Transcript Co-Occurring Disorders, Best Practices and Adolescents

Co-Occurring Disorders, Best
Practices and Adolescents
“Double Trouble - Early”
Main Points
• Section One: Co-Occurring Mental Health and
Substance Use Disorders in Adolescents:
Research
• Section Two: Systems Issues - Parallel
Treatment Systems
• Section Three: Assessment of Co-Occurring
Disorders
• Section Four: Evidence Based Treatments for
Adolescents with Co-Occurring Disorders
• Section Five: Recommendations
Section One:
Co-Occurring Mental Health and
Substance Use Disorders in
Adolescents: The Research
INTRODUCTION
The research tells us the majority of youth
referred for substance abuse treatment
have at least one co-occurring mental
health disorder (COD), a DSM-IV-TR
mental health disorder and a substance
use disorder (SUD).
Research
• Adolescents with substance use disorders are at
a six times risk of having a co-occurring
psychiatric disorder (Dennis, 2004)
• Co-Occurring disorders are associated with
poorer treatment outcomes, both physical and
psychological when either disorder is not treated
(Riggs, 2003)
• Drug abuse changes the brain chemistry of
developing brains.
• Psychiatric symptoms often precede the SUD
Incidence of Co-occurring
Disorders in System of Care
Adolescents
(Turner, Muck, Muck et al, 2004)
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SOC sites (N= 18, 290) 44% reported
COD
Co-Occurring Disorders at Intake: SOC
38.4%
ADHD
13.3%
27.1%
25.2%
Oppositional Defiant Disorders
32.9%
28.4%
Mood Disorders and Depression
13.2%
Adjustment Disorders
8.1%
9.9%
Conduct Disorders
34.0%
8.9%
6.8%
PTSD and Acute Stress
4.6%
3.5%
Impulse Control
5.5%
7.5%
Disruptive Behavior Disorders
4.5%
2.3%
Anxiety
Psychosis
Autistic Disorders
Mental Health Problems Only (n = 10,541)
2.4%
1.8%
Comorbid with Susbtance Use (n = 782)
2.1%
0.1%
5.1%
4.3%
Learning and Related Disorders
Mental Retardation
3.8%
2.4%
Personality Disorder
1.5%
3.8%
5.6%
3.3%
V Code
7.6%
Other
2.8%
0%
20%
40%
60%
80%
100%
Co-Occurring Disorders
Categories
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Co-occurring disorders in adolescents are
usually categorized into internalizing and
externalizing disorders. These should be the
treatment targets for the mental health
interventions.
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Internalizing –anxiety, fear, shyness, low self
esteem, sadness, depression (6%) of COD
Externalizing—non compliance, aggression,
attention problems, destructiveness, impulsivity,
hyperactivity, and antisocial behavior (18-35%) COD
Both (38-65%) COD
Co-Occurring Disorders
Categories
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Disruptive disorders and mood disorders are
associated with earlier onset of use of
substances and increased substance use
disorders
Internalizing disorders are associated with
SUD and are an antecedent of the SUD.
Trauma/victimization in youth with SUD range
from 25% for males to 75% of females
(Kanner, 2004, Dennis, 2004)
Average Scores of Child Behavioral and Emotional Problems* for
children with Co-occurring substance use problems at Intake, 6
Months, and 12 Months
Internalizing and Externalizing Scores:
Average CBCL Problem Scores
100
Internalizing Behaviors
90
Externalizing Behaviors
80
70
60
50
40
30
20
Intake
6 Months
12 Months
Internalizing Behaviors
64.6
60.4
57.3
Externalizing Behaviors
71
67.0
64
Internalizing: n=101; F(3,98)=1396, P<.001.
Externalizing: n=101; F(3,98)=1706, P<.001.
* Child behavioral and emotional problems were measured by the CBCL (Child Behavior Checklist). Clinical range for internalizing and externalizing scores is between 60 and 63, while
clinical range for the eight syndrome scales is between 67 and 70.
