Title : volume3cover.PDF Description : Keywords : Author : tonya ----------------------------------------------- Family Support Network for Adolescent Cannabis Users CYT Cannabis Youth Treatment Series Volume 3 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment www.samhsa.gov ----------------------------------------------- Family Support Network for Adolescent Cannabis Users Nancy L. Hamilton, M.P.A., CAP, CCJAP Laura Bunch Brantley, Ph.D. Frank M. Tims, Ph.D. Nancy Angelovich, M.S., LMHC Barbara McDougall, M.A., CAP U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857 CYT Cannabis Youth Treatment Series Volume 3 ----------------------------------------------- Acknowledgments This is volume three of a series of treatment manuals produced under the Cannabis Youth Treatment (CYT) Project Cooperative Agreement. The document was written by the following staff members of Operation Parental Awareness and Responsibility (PAR), Inc.: Nancy L. Hamilton, M.P.A., CAP, CCJAP; Laura Bunch Brantley, Ph.D.; Frank M. Tims, Ph.D.; Nancy Angelovich, M.S., LMHC; and Barbara McDougall, M.A., CAP. Field reviews and editorial assistance in producing the manual were provided by staff from Johnson, Bassin & Shaw, Inc. (Lynne McArthur, Holly Brooks, Barbara Fink, Nancy Hegle, Wendy Caron, and Tonya Young). The authors also acknowledge input and assistance received from the Executive Steering Committee (Thomas Babor, Michael Dennis, Guy Diamond, Jean Donaldson, Susan H. Godley, and Frank Tims) and many others including Betty Buchan, Jackie Griffin-Doherty, Jim Herrell, Jeannie Lewis, Terri Mathis, Janet Titus, Joan Unsicker, Charles Webb, William White, and Art Woodard. Disclaimer This report was developed with support from the Center for Substance Abuse Treatment (CSAT) to Operation PAR, Inc., through Grant No. TI11317. The report was produced by Johnson, Bassin & Shaw, Inc., under Contract No. 270–99–7072 with the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS). Karl White, Ed.D., served as the CSAT Knowledge Application Program (KAP) Project Officer; Jean Donaldson, M.A., as CSAT CYT Project Officer. The content of this publication does not necessarily reflect the views or policies of CSAT, SAMHSA, or DHHS. Public Domain Notice All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA or CSAT. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization from the Office of Communications, SAMHSA, DHHS. Electronic Access and Copies of Publication This publication can be accessed electronically through the following Internet World Wide Web connection: www.samhsa.gov. For additional free copies of this document, please call SAMHSA’s National Clearinghouse for Alcohol and Drug Information at 1–800–729–6686 or 1–800–487–4889 (TDD). Recommended Citation Hamilton NL, Brantley LB, Tims FM, Angelovich N, McDougall B. Family Support Network for Adolescent Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 3. DHHS Pub. No. (SMA) 01–3488. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 2001. Originating Office Office of Evaluation, Scientific Analysis and Synthesis, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD 20857. DHHS Publication No. (SMA) 01–3488 Printed 2001 Cover images © 2000 Digital Stock. ----------------------------------------------- Table of Contents I. Introduction to and Overview of the Family Support Network Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Treatment Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Service Components: Overview and Objectives . . . . . . . . . . . . . . . .3 Overview of Cannabis Youth Treatment Research . . . . . . . . . . . . . . .8 Staff Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Clinical Supervision Requirements . . . . . . . . . . . . . . . . . . . . . . . .10 II. Parent Education Sessions and Discussion Procedures . . . . . . . . . .13 Parent Education Session 1: Introduction to the Family Support Network, Adolescent Development, and Functional Families . . .14 Parent Education Session 2: Drugs and Adolescents . . . . . . . . . . .26 Parent Education Session 3: Relapse Signs and Recovery . . . . . . . .39 Parent Education Session 4: Boundaries, Limits, Authority, and Discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Parent Education Session 5: Communication, Conflict Resolution, and Fighting Fair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62 Parent Education Session 6: The Family Context . . . . . . . . . . . . . .67 III. Home Visit Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 Review of Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82 Home Visit 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 Home Visit 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92 Home Visit 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96 Home Visit 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99 IV. Case Management Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . .101 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101 Overview of Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102 Components of Case Management . . . . . . . . . . . . . . . . . . . . . . . .104 Qualifications and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108 Missed Appointment Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110 Case Management Service Log . . . . . . . . . . . . . . . . . . . . . . . . . .111 Referral Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112 Case Management Screening Log . . . . . . . . . . . . . . . . . . . . . . . .113 V. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115 VI. Appendixes 1. Quality Assurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117 2. Clinical Management of a Multisite Field Trial of Five Outpatient Treatments for Adolescent Substance Abuse . . . .129 iii ----------------------------------------------- I. Introduction to and Overview of the Family Support Network Intervention Overview The development of drug abuse is multidetermined. Henggler (1997) points out that “with rare exception, treatment programs address only a limited portion of factors contributing to adolescent drug abuse” (p. 265). Teaching life skills, refusal skills, and coping skills may contribute to recovery; however, family support has been cited repeatedly as an important determinant of both intreatment and posttreatment outcomes (Barrett, Simpson & Lehman, 1988; Brown et al., 1994). Thus, substance-abusing adolescents experiencing inadequate family structure and functioning will be at a serious disadvantage with regard to recovery. Their recovery, however, is likely to be enhanced if family functioning can be improved. Deficits in family functioning may be related to dimensions of authority, roles, boundaries, communication, and routines. Parental authority may be eroded and roles confused; boundaries may be blurred or violated; communication may be dysfunctional and conflict laden; and family structure or routine may be lacking. Inadequate parenting skills or poor understanding of family dynamics may also contribute to a chaotic or otherwise dysfunctional family context. The family support network (FSN) intervention seeks to extend the focus of treatment beyond the world of the adolescent by engaging the family, a major system in his or her life. Family therapy has been cited as a potentially valuable tool in the treatment of substance abuse, and a substantial amount of literature about it exists (Stanton & Shadish, 1997; Liddle & Dakof, 1995; Steinglass, 1994; Kaufman, 1994). Studies have shown that retention of adolescents in treatment increases dramatically when a family interven- tion is provided (Henggler et al., 1991; Liddle & Dakof, 1995). Although the value of family therapy is recognized, providing this intervention is beyond the resources of many programs, especially in view of the well- documented erosion of services in community-based treatment programs (Etheridge et al., 1995). Because of declining resources and the restriction of services by managed care, Operation Parental Awareness and Responsibility (PAR), Inc., devel oped the FSN approach. The FSN model uses only a limited number of the more costly inhome therapy sessions coupled with several less costly group sessions. Designed to increase parental support of a child’s recovery, the FSN approach seeks to engage families in the treatment process, improve parents’ competence in supporting their child’s recovery, and shift therapy from time-limited formal treatment to a support group for parents. The FSN process is a family intervention designed to be used in conjunction with any standard adolescent treatment approach. The FSN approach was followed in two locations—Operation PAR, Inc., and the University of Connecticut Health Center. It was effective at treating teens for cannabis 1 ----------------------------------------------- use at both locations. Other approaches may be just as effective. The scope of the study was not to compare family approaches but rather to test treatments for adolescent marijuana users. The FSN approach consists of several components, each designed to achieve specific objectives: • Case management • Six parent education (PE) groups • Three or four inhome family therapy sessions. Case management includes referrals to community support groups and other support services for both parents and adolescents. The procedures presented in this manual combine motivational enhancement and cognitive behavioral therapies as one possible treatment overlay for the adolescent. The motivational enhancement therapy (MET) and cognitive behavioral therapy (CBT) approaches used in the Cannabis Youth Treatment (CYT) study are presented in Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions, Cannabis Youth Treatment (CYT) Series, Volume 1, by Sampl and Kadden (2001) and The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions of Cognitive Behavioral Therapy for Adolescent Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 2, by Webb, Scudder, Kaminer, and Kadden (in press). Thus, while an adolescent is receiving a special MET/CBT program for adolescents, the family is involved in the FSN intervention. This manual guides counselors and thera pists, so they can consistently conduct effective case management, PE groups, and home visits. Treatment Goals The FSN approach is a multicomponent intervention aimed at improving the family context in which adolescent recovery takes place. It is based on an assumption that the adolescent’s outcomes will be improved if the family is involved in the treatment process. Although no short-term treatment can resolve all problems and heal families completely, the goal of FSN is to improve an adolescent’s outcomes by: • Including the family in the recovery process • Enhancing family functioning through communication and relationship building • Improving parental effectiveness in dealing with substance abuse and the behaviors accompanying drug use • Assessing the family’s commitment to the recovery process and suggesting changes in the way the family approaches problems. FSN recognizes that the program’s opportunity for influence is of limited duration and that responsibility for aiding recovery must be transferred 2 ----------------------------------------------- from the program to the family in a short time. The FSN approach provides a strategy for effecting that transfer in a systematic and responsible way. Service Components: Overview and Objectives The FSN model is designed to treat youth who meet American Society of Addiction Medicine (ASAM) Level I (outpatient) or Level II (intensive outpatient) criteria and who report marijuana as their primary drug of choice. Although youth abusers may occasionally use alcohol and other drugs, such as lysergic acid diethylamide (LSD), polysubstance abusers with long histories of drug use, especially use of cocaine and heroin, who have ASAM diagnoses at higher levels or those with serious psychiatric or criminal issues may be inappropriate for this level of treatment. Urban, suburban, and rural youth and families were part of the original research study as were families with parents who had current or past histories of use or abuse of alcohol and drugs. Youth and families of color also participated in the study. No socioeconomic group prevailed in the original sample. Most families were from working-class or lower socioeco- nomic groups. The study involved families of all sizes and situations—single, divorced, or separated parents; blended families; and intact families. Because of limited resources, the study required participants to speak and understand English, although it need not be their first language. Future FSN manuals can be developed for use with youth and families who are not English speakers. The FSN service components are case management, parent education, and home visits. Case Management Case management engages families in the treatment process by providing a means to solve problems and motivate family members. Methods of engagement include telephone outreach to remind families of scheduled meetings, reduction of barriers to treatment participation (e.g., overcoming difficulties with transportation, scheduling, and child care), and prompt intervention to reengage any adolescent or parent who has missed a treatment session. Case managers work with families by assisting them in resolving issues that prevent participation. For example, case managers may provide information about local bus routes or referrals to local resources that provide assistance to families in need. Some providers may have resources that allow them to send vans to the family’s home to pick up clients or provide bus tokens. Case managers work with the family to recognize child care issues that may prevent participation. Solutions for child care problems include care by a relative, referral to local child care agencies, or onsite child care services. Other ways to overcome child care and transportation barriers include getting the families to act as a cooperative—one family helps another with transportation or child care. A good case manager works to assist the families in becoming empowered to solve their problems in creative ways. 3 ----------------------------------------------- Major responsibilities of the FSN case manager are to: • Contact and engage families in the treatment process • Assist families in overcoming barriers to active participation • Identify appropriate service and treatment needs • Provide links for the families to needed services, including community support groups • Monitor the adolescent’s and family’s progress • Provide motivational enhancement • Monitor attendance and act quickly to prevent clients from disengaging or dropping out • Make appropriate referrals (including treatment reentry) • Engage the family and the adolescent in a community support group. An important, but