate –
reduction of alcohol
cravings
Disulfiram/Antabuse –
produces adverse
reaction with alcohol
use
Medication-Assisted
Treatment
•
Methadone – Opiate
addiction – reduces
craving, Driving
mediateswhile using
withdrawal symptoms,
a legally
prescribed
medication,
helps
restore
normal
functioning
(agonist)
including
methadone
taken
according
to
doctor’s
orders,
• Buprenorphine
(Subuxone)
similar a
toDUI charge
can still –trigger
methadone, may be
prescribed in
byall
an 50
MDstates
with
special training (partial
agonist)
Combining Medications and Behavioral
Interventions for Alcoholism
• Finding: Naltrexone in combination
with medication management
sessions delivered by health
professionals was at least as
effective as psychosocial
interventions
• Side note: Pathology of multiple DUI
offenders will likely require
psychosocial interventions in
addition to medications
Those Missed
 92.9% with bipolar disorder
 68.4% with depression
 100.0% with OCD
Does Program include:
1. Blended Screening and Assessment
Approaches?
2. Education on Co-Occurring Disorders?
3. Medication Monitoring and Management
Sessions?
4. Heavy Utilization of Positive Reinforcement
and Flexible Application of Graduated
Sanctions?
5. Mental Health Specialists?
6. Agreements with Community Mental Health
Services Agencies?
Twelve Step
Groups
What About Alcoholics Anonymous?
What about
coerced AA
participation?
What About Alcoholics Anonymous?
“Attendance”
versus
“Involvement”
(active
participation)
What About Alcoholics Anonymous?
Seek
Alternatives
to Mandating
AA
Using Support Groups in
Therapy
“The 12 Step Facilitation
Therapy Manual”
Offer choice (types,
spiritual & secular)
Be selective regarding
approved groups
Try to match demographics,
lifestyles, and level of
substance involvement
www.smartrecovery.org
Next Steps
1. Identify and adopt evidence-based practices
2. Incorporate medication-assisted treatment
3. Utilize alcoholics anonymous and provide secular
alternatives for those with religious-based
objections
4. Treat the hard, core alcohol-dependent impaired
driver
5. Modify (lessen) treatment requirements if treating
non-addicted participants in DWI Court.
6. Stay abreast of latest DUI Court treatment-related
research findings