Gender Differences
Girls
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Conduct disorder associated with SUD in both
girls and boys, but girls with this combination
had the highest CBCL scores for delinquency
Caregivers report more of both internalizing
and externalizing problems among girls (83%)
than boys (41%)
Girls are over represented in groups with poor
outcomes
Gender Differences
Girls
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Females had higher rates of Co-Occurring
disorders and were more likely to have
suffered physical/sexual abuse
Girls report significantly higher level of drug
dependence vs abuse, (72% vs 43%) in boys
Gender Differences
Boys
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Present more often with disruptive behaviors
(ODD/CD)
More often in juvenile justice settings (80%)
with COD referrals
In juvenile justice settings 3/4 of males and
half of all females have COD
Section Two:
Systems Issues - Parallel
Treatment Systems and
Colliding Cultures
Systems Issues –
Treatment Pathways
Different models in mental health and
substance abuse treatment have
resulted in the development of parallel
but not intersecting treatment systems
with different funding streams, mandates
and treatment philosophy.
Clinical Barriers
A) Mental Health Treatment
The fundamental approach to clinical education has
not changed appreciably since 1910 (ICM 2000).
Substance use disorders often are not seen as part of
the “care mandate.”
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Medical model
Emphasis on licensure
Emphasis on minimal self disclosure.
Treatment can not begin until abstinence is
obtained
Clinical Barriers
A) Mental Health Treatment cont.
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Reluctance to medicate individuals with a
substance use disorder
Psychological treatments offered but with no
substance abuse treatment component
Clinicians are reluctant to treat substance
abusing individuals
Clinicians often not cross trained in SUD
Individuals with SUD often minimize the disorder
and vice-versa
Clinical Barriers
B) Substance Abuse Treatment
Knowledge of mental health disorders is often limited
and often out of scope of practice of the providers.
• Based on a peer relationship model
• Licensure not necessary (changing)
• Treatment provider often a recovering individual
• Willing to disclose substance abuse history
• Individual with substance abuse history treated
as an expert valued.
• Often reluctance to allow any medication of any
kind
• Treatment often ignores mental health problems
and focuses on substance abuse
• Providers not cross trained in mental health
treatments
Section Three:
Assessment of Co-Occurring
Disorders
Assessment and Screening for CoOccurring Disorders
The process of screening, assessment, and
treatment planning should be an integrated
approach that addresses the substance abuse
and mental health disorders, each in the context of
the other and neither should be considered
primary.
Expect comorbidity as it is higher than realized
Assess for trauma/victimization
Assessment and Screening for CoOccurring Disorders
Substance use assessment should include:
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Onset, progression, patterns of use,
frequency, tolerance/withdrawal, triggers.
Assessment for patterns of use of multiple
drugs
Consequences of drug usage
Motivation for treatment
Family history regarding substance use
including extended family
Assessment and Screening for CoOccurring Disorders
The assessment process ideally would include:
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A brief screening assessment for substance
use disorders as part of the standard mental
health assessment at entry and throughout
treatment
A full substance abuse disorder assessment
for adolescents with more complicated/ Comorbid disorders and identified SUD
Assessment Instruments
Screening Instruments:
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Adolescent Alcohol Involvement Scale
Adolescent Drug Involvement Scale
Problem Oriented Screening Instrument for
Teenagers (POSIT)
GAIN – Short Version—Sample attached.
Assessment Instruments
Substance Use Disorder Interviews:
• Adolescent Diagnostic Interview (ADI)
• Diagnostic Interview for Children and
Adolescents (DICA)
Comprehensive Assessment Instruments:
• Comprehensive Adolescent Severity
Inventory (CASI)
• The American Drug and Alcohol Survey
(ADAS classroom use)
• Personal Experience Inventory (PEI)
Assessment Instruments
General Checklists:
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Achenbach YSR
Revised Behavior Problem Checklist.
Youth Outcome Questionnaire YOQ
Youth Outcome Questionnaire Self Report
YOQ SR
Section Four:
Evidence Based Treatments for
Adolescents with Co-Occurring
Disorders
Evidenced Based Treatment
• “…the integration of the best research
evidence with clinical expertise and patient
(consumer) values”
• Based on the definition used in “Crossing
the Quality Chasm: A New Health System
for the 21st Century” (2001), by the
Institute of Medicine
Treatment
• New techniques and treatment modalities
based on evidenced based research
methodology are successful with CoOccurring Disorders.