difficult, activity of the FSN case manager is to engage the family and the adolescent in a community support group. The purpose of this is to transfer the responsibility of recovery from the FSN program to the family in the limited time available. The case manager should identify primary referrals for community support groups (e.g., Alcoholics Anonymous [AA], Narcotics Anonymous [NA], Al-Anon/Alateen, Children and Adults with Attention-Deficit/Hyperactivity Disorder [CHADD]) within the first 6 weeks of the program. Contacts for these types of organizations can be found in local phone directories and by calling local hotlines. The case manager should prepare a list that includes addresses, phone numbers, and meeting times as a handout for families. Parents should be contacted regularly and encouraged to use the support group as a source of support after their child completes treatment. Case managers should receive special training in techniques of outreach to and motivation of adolescents and families. Training also should be provided to increase their cultural competence for engaging families of color and those with special cultural, religious, or ethnic needs. Parent Education The PE component is designed to: • Build competence among parents that leads to healthy families • Offer methods for coping with the pressures of parenting 4 ----------------------------------------------- • Promote ways to establish or restore appropriate authority, roles, rules, boundaries, communication, and routines. The six PE sessions, each designed to last 90 minutes, should be scheduled for the same time and location as the adolescent’s CBT sessions. Each PE session has clear objectives and is taught in a didactic manner, and time is allowed for questions and discussion. At the didactic sessions information is presented, and discussion provides clarification and facilitates assimilation of the information into personal frames of reference. To build a “collaborative learning” experience, the counselor should guide and focus the discussion and invite maximum participation by the parents. To prepare for the sessions, the counselor must also consider the following: Size. The size of PE groups may vary but should not exceed 10 parents per session. A larger group may be too impersonal, and groups of fewer than five parents may deprive the parents of an adequate opportunity for discussing and exchanging views with others. To facilitate discussion, the chairs in the room should be arranged in a circle. Objectives. The PE sessions are designed to enhance parental motivation and increase knowledge of parenting skills, family life, and drug/health issues. The ultimate goal of the PE component is to improve parenting and family functioning for a more global improvement of the family environment. Meeting this goal will in turn allow families to better support the recovery of the substance-abusing adolescent. Manual and handouts. The format of the manual for these six sessions is content, major lecture points, and discussion topics. Handouts are provided to participants, and parents are encouraged to review the handouts at home. Preparation. Before each session, the counselor should review the lesson plan and have all necessary materials on hand. Each individual should have a copy of the handouts. Audiovisual equipment (VCR and videotapes, slides and projector, overhead transparencies and projector), magic markers, and any other required materials should be available. The counselor should have a visible watch or clock to time segments of the lecture and discussion. Sequencing of sessions. Missed sessions and home visit schedules may mean that not all parents will have attended sessions in the proper sequence. However, the sessions were designed to be conducted in sequence and should be held in order when possible. Therefore, the therapist should coordinate scheduling of PE sessions and home visits and ensure that the sequence of parent education sessions 1 and 2 is maintained. The FSN model was pilot tested without rolling admissions. Therefore, if the treatment calendar can be set, the following schedule or order is preferred: 1. PE session 1 2. PE session 2 3. Home visit 1 5 ----------------------------------------------- 4. PE session 3 5. Home visit 2 6. No session 7. PE session 4 8. Home visit 3 9. PE session 5 10. No session 11. PE session 6 12. Home visit 4. If rolling admissions are necessary, a proposed method for scheduling is shown in exhibit I–1. Based on the following schedule, clients would enter treatment only in session 1 or 7. This schedule assumes a 12-week cycle with three to six incoming participants per week. Two treatment calendars are scheduled simultaneously during the 12-week cycle. For staffing, this schedule allows for combining groups when possible (e.g., PE sessions 3 to 6 would include group 1 and group 2 members) and alternate weeks for home visit/no session schedule for group 1 and group 2. Exhibit I–1: Proposed FSN Schedules Overview of sessions. Exhibit I–2 provides a brief description of the six PE sessions. Specific procedures for each session are included in Part II of this manual. Treatment Week: Group 1 (Group 2) 1 (7)—start Group 1 2 (8) 3 (9) 4 (10) 5 (11) 6 (12)—end Group 2 7 (1)—start Group 2 8 (2) 9 (3) 10 (4) 11 (5) 12 (6)—end Group 1 Group 1 Schedule PE Session 1 PE Session 2 PE Session 3 Home Visit 1 No Session PE Session 4 Home Visit 2 Home Visit 3 PE Session 5 No Session Home Visit 4 PE Session 6 Group 2 Schedule (Home Visit 2) (Home Visit 3) (PE Session 3) (No Session) (Home Visit 4) (PE Session 4) PE Session 1 PE Session 2 PE Session 5 Home Visit 1 No Session PE Session 6 6 ----------------------------------------------- Exhibit I–2: Parent Education Sessions Session Description PE Session 1 Introduction to the Family Support Network, Adolescent Development, and Functional Families—This session provides an understanding of the family support network, adolescent development, and the role of the family in this development. The session focuses on how healthy family functioning can make the family a source of strength for its members. Emphasis is on understanding the individuation process of developing adolescents and how families can help make it a positive experience. PE Session 2 Drugs and Adolescents—This session helps parents understand drug abuse and dependence and how adolescents become involved with drugs. It addresses the nature and objectives of treatment and stresses the importance of parents in a child’s recovery. PE Session 3 Relapse Signs and Recovery—The issues presented in this session are the recovery process in the context of a healthy family, ways parents can help their child avoid relapse and when to appropriately intervene, how to develop healthy partnerships within the family, and committing to a drug-free life. PE Session 4 Boundaries, Limits, Authority, and Discipline—The concept of boundaries is introduced in this session as a major issue in child and adolescent development. Clarification of major issues in family functioning is provided, and appropriate approaches to discipline and parental authority are suggested. This session helps parents understand the sources of authority in the family and how to maintain that authority in a healthy way. PE Session 5 Communication, Conflict Resolution, and Fighting Fair— This session enhances parents’ understanding of how and why conflict inevitably occurs, imparts concepts and methods of healthy communication, and teaches techniques for engaging family members in open and fair resolution of conflict. Conflict is presented as a learning process, and ways to prevent conflict from becoming dangerous are discussed. PE Session 6 The Family Context—This session helps adolescents and parents understand the importance of family in the recovery process and the nature of the family as an interdependent system. Parents are taught how family functioning has both a direct and an indirect influence on the child’s behavior. 7 ----------------------------------------------- Home Visits The objectives of the home visits are to: • Assess the family environment • Individualize the treatment process • Develop a family commitment to recovery • Encourage a three-way therapeutic alliance (family, adolescent, and program), and translate the lessons parents and adolescents are learning into specific changes in family functioning. The four home visits are to be scheduled by agreement between the family therapist and the family. Ideally, to spread out the treatment experience as much as possible, the home visits should be coordinated so they do not take place during the same week as parent education and discussion sessions. However, depending upon the therapist’s caseload, this coordination may not be possible. Flexibility in scheduling home visits is necessary when time is limited. If this is the case, home visits should be scheduled continuously throughout treatment to ensure that each family receives the full treatment. Each home visit should last approximately 90 minutes. During the first home visit, the family therapist assesses the family environment, motivates the family to actively participate, and obtains a commitment for future family meetings. In the second home visit, the therapist helps the family discuss rules, roles, and routines. The therapist builds therapeutic alliances with the adolescent and the family and acts as a mediator to clarify issues. At the third home visit, the therapist assesses progress and provides feedback on major family and adolescent issues. Some families may require only three visits. Based on the family’s need or request, the final home visit is used to reinforce therapeutic alliances and obtain a family commitment to work together on recovery. The parents also are encouraged to become or remain involved in a community support group. Home visit guidance is detailed in Part III of this manual. Overview of Cannabis Youth Treatment Research This overview presents the development and research phase of this model. Appendix 2 includes an overview of the full research design for the CYT Project Cooperative Agreement. Referrals to the CYT program were provided by juvenile assessment center staff, juvenile addiction receiving facility personnel, community mental health and substance abuse treatment providers, juvenile justice workers, school system staff, and family members. A preliminary screening determined the appropriateness of the level of care provided by this model for an 8 ----------------------------------------------- adolescent. During the initial research project, participants were randomly assigned to one of three treatment groups. Information provided in this manual is pertinent only to those clients assigned to the FSN treatment group. Participants were included in the FSN treatment model if they (1) met the inclusion criteria, (2) did not meet the exclusion criteria, and (3) agreed to participate in the research study being conducted. Once acceptance criteria were met, full baseline assessments and intake procedures were initiated. Those participating in FSN treatment received services for both the adolescent participant and the family. Adolescents in the CYT study received state-of-the-art treatment that included both MET and CBT. Adolescents in the study received 2 individual MET sessions and 10 group CBT sessions (subsequently denoted by MET/CBT5 and CBT7). Separate manuals were developed for each treatment model (Kaminer et al., 1998; Sampl & Kadden, 2001; Webb et al., in press). This manual presents the FSN therapy. In addition to the MET/CBT5 and CBT7 treatment for the adolescent, the family received three or four home therapy sessions, six parent education sessions, and case management services. As mentioned earlier, the FSN and MET/CBT interventions were designed for adolescents meeting American Society of Addiction Medicine Level I (outpatient) or Level II (intensive outpatient) criteria and using marijuana as their primary drug of choice. Exhibit I–3 shows the overview of the FSN process. Staff Requirements Staff requirements for FSN include case managers, parent education specialists or counselors, and home visit therapists. Case managers. A bachelor of arts (B.A.) degree or equivalent and formal or informal training in addiction and substance abuse treatment are required (certification as a certified addiction professional [CAP] is helpful). Specialized training in case management, cultural competence and sensitivity, and sales/motivational techniques should be provided. Personal qualities of empathy, assertiveness, and the ability to persuade others effectively are also valuable. Parent education specialists or counselors. B.A. degree or equivalent certification (e.g., CAP) or higher certification in psychology, sociology, or human development, with specialization in family relations and skill in facilitating discussion groups, is required. Training to increase cultural competence and sensitivity is essential. 9 ----------------------------------------------- Exhibit I–3: The Family Support Network Home visit therapists. A master’s-level therapist with CAP or a licensed mental health counselor (LMHC) qualifies; however, a licensed clinical social worker (LCSW) is preferred. Training in family dynamics, with at least 1 year of experience in family counseling and intervention, is required. Training to increase cultural competence and sensitivity is essential. Clinical Supervision Requirements Clinical supervision, held on a weekly basis, allows the interdisciplinary team to better meet the needs of the individuals, families, and therapists involved in FSN. The clinical supervision staffing allows time to clinically review each case and discuss the progress of the application of the model. This review allows both clinical supervision and supervision of adherence to the FSN model. The original research design called for weekly onsite meet- ings and cross-site conference calls to ensure adherence to the design. Staff Meetings Staff meetings should be held weekly and should last approximately 1 hour. During a meeting, each family’s case should be reviewed, including treatment goals, progress, further interventions that may be necessary, problems encountered, recommendations, and any other issues. The case manager should report on every family. The report should include such issues as referrals made, difficulty with compliance, and any barriers that might prevent a family from successful completion of treatment. Family Support Network Family Parent(s) Home Visits (4) Adolescent MET/CBT Completion Case Management Community Support Parent Education Sessions (6) Exit 10 ----------------------------------------------- Standardization of the FSN model should be reviewed. Discussion should include: • Difficulties in complying with the process and procedures • Problems with recruitment, issues involving retention and census, recommendations for improvement, and development of an action plan • Personal or professional difficulties in treating the adolescents and their families. A clinical supervision log should be kept. Attendance, comments on each agenda item, recommendations, and action plans should be recorded in the log. All clinical staff (e.g., therapist, therapist coordinator, parent education therapist, adolescent counselors, and case manager) should participate in all staff meetings. Adherence and Quality Assurance Procedures have been developed to monitor adherence to the protocol and provide a quality assurance check. After each session, the therapist should use the rating sheets provided in appendix 1 to rate adherence to the protocol and the overall effectiveness of the session. These forms are completed for each parent education session and home visit. The forms can be used to assess the progress of the intervention and to improve the protocol. These rating sheets were developed not to evaluate the therapist but rather to evaluate the protocol. A low rating does not indicate lack of ability on the therapist’s part. Therapists are encouraged to write comments in the spaces provided and discuss particular successes or difficulties with implementation of FSN with their clinical supervisor and in staff meetings. 11 ----------------------------------------------- II. Parent Education Sessions and Discussion Procedures The six parent education sessions, each designed to last 90 minutes, provide information that complements the family support network (FSN) home visits as well as the education that the adolescent receives in motivational enhancement therapy (MET) and cognitive behavioral therapy (CBT). These sessions are interactive and allow parents to discuss and review the following topics: 1. The family support network, adolescent development, and functional families 2. Drugs and adolescents 3. Relapse signs and recovery 4. Boundaries, limits, authority, and discipline 5. Communication, conflict resolution, and fighting fair 6. The family context. A brief overview of FSN is presented at the first session, and the importance of the family’s commitment in the adolescent’s recovery is stressed in all sessions. The philosophical foundation of the parent classes is strength based: by increasing the parents’ understanding of issues that influence families, the family will grow stronger. One of the overriding goals of FSN is to help the family members develop lifelong support of one another. In addition, the experience of FSN helps families consider attending support groups. Some tips on conducting the sessions follow: • Always start the first session with introductions. (Parent Education Session 1) • Distribute name tags or provide new ones. (These can be collected at the end of each session and used in subsequent sessions.) (All Parent Education Sessions) • If name tags are not used, be sure you know the parents’ names (use a card for reference). (All Parent Education Sessions) • Invest 15 minutes of the initial session in having participants talk about why they are attending the group or what they hope to get out of the group. (Parent Education Session 1) • In the beginning of the first five sessions, take 5 minutes to develop rapport and settle in. (Parent Education Sessions 1, 2, 3, 4, and 5) 13 ----------------------------------------------- • For each session, provide a handout with some essential points for parents to take with them for reference. Handouts are grouped together at the end of each session narrative. (All Parent Education Sessions) Parent Education Session 1: Introduction to the Family Support Network, Adolescent Development, and Functional Families General Overview—The purpose of this session is to provide an understanding of adolescent development and the role of the family in this development. The session focuses on how healthy family functioning can make the family a source of strength for its members. One emphasis is understanding the individuation process of normal adolescent development and how families can help make it a positive experience. Rationale—The more information parents receive on normal adolescent development and functional families, the better they can identify family issues and resolve them. Materials— • Overhead equipment • Handouts: u Productive Group Rules for FSN Parent Education Participants u Parent Education Sessions u Home Visits u Summary of Adolescent Classes u Typical Teen Beliefs and Rationalizations and Ways Parents Can Cope u Healthy Versus Troubled Families u Effective Parenting Questionnaire u Life Stressors and Social Resources Inventory* • Functional Family Qualities poster (purchased or made by the therapist) • Treatment calendar (a 12-week calender with parent education and adolescent education sessions preprinted. Parents can add home visits as they are scheduled.) Preparation for the Session • Review the handouts. • Purchase or create posters to decorate the family meeting space that promote positive healthy family behaviors. If you are creating them, make them big and colorful. Include the following information: Healthy families communicate and listen to, affirm, and support one another; teach respect for others; develop a *Available from Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, FL 33549, 813–968–3003, www.parinc.com. 14 ----------------------------------------------- sense of trust; have a sense of play and humor; share responsibility; teach a sense of right and wrong; have family traditions; have a balance of interaction; have a shared religious core; respect one another’s privacy; value service to others; value shared meals and conversation; share leisure time; and admit to and seek help with problems. Goal: To communicate an overview of the FSN model and the importance of family participation 1. Present the FSN model, and discuss the importance of family participation. Give a brief description of the course of treatment, including the number of meetings, length of time in treatment, and so forth. Explain that families participate in six parent education (PE) groups. Distribute the Productive Group Rules for FSN Parent Education Participants and Parent Education Sessions handouts. Discuss the three or four inhome family therapy sessions. Distribute the Home Visits handout and the Summary of Adolescent Classes handout, and briefly describe what the children will be learning and the plan for family involvement. Talk about how the families are assuming responsibility by their participation and how the parents can take advantage of community support groups. Hand out preprinted 12-week treatment calenders. These can easily be created on most computers. Explain that the parent education sessions and the adolescent education sessions are on the treatment calender. Explain that the parents can write the dates for the home visits on the calendar once they schedule them with the therapist or case manager. Encourage parents to post this calendar in a place where the family can readily see it. Explain that this will help the family schedule its time and avoid conflicts that may interfere with successful completion of treatment. Goals of FSN: • Include the family in the recovery process. Family participation will improve an adolescent’s success in recovery. • Improve family functioning, primarily by improving communication and relationships. • Improve parents’ effectiveness in dealing with substance abuse and accompanying behaviors. • Assess the parents’ and family’s commitment to the recovery process. Commitment to recovery requires changes in how the parents and family approach the problem. 15 ----------------------------------------------- Goals of home visits: • Reestablish relationships. • Develop a new contract for rules. • Improve communication skills. • Develop a Family Relapse Prevention Plan (which is discussed in detail in PE Session 3). 2. Present information on typical teen rationalizations. Define rationalization. Explain to parents that rationalizations are excuses people use to minimize their responsibility for their behaviors. Say: “When we experience consequences that are unpleasant, we seek excuses for why we should be exempt from such consequences. Adolescents often fluctuate between being autonomous one day and dependent the next. When teens seek to do what they want and experience resistance, they blame adults, particularly parents, for failing to understand their needs.” Discussion. Distribute the Typical Teen Beliefs and Rationalizations and Ways Parents Can Cope handout. Ask parents to interject any recent situations at home that are examples of these beliefs (this should be a light-hearted discussion). It is important for the therapist to provide examples of what is harmful and what is harmless behavior. 3. Present material on functional family qualities. Discussion. Provide the Healthy Versus Troubled Families handout. Discuss the differences between healthy and troubled families regarding rules, communication, alliances, feelings, self-worth, openness to change, defense mechanisms, stress, growth, and control. Discuss the handout with the parents, and allow them to ask questions. Show parents the posters of qualities of healthy families that the therapist purchased or made prior to the session (see Preparation for the Session). Have the parents discuss the information on the posters. Ask them to add other qualities. Discuss ways that families can enjoy more quality time together (e.g., take meals together, play together). Have the parents make a list of characteristics they like about their child or identify at least one good quality in the child. Discuss with the parents feelings they experience while making the list. 4. Discuss effective parenting behaviors. Distribute the Effective Parenting Questionnaire handout, and ask the parents to rate themselves. 16 ----------------------------------------------- Discussion. Have parents share where they see themselves today and how they would like to rate themselves following treatment. 5. Present material on ineffective parenting behaviors that will help parents identify habits that may potentially prove unproductive to healthy communication. Discussion. Information on styles that can inhibit effective parenting include the following: • Sometimes parents cannot be effective because they are preoccupied with their own problems. These problems can include chemical dependence or psychological impairment; however, problems can also include less complicated situations such as stress from work or a relationship. It is important for parents to recognize their own problems and realize that their parenting style will be affected by personal factors they deal with daily. • Sometimes parents attempt to protect their child by overreacting to inappropriate behaviors. Parents have a tendency to discount the opinion of a child, and this can hinder individuation of the child. In extreme cases, parents may be so angry with a child that they lose respect for the child and feel they need to be strict dis ciplinarians. The child is often pronounced guilty without a trial. • Some parents may be interested in keeping things well under control. When this happens in extreme cases, the child can become insecure and timid or rebellious. On occasion, parents may be insecure with their parenting style. As a result, they may lose the ability to set and enforce limits or rules for their children. These parents have difficulty seeing how the problem behaviors affect their family. Sometimes their children will have a difficult time in school because they are not used to taking direction and cannot accept authority. When parents have personal needs that are not being met, they sometimes look to their children to fulfill those needs. These parents tend not to punish but to love their children to extremes. Children of such parents find it difficult to achieve independence from their parents. People with strong beliefs are often rigid and strongly opinionated. They have a tendency to approach all people and all problems in the same manner. Sometimes, as parents, they are perceived as uncompassionate and unemo tional parents. They have a difficult time seeing beyond their beliefs to the individual needs of others. These parents tend to lecture and advise often. Summarize by pointing out that “we all face many stressors—every day. It is important to be aware of how we relate to others, especially when we are feeling pressure and stress. Parents are people, too. With strong 17 ----------------------------------------------- self-understanding, parents can become aware of factors that keep us from being effective parents.” 6. Process, reflect on, and review information introduced on normal adolescent development and functional families. Discussion. Open up the discussion by asking for reactions to the material covered. Ask parents whether they recognize any of the parenting styles discussed, and talk about ways to avoid bad habits. Talk about knowing when a teen’s behavior is normal (even though it’s still difficult to deal with) and when behavior is extreme and should be considered a warning sign. Ask everyone to look at the Effective Parenting Questionnaire handout. Ask the group to brainstorm different examples of activities that can be used to demonstrate each of the 10 categories. 7. Discuss life stressors with parents. Introduce the Life Stressors and Social Resources Inventory (LISRES). Give parents a copy of both the adult and juvenile versions. (LISRES—Adult Version ©1994 and LISRES—Youth Version ©1984, revised in 1994, are available from Psychological Assessment Resources. Visit www.parinc.com.). It is not necessary to use this particular inventory. Similar assessment tools exist that will provide parents and adolescents with insights into the stres sors that affect their lives (Butcher et al., 1992; Achenback & Edelbrock, 1987; Kaminer et al., 1997; Meyers et al., 1995; Miller 1985; Winters & Henly, 1989; Dennis, 1999). Explain that this inventory will be scored and placed on a graph. Explain that understanding the types and degrees of stressors helps people develop strategies to decrease stressors and lessen the effects of them. Ask parents and adolescents to fill out the questionnaires. Ask that they return these forms before the first home visit to ensure that the instrument can be scored. Tell them that during the first or second home visit, the therapist will review the results and discuss strategies with the parents and youth for reducing stress. 