Evidenced Based Treatments
National Registry for Evidenced Based
Programs and Practices—SAMSHA
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Treatment for Co-occurring Disorders
Mental Health Treatments successful with Cooccurring disorders
Treatments for Substance Use Disorders
Preventative Practices
Brief Manualized Treatments
Evidence-Based Treatments
for Co-Occurring Disorders
Family Behavior Therapy
Multisystemic Therapy
Dialectical Behavior Therapy
Seeking Safety
TREM
TARGET
Integrated Community Treatment
Family Treatment
Family Behavior Therapy (FBT)
 Outpatient behavioral treatment aimed at
reducing drug and alcohol use in adults
and youth along with common cooccurring problem behaviors such as
depression, family discord, school and
work attendance, and conducts problems
in youth.
Family Behavior Therapy (FBT)
Populations
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Adolescents ages 13 to 17
Young adults ages 18 to 25
Adults ages 26 to 55
Male and Female
Races: White, Black or African American,
Hispanic or Latino, Race/ethnicity
unspecified.
Family Behavior Therapy (FBT)
Outcomes
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Decreases illicit drug use
Decreases frequency of alcohol use
Improves quality of Family relationships
Reduces symptoms of Depression
Reduces symptoms of Conduct Disorder
Improves School / Employment
attendance
Family Behavior Therapy (FBT)
References & More Info
• SAMHSA’s National Registry of Evidencebased Programs and Practices (NREPP)
• Bradley Donohue, Ph.D. Associate
Professor
• University of Nevada, Las Vegas
• E-mail: [email protected]
• Web site:
http://www.unlv.edu/centers/achievement
Multisystemic Therapy (MST)
 A family and community-based treatment
for adolescents presenting serious
antisocial behavior and who are at
imminent risk of out-of-home placement.
Multisystemic Therapy (MST)
Populations
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Children ages 6-12
Adolescents ages 13-17
Male and Female
Races: American Indian/Alaska Native,
Asian American, Black or African
American, Hispanic or Latino,
Race/ethnicity unspecified, White
Multisystemic Therapy (MST)
Outcomes
• Alcohol and drug use frequency reduced
and higher rates of abstinence
• Increased perceived family functioningcohesion
• Decrease peer aggression
Multisystemic Therapy (MST)
References & More Info
• SAMHSA’s National Registry of Evidencebased Programs and Practices (NREPP)
• Scott W. Henggeler, Ph.D.
• Dept of Psychiatry and Behavioral
Sciences
• Medical University of South Carolina
• E-mail: [email protected]
Dialectical Behavioral Therapy
(DBT)
• A cognitive-behavioral treatment approach with
two key characteristics: a behavioral, problemsolving focus blended with acceptance-based
strategies, and an emphasis on dialectical
processes.
• “Dialectical” refers to the issues involved in
treating patients with multiple disorders and to
the type of thought processes and behavioral
styles used in the treatment strategies.
Dialectical Behavioral Therapy
(DBT) Populations
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Young adults ages 18-25
Adults ages 26-55
Older adults ages 55+
Male and Female
Race: American Indian/Alaska Native,
Asian American, Black or African
American, Hispanic or Latino,
Race/ethnicity unspecified, White.
Dialectical Behavioral Therapy
(DBT) Outcomes
• Decrease suicide attempts
• Decrease nonsuicidal self-injury
(parasuicidal history)
• Increase psychosocial adjustment
• Increase treatment retention
• Reduces drug use
• Reduces symptoms of eating disorders
Dialectical Behavioral Therapy
(DBT) References & More Info
• SAMHSA’s National Registry of Evidence-based
Programs and Practices (NREPP)
• Marsha M. Linehan, Ph.D., ABPP
• Professor and Director of Behavioral Research
and Therapy Clinics
• Dept of Psychology University of Washington.
• E-mail: [email protected]
• Web site: http://www.brtc.psych.washington.edu/
Seeking Safety
• A present-focused treatment for clients with a
history of trauma and substance abuse. The
treatment was designed for flexible use: group
or individual format, male and female clients,
and a variety of settings. (i.e., outpatient,
inpatient residential).
• Treatment and intervention focuses on coping
skills and psychoeducation and has five key
principles.