18 ----------------------------------------------- PRODUCTIVE GROUP RULES FOR FSN PARENT EDUCATION PARTICIPANTS • I have made a commitment to attend this group on a regular basis, and it is my responsibility to inform the case manager or family therapist if I am unable to attend a session. • By participating, I will be support ing other group members while gaining support from them. • It is my responsibility to keep what others say and do in the group meetings confidential, that is, “What’s said in the group stays in the group!” • I should be myself and accept responsibility for my behavior. • I will listen with an open mind and not be judgmental. • I will respect others’ ideas and suggestions discussed in the group. ----------------------------------------------- PARENT EDUCATION SESSIONS PE Session 1: Introduction to Adolescent Development, and Functional Families. This session provides an understanding of adolescent development and the role of the family in this development. The session focuses on how healthy family functioning can provide a source of strength for the family members. Ways families can help a child make the journey from adolescence to adulthood a positive experience are presented. PE Session 2: Drugs and Adolescents. This session helps parents understand the nature of drug abuse and addiction and how adolescents become involved with drugs. The nature and objectives of treatment are addressed, and the importance of the parents’ motivation to be part of their child’s recovery is stressed. PE Session 3: Relapse Signs and Recovery. The issues presented in this session are how to understand the recovery process in the context of a healthy family, ways parents can be effective in helping their child avoid relapse (a return to substance abuse), and how they can know when to appropriately step in to assist their child. Developing a healthy partnership within the family and making a commitment to a drug-free life are discussed. PE Session 4: Boundaries, Limits, Authority, and Discipline. The concept of boundaries is introduced as a major issue in adolescent development and family life. Clarification of major issues in family functioning is provided, and appropriate approaches to discipline and parental authority are suggested. The session materials help parents understand the sources of family authority and healthy ways to maintain it. PE Session 5: Communication, Conflict Resolution, and Fighting Fair. This session enhances parents’ understanding of how and why conflict inevitably happens in families, provides concepts and methods of healthy communication for families, and presents techniques for engaging family members in open and fair resolution of conflict. Conflict is presented as a learning process, and ways to prevent conflict from becoming dangerous to the individual and family are discussed. PE Session 6: The Family Context. This session helps adolescents and parents understand the importance of family in the recovery process and the nature of the family as an interdependent system. Parents learn how family functioning has both a direct and an indirect influence on a child’s behavior. ----------------------------------------------- HOME VISITS Goals of FSN: • Include the family in the recovery process. • Improve family functioning, primarily by improving communication and relationships. • Improve your effectiveness as parents in dealing with substance abuse and accompanying behaviors. • Assess your commitment to the recovery process because commitment to recovery requires changes in how you and your family approach the problem. Goals of Home Visits: • Reestablish relationships. • Develop a new contract for rules. • Improve communication skills. • Develop a Family Relapse Prevention Plan. First Home Visit: • Discuss the adolescent’s progress in treatment and urinalysis (UA) results. • Develop family treatment goals and a treatment contract. • Discuss the adolescent’s treatment issues. • Conduct the “family sculpting” exercise. Second Home Visit: • Discuss the adolescent’s progress in treatment and UA results. • Discuss family rules, fair fighting, and conflict resolution. • Develop the family mission statement. Third Home Visit: • Discuss the adolescent’s progress in treatment and UA results. • Practice problem solving and improving communication. • Develop the Family Relapse Prevention Plan. Fourth Home Visit: (conducted when indicated by treatment progress or requested by family) • Discuss the adolescent’s and family’s progress in treatment and the adolescent’s UA results. • Address any family-specific treatment issues, and seek closure. ----------------------------------------------- SUMMARY OF ADOLESCENT CLASSES Modality Main Topics To Be Covered Session 1 Individual Motivation building, CYT Volume 1 (Sampl & Kadden, 2001) Session 2 Individual Goal setting, introduction to functional analysis, and preparation for group, CYT Volume 1 (Sampl & Kadden, 2001) Session 3 Group Marijuana refusal skills, CYT Volume 1 (Sampl & Kadden, 2001) Session 4 Group Enhancing the social support network and increasing pleasant activities, CYT Volume 1 (Sampl & Kadden, 2001) Session 5 Group Planning for emergencies and coping with relapse, CYT Volume 1 (Sampl & Kadden, 2001) Session 6 Group Problem solving, CYT Volume 2 (Webb et al., in press) Session 7 Group Anger awareness, CYT Volume 2 (Webb et al., in press) Session 8 Group Anger management, CYT Volume 2 (Webb et al., in press) Session 9 Group Effective communication, CYT Volume 2 (Webb et al., in press) Session 10 Group Coping with cravings and urges to use marijuana, CYT Volume 2 (Webb et al., in press) Session 11 Group Depression management, CYT Volume 2 (Webb et al., in press) Session 12 Group Managing thoughts about marijuana, CYT Volume 2 (Webb et al., in press) ----------------------------------------------- TYPICAL TEEN BELIEFS AND RATIONALIZATIONS AND WAYS PARENTS CAN COPE “Everything is great.” Teens can be on top of the world one minute and depressed and disagreeable the next. Remember that rapid and frequent changes in feelings are normal for teens. “Private—stay out!” This refers not just to teens’ physical space (e.g., their bedroom) but also to their thoughts and feelings. They may be so confused by their feelings that they don’t know how to express them. Let your teen know that you are willing to listen. “Adults don’t know anything.” Teens are in the process of deciding what they believe in and what they value. It is normal for them to rebel—at least temporarily—against what they have been told by parents. By ignoring harmless rebellions about food and clothes, you give your teen a safety valve to express himself or herself. This may prevent your teen from getting into self-destructive rebellions such as drug abuse. “They’re my friends.” Teens want the acceptance and approval of people their own age, just as adults do. The more teens feel accepted and supported at home, the less likely they are to be negatively influenced by their peers. “Sometimes I hate myself.” Nearly all teens have periods of low self-esteem. They need your encouragement. Look for honest ways to boost your teen’s self-esteem. “No one else has to be in by 11 p.m.” Teens often test the boundaries their parents set for them. They need to know that you are going to prevent them from harming themselves. Establishing some basic ground rules about chores, dating, driving, and curfew gives teens something to fall back on as they develop their own decisionmaking abilities. Rules should be few, arrived at by negotiation between you and your teen, and clear to everyone involved. Writing them down is a good idea. “But everyone drinks and tries pot!” Sooner or later teens find themselves in a situation in which they must decide whether to use drugs. You can help by modeling infrequent use of alcohol and prescription or over-the-counter drugs. If you overuse alcohol or drugs, it is likely that your teen will as well. Plan with your teen, ahead of time, how he or she can handle a drug-using situation, and specify ways you can help. Note: The above behaviors are exhibited by non–drug-using teens as well as drug-using teens. It is important to learn when your teen is using these beliefs to manipulate you or to cover up inappropriate behavior. Unfortunately, there is no certain way of knowing which is the case. ----------------------------------------------- HEALTHY VERSUS TROUBLED FAMILIES Remember, there is no right or wrong, good or bad, black or white. If emotional pain exists, we have a choice to stay in the pain or make changes to remove the pain. Healthy Families Troubled Families 1. Rules Few rules exist, and they are clear and specific. Rules are respected, consistently enforced, fair, and negotiable. Rules lead to a predictable environment. 2. Commu- Clear responsibility is taken for nication statements, which are open and considerate of others. People take risks to express feelings, ideas, and beliefs. If a problem exists, the family discusses it and seeks outside help if necessary. 3. Alliances Members take time with one another individually and together. There is a strong parental relationship. 4. Feelings Members allow and respect feel ings. There is an honest expression of vulnerable feelings. 5. Self-worth High self-worth exists. Persons are separated from their behavior. Members listen with interest and respect. Members respect others’ views. 6. Change Members are open to change. 7. Defenses Members display defenses that are functional and appropriate to the situation. 8. Stress Members know how to deal with stress. They can see when others are in pain and can nurture and comfort. 9. Growth Members accept and welcome life stages. 10. Control There is less need to control. Parents are in charge but can negotiate. They respect children’s opinions. Some rules are occasionally enforced, but others are not. Often no discussion is allowed on changing or modifying rules. In some cases rules are completely absent, making members feel uncertain or anxious because they do not know what is OK and what is not. Communication is almost nonexistent. There is a lot of talking about the person instead of to the person. Double messages, secrets, and a lot of “should’s” and “ought to’s” are frequent. Family secrets are protected at all costs, and there is fear of seeking outside help. Family members take sides and reject other members. They form hidden relationships (even across genera- tions). The parental relationship is weak or nonexistent, or one parent may dominate. Members do not discuss or allow feelings. There is fear of feelings; people try to hurt one another. Some feelings are OK, whereas others are not. Individuals are treated without respect (this includes adults and children). Children are seen but not heard. A person is condemned, not his or her behavior. Shame is used for punishment. Blaming is common. Cynicism and negative attitudes exist. Members are rigid, fixed, and not open to change. “Nothing can be done; what is the use.” Problems and feelings are denied. Pain is hidden. Strange or unusual behavior is ignored. There is a “no talk” rule—even about serious problems. Members avoid pain in themselves and others. They deny stress and often feel they can’t cope. Parents may compete with children, growth is painful, and change is feared. There is rigid control or shifting patterns of domination, possible upside-down family (children running the family). ----------------------------------------------- EFFECTIVE PARENTING QUESTIONNAIRE Rate yourself in the following categories on a scale of 1 to 10. A rating of 10 is the highest score. 1. Listening without judging ______ 2. Showing love and affection ______ 3. Developing regular family times ______ 4. Asking questions about your teen’s daily and weekly activities ______ 5. Criticizing behavior—not the person ______ 6. Supporting your teen’s problem-solving efforts ______ 7. Being courteous ______ 8. Praising your teen ______ 9. Spending time with your teen ______ 10. Delaying some gratifications ______ ----------------------------------------------- Parent Education Session 2: Drugs and Adolescents General Overview—This session helps parents understand the nature of drug abuse and dependence and how adolescents become involved with them. It presents the nature and objectives of treatment and the importance of parents’ motivation to be part of their child’s recovery. Rationale—The more information parents receive about adolescence, drug use, and its signs and symptoms, the better able they are to intervene and help their children. Materials— • The National Institute on Drug Abuse video Drug Abuse and the Brain* • Markers and whiteboard • Handouts: u Disease Progression Chart u Drug Category Information and Consequences of Use u Drugs of Abuse Detection Times u Developmental Changes for Adolescents • Overheads u Developmental Changes for Adolescents u Questions About Drug Issues Goal: To provide parents a better understanding of adolescent drug abuse 1. Discuss the disease concept of addiction and what it means in the process of recovery. Discussion. Share with parents that their children may be at different stages of drug use. Some may be in the experimental stage. This means that they are just now trying substances and have not established a regular pattern of use. However, some may have established a regular pattern of use, meaning that they regularly use and look forward to using. This pattern could be monthly, weekly, or daily. Explain that if their child uses in a regular pattern, this means that the adolescent is abusing drugs. Most of the time, but not always, establishing a pattern takes time. But for some people, a regular pattern of use can develop quickly. They try a substance, and in a short time they can be using daily. Explain, “Once anyone, youth or adult, has established a pattern of use, we need to examine whether the process of addiction has begun. Not everyone who uses becomes addicted. We will talk about all the factors that influence a youth’s desire to pick up and maintain continued use.” *Information on ordering the video is available from the National Institute on Drug Abuse online publication catalog. Visit www.nida.nih.gov/PubCat/PubsIndex.html. 26 ----------------------------------------------- Distribute the Disease Progression Chart handout. Discuss addiction and how a person’s body responds to drugs and alcohol. Explain that a video will be shown that will explain how drugs affect the brain. Tell parents that there is a real physical basis for addiction, including addiction to marijuana. Addiction ultimately means that the substance, whether it is alcohol or a drug, takes over the person’s life. Remember to take time to answer any questions on this issue. 2. Distribute the Drug Category Information and Consequences of Use and Drugs of Abuse Detection Times handouts. Discussion. Discuss the urinalysis (UA) for drug screening and how it works, explaining what it means and what it does not mean. Briefly cover information on the handouts, stressing the following points: • A negative UA, or one that indicates that marijuana is not present, does not “prove” that the child is not using but only that the child has not used within the window of detection for testing or that the amount is below the level needed for identification. • Testing for tetrahydrocannabinol (THC) is not 100-percent accurate. It is possible to obtain a positive result, or a result that indicates that marijuana is present, even if the child has not recently used because THC is stored in fat cells. If the child changes his or her exercise pattern or diet and loses weight rapidly, a positive result can be obtained without the child recently using the drug. Subsequent UAs should result in lower levels of THC if the child is no longer using. Answer any questions. 3. Initiate a discussion based on essential points. Discussion. Initiate a discussion with the group on the following points: • Parental ambivalence. Research has shown that an important protective factor for adolescent drug use is parental attitudes. Adolescents perceive parental ambivalence the same as parental acceptance of drug use. This is particularly true for baby boomer parents. Not saying anything to your kids is the same as telling them it is OK. • Parental use. Some parents use alcohol and drugs. If adolescents are aware of their use, it will be very difficult to motivate them to quit. Parents who do not currently use drugs but used them when they were younger may feel guilty when talking about not using drugs to their children and will often avoid the discussion. Parents in this situation should not let the child know about past drug use. The parents’ admission usually only gives the teen permission to use drugs. If children know about their parents’ drug use, parents should do the best they can to explain the 27 ----------------------------------------------- negative consequences they experienced. If children ask about parents’ past drug use, parents should avoid the topic by saying, “Let’s stay on track; this conversation is about you, not me.” • Other life problems. Children often turn to substance abuse to meet a need. Therefore, substance abuse is often a symptom of another problem. The problem could have a multitude of factors. It may be beneficial to explore what a child might be experiencing that caused him or her to turn to drugs by asking the following questions: u Were there any recent events that might have been a trigger to use? u What personality characteristics or tendencies does the teen have that may lead him or her to use? u Has the teen experienced any difficulties in relationships, either inside or outside the family? u How does the teen cope with stressful life events? u How does the teen cope with feelings? u How is the teen’s self-esteem? What can parents do to help boost the teen’s self-esteem? • Substitution of one drug for another. It is important to be aware that, as adolescents progress through treatment, they will often switch drugs. Therefore, it is important to watch for signs and symptoms of all the drugs discussed earlier, not just the ones the teen is currently using. Often alcohol use will increase as a substi tute for the drug of choice, especially if the youth’s urine is being tested regularly. • Negative consequences of marijuana use. Adolescents believe that marijuana is not harmful. It is a difficult battle to convince them that marijuana has negative consequences. Parents should share with their child any information they have that would change the child’s perception. Let the child know the following: u Continued marijuana use in early years interferes with the ability to learn and remember. u Childhood and adolescent learning provides the foundation for the years to come. u Marijuana affects the ability to be responsible. (Remind children that parents believe they desire to be mature and responsible.) 4. Introduce, show, and discuss the Drug Abuse and the Brain video. 28 ----------------------------------------------- Discussion. Before showing the video, ask participants to look for two or three key messages in the video. Show the 25-minute video. Initiate a discussion about the video. 5. Introduce the stages of adolescent development. Point out that there are special issues to consider when dealing with adoles- cent substance abuse. Teens are going through developmental stages that can be affected by drug use. Introduce the effects drugs have on an adoles- cent’s developmental stages. Distribute the Developmental Changes for Adolescents handout. This handout provides a comparison of normal development with developmental changes due to chemical dependence. Make an overhead of the handout if appropriate. Discussion. Direct parents to the first grid that describes normal adolescent development for early and late teen years. Explain that some adolescent behaviors, although less than desirable, are normal and are part of growing up. Direct parents to the second grid that compares normal and chemically dependent phases. Make sure parents understand the terminology and the difference between normal development and inappropriate developmental changes associated with drug use. Finally, mention the last grid that gives some reasons why adolescents may turn to drug use. Have the parents relate the characteristics listed in the grid to their own children and try to understand why their children may have started using drugs. Have parents openly discuss the possible reasons their children may have turned to drugs. 6. Initiate a wrapup discussion using probing questions to reinforce the valuable information introduced in this session. Discussion. Show an overhead of the following questions: • How do drugs create problems for families? • Why do children use drugs? • Are families powerless in helping their children? • What do you expect from treatment? The purpose of this overhead is to generate group interaction and encourage participants to share responses. There are no right or wrong answers to the questions. Discuss these questions, and then spend a few moments writing down additional questions from the group and sharing some answers. Responses should be general feelings rather than personal answers. Reinforce positive responses, and write essential observations on the board. 7. Obtain a commitment from parents to continue attending the group sessions. 29 ----------------------------------------------- Discussion. Ask for a commitment from the parents, for the sake of their child and other group members, to continue with the group. Close the session by stating the topic of the next meeting and encouraging parents to do a family activity before that meeting. Suggestions for a family activity should be simple, short in duration, and cost no money. These suggestions should provide the family with some guidance but should not be an unnecessary strain on their functioning in the beginning of treatment. Examples include having at least one family meal at which everyone agrees to discuss only an interesting event they observed that week. Explain that the family can agree that during this meal no one will be allowed to criti- cize or make fun of others at the table. Another event could be watching an appropriate television show or movie that everyone would like to see. Tell parents that they will be asked to share how the event went with the other members of the group at the next session. Thank everyone for attending and being supportive parents, and remind them how important their attendance and commitment are to their teens. 30 ----------------------------------------------- DISEASE PROGRESSION CHART 1. Sneaks drinks/drugs 2. Is preoccupied with alcohol/drugs 3. Gulps drinks 4. Avoids reference to alcohol/drug use 5. Has memory blackouts 6. Has increased alcohol/drug tolerance 7. Drinks/uses before and after social occasions 8. Begins relief drinking/using 9. Is uncomfortable in situations without alcohol/drugs 10. Experiences loss of control 11. Is dishonest about alcohol/drug use 12. Has increased frequency of relief drinking/using 13. Hides and protects supply 14. Experiences urgent need for first drink/drug 15. Tries periods of forced abstinence 16. Receives disapproval from others for drinking/drug use 17. Rationalizes drinking/drug use 18. Experiences flashes of aggressiveness 19. Exhibits grandiose behavior 20. Has guilt about drinking/drug use 21. Neglects eating 22. Builds unreasonable resentments 23. Devalues personal relationships 24. Considers geographic escapes or geographic “cures” 25. Has decreases in sexual drive 26. Quits or loses job 27. Exhibits unreasonable jealousy 28. Drinks/uses alone 29. Tries to control drinking/drug use 30. Experiences tremors and shakes 31. Drinks/uses in early morning 32. Has persistent remorse 33. Participates in lengthy drinking/drug binges 34. Experiences impaired thinking 35. Drinks/uses with inferiors 36. Loses tolerance for alcohol/drugs 37. Has indefinable fears 38. Is unable to work 39. Has deteriorating physical state 40. Has deteriorating moral standards 41. Is admitted to hospital 42. Feels persistent remorse 43. Loses family and friends 44. Exhausts all alibis Early Stage Middle Stage Late Stage ----------------------------------------------- DRUG CATEGORY INFORMATION AND CONSEQUENCES OF USE ALCOHOL—Alcohol is the substance most commonly abused by Americans. It is a potent depressant, quickly assimilated into the bloodstream. On reaching the brain, it acts on the central nervous system to depress brain activity on all levels and reduce coordination. Slang Names: booze, brew, spirits Effects: relaxation, decreased alertness, impaired coordi nation, repression of normal fears and inhibitions Duration of Physical Effect: one drink lasts between 1 hour and 2 hours (maximum) Symptoms: flushed face, vessel dilation, loss of motor control Symptoms of Overdose: blue clammy skin, shallow respiration, weak pulse, arrested cardiac functioning Chronic Use: heart, brain, liver, circulatory system, and intestinal damage; also, damage to the fetus of a pregnant woman Dependence: moderate to high Method of Ingestion: oral NICOTINE—Tobacco is the leading drug problem today in terms of health consequences. There are an estimated 56 million users in the United States alone. Slang Names: coffin nails, butts, smokes Effects: relaxation and easing of tension, appetite suppression Duration of Physical Effect: 1 to 6 hours Symptoms: smell of tobacco, stained teeth, increased blood pressure and heart rate Chronic Use: cancers of the lung, throat, mouth, esophagus; bronchitis; stomach ulcers; lowered immunity; heart disease; emphysema Dependence: high Method of Ingestion: smoked, chewed (Continued on next page) ----------------------------------------------- MARIJUANA—Marijuana comes from the hemp plant, Cannabis sativa, which grows in many parts of the world. The dried flowers and leaves are usually smoked in a cigarette, or “joint,” or a pipe. Marijuana can also be eaten. Marijuana contains hundreds of different chemicals that produce diverse effects on the mind and body. The most significant of these chemicals is THC, the major psychoactive (i.e., mind-altering) ingredient. The average “joint” contains 2 to 7 percent THC; however, stronger strains with a THC level of 13 to 14 percent are now available on the street, posing a significant risk to users. Slang Names: pot, reefer, Mary Jane, hash, loco weed, hemp, blunt Effects: relaxation, euphoria, alteration of inhibitions Duration of Physical Effects: euphoria lasts 2 to 4 hours; heavy use lasts 24 hours; drug may be detected in urine and blood for several weeks Symptoms: drowsiness; impaired coordination; confused speech; eyes red, but pupils appear normal; coughing; dry mouth and throat Chronic Use: memory distortions, reproductive system effects, lung and lung function damage, psychosis Dependence: moderate to high Method of Ingestion: smoked, eaten STIMULANTS—These drugs stimulate the central nervous system and include cocaine, amphetamines, caffeine, nicotine, Ritalin, and methylenedioxymetham phetemine (MDMA also know as ecstasy). Stimulants were once known as the drug of the rich and famous, but they are now used by individuals at all economic and social levels. Cocaine is the most reinforcing drug used by people to produce pleasure. Slang Names: coke, snow, toot, white lady, happy dust, speed, uppers, pep pills, bennies, dexies, meth, crystal, crank, ice, black beauties, hearts, co-pilots, cartwheels, greenies, browns, whites, diet pills Effects: loss of appetite, indifference to pain, feelings of intense sexuality, exhilaration, increased alertness, anxiety, irritability Duration of Physical Effects: from a few minutes to 2 to 4 hours; smoked ice can last up to 24 hours Symptoms: restlessness, intense short-term high, dilated pupils, excess activity, mood swings, needle marks, burn marks on lips or fingertips, burned holes in clothing Chronic Use: nausea, deterioration of the lining of the nose, stomach disorders, paranoia and “formication” (the feeling that insects are crawling beneath the skin), death occurring from overdose, psychosis, hallucinations, convulsions, coma (Continued on next page) ----------------------------------------------- Dependence: high Method of Ingestion: snorted, injected, oral; ice can be smoked, snorted, or injected INHALANTS—Inhalants are legal products abused by sniffing (e.g., spray paint, hairspray, gasoline, lighter fluid, airplane glue, paint thinner, nail polish remover, typewriter correction liquid). Slang Names: poppers, laughing gas, rush, white-out Effects: euphoria, relaxation, violent behavior, hallucinations, alcohol-like high Duration of Physical Effects: a few seconds to several hours Symptoms: numbness, confusion, nausea, vomiting, tremors, memory loss, visual impairment, possible respiratory arrest, coma, death Chronic Use: lung, kidney, bone marrow, and brain damage Dependence: high Method of Ingestion: inhaled HALLUCINOGENS—Hallucinogens are drugs that alter perceptions of reality, including phencyclidine (PCP), lysergic acid diethylamide (LSD), mescaline, and psilocybin. Slang Names: angel dust, killer weed, supergrass, hog, peace pill, LSD, acid, trips, cubes, sunshine, windowpane, purple haze Effects: varies from relaxation and euphoria to vivid distortions; paranoia; psychosis; visual, tactile, auditory, and olfactory hallucinations; altered perceptions; breakdown of inhibitions; dilated pupils; mood swings Duration of Physical Effects: PCP lasts 2 to 4 hours, PCP-related psychosis may last for weeks; LSD lasts 8 to 12 hours, flashbacks may last for weeks or up to 1 year Symptoms: users are physically anesthetized and may appear to possess superhuman strength; respiratory depression, seizures Chronic Use: memory disturbances, speech problems, anxiety, extremely violent behavior, paralysis, death occurring from both accidents and overdose, increased delusions, panic, psychosis, emotional breakdown, brain damage (Continued on next page) ----------------------------------------------- Dependence: moderate to high Method of Ingestion: oral, smoked, snorted; acid can also be placed on mucous membrane areas—eyes, anus, etc. DEPRESSANTS—Depressants are drugs that relax the body muscles, temporarily relieve feelings of tension and worry, and bring on sleep. Low doses produce mild sedation; high doses induce euphoria. Depressant overdose is the leading cause of suicide among American women. These drugs are extremely dangerous when consumed with alcohol. Types of depressants are barbiturates, tranquilizers, Rohypnol, benzodiazepines, and methaqualone. All are easily available by medical prescription. Slang Names: downers, reds, pinks, yellow jackets, bluedevils, Christmas trees, barbs, Xanax, Valium, roofies, Ativan, Quaaludes, black beauties, goof balls Effects: depresses central nervous system and respiration system, slows heartbeat rate, and relaxes muscles Duration of Physical Effects: 3 to 24 hours Symptoms: drowsiness, confusion, slurred speech, impaired judgment, belligerent behavior, needle marks in people who are severely addicted Chronic Use: rapid physical and psychological dependence, addiction with severe withdrawal symptoms, loss of appetite, death from overdose Dependence: high Method of Ingestion: oral, injected ----------------------------------------------- Drugs of Abuse Detection Times Substance How Used Possible Dangers Approximate Detection Time in Urine Alcohol Orally Liver disease, respiratory failure, anxiety, depression, 3–10 hours coma, psychological or physical addiction, death Uppers/Stimulants Orally, injected, High blood pressure, loss of appetite, stroke, fever, 2–4 days (amphetamines, or inhaled heart failure, psychosis, death speed, dexedrine, ice, Ritalin, ecstasy) Downers/ Orally Respiratory failure, depression, anxiety, convulsions, Short-acting or Depressants or insomnia, coma, psychosis, psychological or physical immediate: Sedatives addiction, death 2–4 days (barbiturates, black Long-acting: beauties, goof balls, up to 2–4 nembies, seccies) weeks Tranquilizers Orally Respiratory failure, depression, anxiety, convulsions, 1–5 days or (benzodiazepines, insomnia, coma, psychological/physical addiction, death up to 2 weeks roofies, Xanax, following Valium) heavy abuse Marijuana, Hashish Smoked or Damage to short-term memory and lungs, psychosis, Infrequent (cannabinoids, eaten psychological dependence, birth defects user: reefers, grass, up to 10 days blunts) Chronic user: 30 days or more Cocaine Inhaled, Damage to nasal passages, weight loss, high blood 2–4 days (coke, crack, blow, injected, or pressure, heart attacks, strokes, convulsions, nose candy) smoked psychological or physical addiction, death Hallucinogens Orally or in High blood pressure, loss of appetite, sleeplessness, 1–2 days (LSD, white eye drops anxiety, flashbacks, tremors, psychological disorders lightening, acid, microdot) Heroin, Morphine Orally, inject- Loss of appetite, nausea, vomiting, respiratory failure, 2–3 days (opioids, smack, ed, inhaled, or convulsions, coma, psychological or physical china white, brown smoked dependence, death sugar, percs) PCP Orally, Dulled coordination and senses, anxiety, depression, 3–8 days (phencyclidine, angel injected, or high blood pressure, convulsions, violent behavior, dust, rocket, fuel, inhaled heart failure, stroke, coma, death hog) Synthetic Narcotics Orally, Nausea, vomiting, respiratory failure, infections from 1–4 days (Demerol, Dilaudid, injected, or needles, convulsions, psychological/physical addiction, Darvon, methadone) inhaled death ----------------------------------------------- DEVELOPMENTAL CHANGES FOR ADOLESCENTS Normal Development in Adolescents Characteristics of Early Teen Years Often has extreme emotions Begins to assert himself or herself; is no longer a child Shifts back and forth from relatively mature to childish Is concerned about appearance to others Searches for self-understanding Is often happy and outgoing Relates successfully to adults and peers Can be sensitive Likes developing his or her own ideas Has more worries than fears Likes showing individuality Characteristics of Late Teen Years Has somber, quiet demeanor Establishes his or her own beliefs Wants to know where adults stand on issues Is relatively uncommunicative Resents infringements on his or her freedom Divorces himself or herself from family activities Has group friendships Is in the first stage of real independence Has increased interest in sexual activities Is more autonomous with respect to parents (Continued on next page) ----------------------------------------------- Adolescent Developmental Phases Normal Becomes more egocentric and self- involved Anticipates consequences of actions Looks for “fairness”; can detect logical inconsistency Is preoccupied with his or her own thoughts Is somewhat withdrawn and isolated Is moody Has intensified feelings Debates and argues for the sake of argument Questions adult decisions and authority Changes previously held values Questions values and family rituals Feels accepted by chemical users Feels pressured to conform to drug group Feels chemicals work “first time, every time” to make a person feel good Feels more self-accepting Chemically Dependent Cannot see reality of his or her own condition Confuses “what I am” with “what I do” Thinks drug is “me” Blames others for his or her own feelings Identifies himself or herself as a “druggie”; is obsessed with drugs and drug-using activities Is socially withdrawn Becomes excessively moody due to chemical use Has inflated image of his or her own importance Feels indifferent to criticism Debates and argues with authority Rejects previously held values and authority Rejects previously respected authority figures Remembers selected information Motivation for Adolescent Drug Use Finds it easier to have a relationship with chemicals than with a person who can reject him or her Feels less inhibited when using chemicals Uses drugs to numb bad feelings about self and others ----------------------------------------------- Parent Education Session 3: Relapse Signs and Recovery General Overview—This session focuses on understanding the recovery process in the context of a healthy family and presents ways parents can effectively help their child avoid relapse and how they can know when to intervene appropriately. It also focuses on developing a healthy partnership within the family and a commitment to a drug-free life as well. Rationale—The more information parents have regarding the signs and symptoms of relapse, the better able they are to intervene. Materials— • Handouts: u Signs and Symptoms of Substance Abuse u Relapse Prevention Plan u Fire Drill Plan for Staying Drug Free u Signs of Recovery u Recovery Expectations u Plan for Recovery u Family Relapse Prevention Plan (in preparation for home visit) Goal 1: To develop an understanding of the potential problems resulting from continued use of drugs, including the process of addiction 1. Assist parents in recognizing the difficulties of parenting. Write on the board: Our children are in trouble, and drugs have become a major part of the trouble; our goal is to set out a new life for them and our families. Ask a parent to read the statement and share his or her feelings about trying to meet this goal, the importance of reaching the goal, and the difficulties he or she foresees in reaching the goal. 2. Introduce the topic of recovery, and discuss the importance of family involvement in the adolescent’s recovery. Write on the board: The adolescent can’t do it alone. Discussion. Briefly present information on the importance of the family’s involvement in the treatment and recovery processes of the adolescent. Family involvement helps build mutual responsibility and empathetic interactions between the parents and children. For example, say, “The family is involved, like it or not. Whether children grow up to be healthy or to be long-term drug abusers may be up to us. That is why we are here. We care. We want to make a difference in their lives. We want our children to 39 ----------------------------------------------- be healthy and have a good life. This is our chance, but we have to go about it intelligently.” 3. Discuss the signs and symptoms of substance abuse. Distribute the Signs and Symptoms of Substance Abuse handout. Advise parents that in addressing relapse prevention, they will look at two issues: (1) signs and symptoms and (2) addiction. Remind parents that their children have made progress in their commitment to treatment and not using substances. State that parents must still remain alert. This does not mean that they should distrust their child. However, they must remember to stay aware because the child may not be completely out of trouble. Parents should watch (though not obsessively) for the signs and symptoms of relapse that are presented in the handout. Review the handout. Goal 2: To develop an understanding of the recovery process and to learn that recovery is a long process and that part of this process is relapse prevention 1. Discuss the recovery process, ways to prevent relapse, and subtle signs of relapse. Discussion. Recovery begins with some type of intervention. This intervention means that the person will receive knowledge and tools to help maintain abstinence. In addition to remaining drug free, it is extremely important that the youth work on making healthy personal changes and understand relapse preven- tion. This is where the family can make a difference. Relapse prevention involves: • Maintaining health. It is important to develop good health habits to stay strong. This strength will give the youth the necessary energy to combat problems and take care of himself or herself. • Identifying all triggers. Triggers are events or things that initiate a desire to use. • Identifying all danger points. Some days will be exceptionally difficult in the process of recovery. These critical times are related to the withdrawal of drugs from the body. The process of withdrawal is different for different substances. • Determining emotional growth issues. The individual must learn to (1) deal with negative feelings (e.g., anger, guilt, loneliness, stress, fear), (2) establish or reestablish values (e.g., not 40 ----------------------------------------------- lying/being honest with oneself and the family), and (3) find new challenges. • Addressing environmental or social issues. The affected individual must find new activities, new friends, and new surroundings. • Developing support groups. For some people, this is the most important determinant of recovery. A support group can help with all areas of life where triggers to relapse often occur. In this intervention, the family is the support group. 2. Discuss and identify potential problems that can lead to relapse. Discussion. Relapse is a process that starts well before the actual use of drugs. If the individual is not practicing or using his or her coping tools on a daily basis, the risk of returning to substance use increases. Relapse Prevention Guidelines: • It is important not to let a child deteriorate physically. This will contribute to feeling poorly and will make it easier for urges to “sneak up” on him or her. • It is important for a child to be aware that “old thinking” can return, which includes justifying negative behaviors and denial (e.g., I can use once in a while). It is important for the person to talk about the desire to use by letting someone know what is going on in his or her life to trigger the urge. • It is important for both parents and their child to be aware of “danger points” and to plan to be particularly open and watchful with one another during these times. • It is important for a child to share feelings. Feelings are always eventually expressed, either in a direct, healthy manner or in an indirect, negative manner. Painful feelings about past events may need to be discussed. Parents should share with their children how past events are still affecting the family to begin the healing process. • It is important for a child to develop new interests and activities. Slowly, he or she needs to begin to become involved with new people and to explore ways to make new friends. Children should be aware that even adults have to do this sometimes. • It is important for your child to identify a support system and maintain regular contact with that support system. This support could include a coach, minister, neighbor, and/or a relative. Distribute the Relapse Prevention Plan and Fire Drill Plan for Staying Drug Free handouts. Discuss handouts with parents. Explain to parents that their 41 ----------------------------------------------- teens may be filling out forms similar to these during their counseling sessions. 3. Present the Signs of Recovery, Recovery Expectations, and Plan for Recovery handouts. Distribute the Signs of Recovery and Recovery Expectations handouts, and discuss what parents can expect as their adolescent begins the recovery process. Review the Plan for Recovery, and explain that parents who understand the problems that adolescents may encounter during recovery can develop a plan to cope with situations. Explain that the more prepared parents are, the more they can help their child deal with potential relapse issues. Elicit discussion from all parents about the feelings adolescents may have during treatment and early recovery and how a parent can react effectively. 4. Introduce the importance of a family relapse prevention plan, and explain the need for the adolescent abusing drugs to have a relapse prevention plan. Discussion. Present the research that shows that relapse prevention plans increase the chances of recovery and enable individuals and families to preplan strategies for troubling times. A good resource for information is Bell (1992). Bell is a prominent researcher and author on the subject of adolescent addiction, relapse, and recovery. Discuss the essential components of an effective plan (e.g., awareness of the problem, problem-solving methods, where to get help, necessary changes in family routines). Point out that relapse is a “process and not an event.” Encourage a discussion that explores the concept that relapse starts long before the return to substance abuse or a return of family dysfunction. Refer to the Signs and Symptoms of Substance Abuse handout discussed earlier. Discussion should center on the need for awareness of typical signs and symptoms of family and individual relapse to prevent rapid deterioration. Distribute the Family Relapse Prevention Plan. Instruct parents that they, and each member of the family, must briefly answer each item. For instance, under “Previous Signs,” ask each member to name a sign or symptom that the family displayed that caused problems. An example from one child might be, “There was always a lot of yelling, and no one listened to anyone.” Under the item “If the family has a problem,” each member writes down something about the problem that he or she will commit to doing. For example, the parent might say that if there is a problem, he or she will bring it to the attention of the whole family immediately. Under “Support Groups and Meetings,” each member writes down the name of the group he or she will commit to attending. The importance of this relapse prevention plan is to acknowledge the previous signs of problems and commit to doing things differently as 42 ----------------------------------------------- individuals and as a family unit. The counselor should ask family members to work on it at home. The inhome therapist will review it with them during home visit 3. At that visit, all family members will discuss their ideas with the therapist. The therapist will help them finalize the plan and will ask each member to sign the final plan. 5. Provide parents with information about community support groups. Discussion. Share information about Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and other community support groups. Provide information about where and when the meetings occur. Discuss the importance of having a support network after treatment, and note that the recovery process does not end with this program. 6. Discuss questions regarding relapse and recovery. Allow parents to expand this discussion to address their concerns. Ask group members to share what they expect from treatment. Encourage them to discuss what they can do and to continue this discussion at home. Ask the following questions: • What do you expect from treatment? • How can you help with this process? • How long term is the problem? • What changes will you have to make? • Are you willing to make changes in the way you do things? 43 ----------------------------------------------- SIGNS AND SYMPTOMS OF SUBSTANCE ABUSE If you notice any of the following, you may want to seek help immediately. • Physical signs of renewed substance use: u Peculiar odors of marijuana, alcohol, or solvents on your child, on his or her clothing, in the house, or in the car u Presence of drugs or drug paraphernalia in your child’s environment or in dirty laundry (e.g., presence of seeds, leaves, or butts in ashtray or clothing pockets; use of small baggies, cigarette papers, or other unusual small containers) u Use of eye drops, room deodorizers, or incense u Slurred speech or intoxication (Note: Impairment of physical function may signal an event requiring immediate medical attention. In a medical emergency, call 911.) • Noticeable change in school performance (e.g., drop in grades or attendance, disciplinary reports from the school) • Sudden change in social pattern (new friends, activities, choice of music, etc.) • Secretiveness about friends or activities • Sudden change in family relations (withdrawal, belligerence, marked increase in family arguments either with parents or with siblings, especially regarding setting limits) • Noticeable change in personality (lethargy, loss of motivation or interest) • Sudden changes in mood (e.g., aggressive anger, sullenness, uncaring attitude and behavior) • Deterioration in physical appearance (general unhealthy appearance, bloodshot eyes, lack of alertness, decrease in neatness or personal hygiene) • Involvement in legal problems or delinquent behavior • Unusual financial problems, repeated pawning or selling of personal effects • Extreme dress, language, opinions, or behavior. ----------------------------------------------- RELAPSE PREVENTION PLAN Relapse is preventable. By answering these questions, you become aware of possible relapse-producing events or causes. This plan can work against your usual excuses. Please be specific, and, if possible, answer each question with more than one answer. Remember, the more you put into it, the more you get out of it! How many 12-Step (or other self-help) meetings will you attend? Please indicate the place, day, and time. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ What times are you most likely to use alcohol or drugs? What will you do instead? Be specific. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ What actions will you take when you get angry or frustrated? Please indicate immediate and future actions. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ (Continued on next page) ----------------------------------------------- Describe your plan to handle situations that make you afraid. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ What life events or losses could cause you to use drugs or drink? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Make a list of those people who can give you support in times of need. Indicate how often you will meet with them. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Will you be able to ask these people for help? Write down how you will ask them for help. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ (Continued on next page) ----------------------------------------------- How will you start each day? End each day? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ What are some positive actions you can take when you are lonely? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ What are some positive actions you can take when you’re not getting along with friends or family? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ What are some actions you can take if 12-Step meetings begin to feel boring or unimportant? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ----------------------------------------------- FIRE DRILL PLAN FOR STAYING DRUG FREE ____________________________ ______________________ Name Phone number _______________________________ ________________________ Sponsor, AA, NA Phone number _______________________________ ________________________ Counselor Phone number _______________________________ ________________________ Other support Phone number Smoke Plan: If I am in a crisis situation, this is what I will do! What emotions can trigger drinking/drug using? Planned preventive action _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ What situations can trigger drinking/drug using? Planned preventive action _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ If I return to drinking/drug using, this is what I will do! ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ This is a plan of action—TOUGH LOVE—because I want to be part of the solution and not part of the problem. This fire drill may need to be updated at some time. I am open to discussing any changes and open to asking an influential person to help. Date:_______ Signature of client:______________________________ Date:_______ Signature of counselor:___________________________ Date:_______ Signature of parent/guardian:_____________________ ----------------------------------------------- SIGNS OF RECOVERY The Recovering Person: • Continues to build a sober lifestyle • Respects the boundaries of oneself and others—has reasonable expectations • Builds relationships with people who share the same values and the desire to live responsibly • Continues to trust others and to gain the trust of others • Finds being honest and trustworthy gets easier and easier • Has a network of support (AA, NA, faith-based groups, parents, coaches, teachers), and expresses a sober belief system in word, deed, and thought • Makes reasonable short- and long-term goals, and begins to achieve them • Avoids those who abuse drugs and places where they are being used. The Recovering Family: • Ensures that the family home is a place that becomes increasingly comfortable and peaceful for its members (It does not have to be “perfect” all the time—that’s an unrealistic expectation.) • Remembers to fight fair, respect one another, and give support when others need it • Celebrates the accomplishments of each member, and shares feelings of joy, pain, fear, and excitement • Continues to grow to form a lifelong FAMILY SUPPORT NETWORK. ----------------------------------------------- RECOVERY EXPECTATIONS 1. It is not necessary to promise sobriety. Slips happen, so plan to deal with them. Broken promises only increase guilt and failure. 2. Watch for unrealistic expectations. At this point in recovery, it is important to keep feelings of resentment and disap- pointment to a minimum. These feelings can be used as an excuse to return to substance use. 3. Be aware of how the adolescent deals with and expresses anger, frustration, and depression. Discuss plans to deal with these emotions as a family. 4. Physical and emotional pain will be more pronounced without substance use. Families need to be aware of this and have a plan to deal with emotional pain. 5. Rebuilding trust will take time for the family. Overcoming suspicion and distrust is a slow process. 6. Often, the early recovery stage includes the “pink cloud” effect. During this time, adolescents may feel happy with themselves and have a sense of power. This usually lasts between 1 and 4 weeks. Remember, nonusing adolescents’ emotions are typically up and down as well. 7. When quitting substance use, some adolescents experience a feeling of loss. Grieving the loss of drugs is a healing process. Try to be patient. 8. Recovery is a time for adolescents to become honest with themselves and with others. This process of honesty can result in hurt or harm to the family as a whole and to its individual members. Family members may need to confront one another, apologize, listen, make amends, and leave the past behind. ----------------------------------------------- PLAN FOR RECOVERY 1. Adolescents need plenty of rest, and they need to eat properly. Sleep patterns are disturbed during early recovery by nightmares, short sleep periods, and restlessness. 2. The adolescent will have more free time, time that was previously spent using drugs. A plan needs to be developed to spend free time positively. 3. Alcohol and drugs need to be removed from the home. Prescriptions must be secured in a medicine cabinet. Parents need to be aware that other items around the house can be used to get high. These include gasoline, chemicals under the sink and in the garage, and whipped cream and other aerosol cans. 4. It is important for the adolescent and family to be involved in support groups. 5. It is important to keep the concept of sobriety as a priority. 6. Families need to understand triggers causing the adolescent to slip. (The relapse plan homework helps in understanding these triggers.) 7. Rewarding and celebrating are important areas to discuss and plan. Celebrations are often occasions when the adolescent would likely use drugs. 8. Stay focused on the “here and now.” The idea of “never using again” is too overwhelming. It is important to “take 1 day at a time.” 9. The adolescent needs to avoid settings where drugs and alcohol are being used. Relationships with nonusing peers need to be developed and encouraged. 10. Overall, be patient and communicate. Changes in the family, even good ones, are stressful. Everyone needs to work together. ----------------------------------------------- FAMILY RELAPSE PREVENTION PLAN Instructions: This worksheet will help you and your family think and talk about what each fami ly member will do to prevent a relapse. Discuss each item with your family at home. To help get a discussion going, ask the opinions of each child. Remember that each commitment reinforces that the whole family is making a pledge to recovery. (Use the back of the form if more space is needed.) The therapist will discuss the plan with your family during home visit 3. During that visit, the therapist will review the draft with the family, confirm all members’ commitments, and ask that all members sign the plan. A copy will be made for each family member and the therapist. Commitments Mother Father Client Sibling 1 Sibling 2 Sibling 3 (Continued on next page) Communica tion: “I will improve my communications by always . . .” Fair Fighting: “I will fight fair by always . . .” Improving Trust: “I agree to improve trust and be more trustworthy by . . .” Healthy Habits and Activities: “I believe . . . are healthy habits and activities for me.” ----------------------------------------------- Commitments Mother Father Client Sibling 1 Sibling 2 Sibling 3 Previous Signs of Problems: “When . . . hap pened before, it was a sign that things were not going well.” Concerns on Warning Signs: “I agree to accept concerns from all family members.” If the family has a prob lem: “I agree to . . .” Support Groups and Meetings: “I agree to attend support group meetings.” We agree to do our part in meeting the Family Relapse Prevention Plan. (All members sign below.) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ----------------------------------------------- Parent Education Session 4: Boundaries, Limits, Authority, and Discipline General Overview—This session provides clarification of major issues in family functioning and appropriate approaches to discipline and parental authority. It helps parents understand the sources of authority in the family and how authority is maintained in a healthy way. The concept of boundaries is introduced as a major issue in family structure. Rationale—The more information parents have regarding parental authority, the better able they are to intervene in their child’s behavior. Materials— • Handouts: u Setting Boundaries and Limits u Characteristics of People With Unhealthy Boundaries u Parent Guidelines u Parent/Child Contract Goal: To teach participants how to set limits and boundaries, establish appropriate discipline methods for youth, recognize characteristics of unhealthy boundaries, and develop a parent/child behavioral contract 1. Discuss the process parents undergo in developing discipline. Discussion. Present the following in narrative form. “We are different from our children. We know the rules. We know that if you use your credit card, a bill will come in the mail and the bank will expect you to pay it. Small children are helpless and they depend on us entirely. As they grow and learn, we have to guide them by setting rules and expectations. When our children become teenagers, it is a confusing time for us, but an even more confusing time for them. So rules are important, even if the reason for the rules is not obvious. We are going to discuss how to develop a set of age-appropriate rules for your children, how to get their compliance with those rules, and what to do if the rules are broken. “It is important to realize that drug behavior is associated with rebellion, risk taking, stress reduction, identity formation, and assertiveness. Parents must provide structure, limits, and direction for their teenagers. Parents can build contracts with teenagers allowing them freedom of choice (within structured limits) but also defining consequences for failure to maintain the contract.” Distribute the Setting Boundaries and Limits handout. Allow time for parents to read the handout. Discussion. Answer questions or ask whether parents need clarification on the concepts before continuing. Ask parents whether they have examples to 54 ----------------------------------------------- help clarify the guidelines. Ask whether any guidelines are particularly easy or hard to do. 2. Define boundaries, and explain the need to develop boundaries with children. Distribute the Characteristics of People With Unhealthy Boundaries handout. Discussion. State, “Knowing boundaries involves taking care of ourselves, no matter what happens or with whom it happens.” Write on the board: Healthy boundaries are taught and are learned as a result of life lessons. Knowing healthy boundaries can be beneficial. Boundary—something that indicates bounds or limits Bound—inseparably connected with. Boundaries emerge from: • Deep decisions about what we believe we deserve and don’t deserve • What we want and need • What we like and dislike • What is important to us • A deeper sense of our personal rights, especially the right we have to take care of ourselves (Boundaries emerge as we learn to value, trust, and listen to ourselves.) • Deciding what is good for us and for others. Discussion. Review the characteristics of unhealthy boundaries. Discuss the Characteristics of People With Unhealthy Boundaries handout. Ask the parents to discuss signs of unhealthy boundaries between parents and their children. Point out, “Unhealthy boundaries lead to resentment, unhappiness, and a feeling of dissatisfaction and can damage relationships. One person may be hurt in this kind of relationship and will eventually distance himself or herself and may leave the relationship.” 3. Introduce the topic of setting limits with children. Discussion. Distribute the Parent Guidelines handout to the participants and discuss. 55 ----------------------------------------------- Distribute and discuss the Parent/Child Contract handout. Conduct a practice exercise by having parents develop a contract for a 16-year-old 10th grader. Explain that parents may want to use this contract as a guide when filling out the Family Contract during home visit 1. Assignment. Ask parents to practice setting limits and rules for teens by completing a parent/child contract with their child. Before they start, ask, “What are the difficulties in setting limits and boundaries when your child is exhibiting rebellious behavior? What are reasonable limits and expectations?” Then discuss the following: • Feelings of uncertainty and guilt when disciplining teens • How parents can know their own boundaries and limits of tolerating teen behavior • How parents can take care of themselves • Where to draw the line. 56 ----------------------------------------------- SETTING BOUNDARIES AND LIMITS As a parent it is important that you: 1. Show confidence in the teen’s ability to make decisions 2. Support your teen without suffocating his or her interests 3. Allow your teen to experience the consequences of his or her behavior 4. Learn to say “no” when appropriate 5. Exercise leadership without giving in and without fighting 6. Learn that both coercive and pampering approaches to parenting steal initiative and self-confidence from your teen. Setting Rules and Limits 1. Establish and discuss rules and limits with your child before they need to be enforced. These rules should be appropriate for the child’s age and abilities. 2. Make sure that the consequences for not abiding by the rules are clear. 3. Make only rules you can enforce. A child will test rules to see whether the consequences are real. It is crucial that you are consistent in enforcing the rules. 4. Remain fair but firm with your child. (Continued on next page) ----------------------------------------------- 5. If you have a spouse or a significant other involved in the rearing process, make sure you and that person work together, that you agree on the set rules, and that you are consistent in disciplining. Unity of parents helps discourage the child from playing “divide and conquer” and provides a feeling of stability for the child. 6. Remember, if the child intentionally, willfully, or arrogantly breaks a major rule, the child has made the choice to be disciplined. Discipline is not something the parent does to the child but is something that is done for the child. 7. When grounding your child, set a realistic time that can be adhered to (e.g., 6 months is not realistic, but the weekend is realistic). Make the consequences natural and logical (e.g., the child didn’t bring the car back on time so the child can’t use the car for 1 week). 8. Make the rules explicit by forming a verbal or written contract with the child. The content of the contract includes behaviors you want from the child (e.g., cleaning his or her room) and behaviors you don’t want from the child (e.g., staying out past curfew), rewards for exhibiting positive behaviors, and consequences for breaking the rules. 9. Let the punishment fit the crime. Consequences should be natural and logical. Solicit input from your child—what does he or she think the consequences should be? Focus on the most troubling behavior and not on the “little things.” ----------------------------------------------- CHARACTERISTICS OF PEOPLE WITH UNHEALTHY BOUNDARIES • We have an overdeveloped sense of responsibility and more concern for others than for ourselves. This prevents us from looking too closely at our faults. • We hide traumatic feelings from childhood, and we lose the ability to feel or express our feelings because it hurts too much. • We have isolated ourselves from others and are afraid of people and authority figures. • We have become approval-seekers and have lost our identity in the process. • We are frightened by angry people and any personal criticism. • We live from the viewpoint that we are victims and are attracted to friendships and love relationships that feed that weakness. • We judge ourselves harshly and have low self-esteem. • We have dependent personalities and are terrified of abandonment. We will do anything to hold onto a relationship, so we do not experience the painful feelings of abandonment that we have from caring about people who were never there for us emotionally. • We experience guilt feelings when we stand up for ourselves. • We confuse love and pity and tend to “love” people we can pity and rescue. • We have become chemically dependent, married a chemically dependent person, or found another compulsive personality, such as a workaholic, to fulfill our own compulsive needs. • We are addicted to excitement. • We are reactors in life rather than actors. ----------------------------------------------- PARENT GUIDELINES Identify your limits as parents regarding your child’s drug abuse problem and recovery. Despite concerns, parents: q Cannot control behaviors and attitudes of a drug-abusing teen q Cannot prevent all bad things from happening q Cannot dwell on guilt over past failures q Cannot try to rescue teens who get into trouble because of their poor judgment and bad behavior q Cannot try to rescue a teen because this will lead to irresponsibility and resentment in the child (We all learn from mistakes.) q Cannot give in to unreasonable demands that will encourage more bad behavior q Cannot scold, lecture, reason with, or threaten teen. Parents can work for healthy survival of their family by: q Managing their home the way they see best q Practicing patience to become strong and skilled in dealing with drug- related behavior q Loving with a firm approach that at times is difficult to implement q Detaching themselves from the burden of worry and responsibility (The abuser must take responsibility for his or her behavior.) q Continuing to care with clear, firm guidelines about what is acceptable behavior q Making treatment available to the abuser and realizing parents cannot force adolescents to benefit from the treatment. Remember: q Recovery is a long process and begins with 1 day at a time, so try not to become disillusioned too quickly. q Love, hope, faith, and patience are the cornerstones of recovery, especially for parents. ----------------------------------------------- PARENT/CHILD CONTRACT RESPONSIBILITIES S M T W T F S CONSEQUENCES POSITIVE NEGATIVE Parent’s/Guardian’s Signature:_______________________________________ Child’s Signature:__________________________________________________ Date:______________________________________________________________ ----------------------------------------------- Parent Education Session 5: Communication, Conflict Resolution, and Fighting Fair General Overview—The purpose of this session is to enhance parents’ understanding of how and why conflict inevitably happens in families, impart concepts and methods of healthy communication, and teach techniques for engaging family members in open and fair conflict resolution. Conflict is presented as a learning process, and ways to prevent it from becoming dangerous to the individual and family are discussed. Techniques for dealing with conflict through negotiation are also presented. Rationale—The more information parents have about understanding healthy communication, conflict resolution, and timing negotiations with teens, the better able they are to improve communication in the home. Materials— • Whiteboard and markers • Handouts: u Tips for Fighting Fair u Ways To Improve Communication With Your Teenager Goal: To teach parents how to communicate effectively, how to have arguments using fair rules, and how to resolve conflicts with adolescents 1. Introduce and encourage discussion on conflict resolution, and motivate the participants to learn the information. Discussion. Write on the board: When one seeks to win, both lose. Ask the group to explain this statement. Lead the group to the concept of conflict resolution. Ask parents to indicate by a show of hands which members of the group have experienced a recent conflict with their teen. Ask whether any parents would like to share what the conflict was about. Encourage other parents to contribute to the discussion or acknowledge others in the room who are relating to the topic by nodding their heads, etc. Ask the group to consider the question, “Why do conflicts occur between parents and their children?” Write the responses on the board. Examples could include because children want freedom and parents want to keep a handle on their children; because family members fight rather than listen to one another; because each member feels he or she is right. 62 ----------------------------------------------- Ask the group to identify the most important tool for conflict resolution. Encourage involvement until “communication” is mentioned. Let the group know this is the most important tool. 2. Introduce the topics of mutual respect in communication and effective communication tools. Identify specific guidelines for fighting fair. Discussion. Present the following information in narrative form: “What we want is communication among family members to be based on mutual respect. Mutual respect is allowing each other to express beliefs and feelings honestly without fear of rejection. Although one may not agree with the other, both can demonstrate acceptance of each other’s feelings. The goal of this communication technique is to help the person feel understood. Effective listening may also allow people to clarify their feelings and work out their own solutions.” Discuss personal qualities that can interfere with communication. Examples include the following: • Being impaired or preoccupied with other personal problems • Being angry • Being insecure • Not meeting personal needs • Being task oriented • Being too critical • Being too busy • Not accepting problems; wanting a perfect family. Allow the group to come up with its own list, but use these ideas to stimulate conversation. Briefly highlight ways to improve communication with teenagers, such as the following: • Remembering that effective communication is based on mutual respect • Having a willingness to listen • Remembering to listen to ideas or beliefs that you may not agree with; you do not have to agree, just listen • Trying not to criticize the other person • Providing the opportunity to work through feelings. Identify specific guidelines for “fighting fair.” Discussion. Distribute the Tips for Fighting Fair handout. Review and clarify the tips with parents. Ask whether parents have anything to add. 63 ----------------------------------------------- 3. Distribute the Ways To Improve Communication With Your Teenager handout. Briefly discuss each point and provide examples when necessary. Ask parents whether they have questions about the ways to improve communication. Ask whether anyone needs an example to make any of these ideas clearer. 4. Discuss how to build or rebuild relationships in the family. Discussion. Explore ways to rebuild relationships in the family. Mention that the family should: • Try to focus on other members’ positive qualities • Think about what the relationship would be like if the stress of substance abuse had not entered the picture • Strive toward this ideal relationship • Set time aside to have fun (During this rebuilding time, avoid disagreements.) • Identify opportunities to communicate • Identify areas of mutual interest • Set aside time to do something together, even if it is only once every couple of weeks. Discussion/Roleplay. Ask some parents to be volunteers to roleplay a scenario that another parent describes. An example may be a teenager wanting a curfew of 11 p.m. changed to 1 a.m. When the roleplay is over, discuss the conflict resolution techniques used; ask for other techniques that could also have been used. Tell volunteers they should try to use the tips in the Tips for Fighting Fair handout and the Ways To Improve Communication With Your Teenager handout. Wrap up the session by asking for questions and asking parents what conflict resolution techniques they could easily begin using at home. 64 ----------------------------------------------- TIPS FOR FIGHTING FAIR Select a Time: Pick a time that is right for both participants. Stay on Track: Discuss one issue at a time. If more than one topic/problem come up, write them down. Maintain Respect: Do not allow sarcasm, put-downs, or discounts (disrespect for what another person says). A good way to keep this type of communica tion under control is to use a “buzz word.” Pick a word the family will use to indicate a “low blow.” When someone says something that is cruel or uses name-calling or profanity, use the buzz word as a signal. When the buzz word is us