Seeking Safety
Population
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Adolescents ages 13-17
Young adults ages 18-25
Adults ages 26-55
Male and Female
Races: American Indian/Alaska Native,
Asian American, Black or African
American, Hispanic or Latino,
Race/ethnicity unspecified, White.
Seeking Safety
Outcomes
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Reduces Substance abuse
Improved trauma-related symptoms
Improved psychopathology
Increased treatment retention
Seeking Safety
References & More Info
• SAMHSA’s National Registry of Evidence-based
Programs and Practices (NREPP)
• Lisa M. Najavits, Ph.D.
• Director, Treatment Innovations
• Professor of Psychiatry, Boston University
School of Medicine
• Lecturer, Harvard Medical School
• E-mail: [email protected]
• URL: http://www.seekingsaftey.org
Trauma Recovery and
Empowerment Model (TREM)
 TREM is a fully manualized group-based
intervention designed to facilitate trauma
recovery among women with histories of
exposure to sexual and physical abuse.
Trauma Recovery and
Empowerment Model (TREM)
Population
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Young adults ages 18-25
Adults ages 26-55
Female
Race: American Indian/Alaska Native,
Black or African American, Hispanic or
Latino, Race/ethnicity unspecified, White
Trauma Recovery and
Empowerment Model (TREM)
Outcomes
• Reduces severity of problems related
to substance abuse
• Reduces psychological
problems/symptoms
• Reduces trauma symptoms
Trauma Recovery and
Empowerment Model (TREM)
References & More Info
• SAMHSA’s National Registry of Evidencebased Programs and Practices (NREPP)
• Roger D. Fallot, Ph.D.
• Director of Research and Evaluation
• Community Connections
• E-mail: [email protected]
• Web site: http://www.ccdc1.org
Trauma Affect Regulation:
Guide for Education and
Therapy (TARGET)
 Is a strengths-based approach to
education and therapy for survivors of
physical, sexual, psychological, and
emotional trauma.
Trauma Affect Regulation:
Guide for Education and
Therapy (TARGET) Population
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Young adult ages 18-25
Adults ages 26-55
Male and Female
Race: Black or African American, Hispanic
or Latino, Race/ethnicity unspecified,
White
Trauma Affect Regulation:
Guide for Education and
Therapy (TARGET) Outcomes
• Decreased severity of PTSD symptoms
• Decreased PTSD diagnosis pre to posttreatment
• Reduced negative beliefs related to PTSD and
attitudes toward PTSD symptoms
• Reduced severity of anxiety and depression
symptoms
• Improved self-efficacy related to sobriety
• Increased emotional regulation
• Improved health-related functioning
Trauma Affect Regulation:
Guide for Education and
Therapy (TARGET) References
& More Info
• SAMHSA’s National Registry of Evidencebased Programs and Practices (NREPP)
• Julian D. Ford, Ph.D.
• Associate Professor
• Dept of Psychiatry, MC1410
• University of Connecticut Health Center
• E-mail: [email protected]
Evidenced Based Practices
• Integrated Co-Occurring Treatment Model
(ICT)
• Family Integrated Transitions (FIT)
Evidence-Based Mental Health
Programs that have had Success
with Substance Abuse Treatment
Evidenced Based Mental Health
Treatment that has success with COD
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MST*
Adolescent Transitions Program
Strengthening Families Program
Brief Strategic Family Therapy (Promising)
Multidimensional Family Therapy (Effective)
Functional Family therapy (effective)
ART
Dialectical Behavior Therapy*
Anger Management for substance abuse and
mental health clients
Multidimensional Treatment Foster Care
Adolescent Transitions
Program
• Promising Practice
• Outcomes
– Reduces Negative Parent/Child Interaction
– Decreases Antisocial Behavior at School
– Reduces Smoking at 1 Year Follow Up
Evidence-Based Practices
Parent Training
Adolescent Transitions Program
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School-based Universal, Selected, Indicated
Twelve Group and Four Family Meetings
Social Learning Theory – Skill Devel
Est cost to Implement $2,000 - $5,000
Thomas Dishion PhD, Kate Kavanaugh PhD –
University of Oregon
Evidence-based Mental Health Treatments
Strengthening Families Program
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Effective Practice
Targets high-risk children 6-12 yrs / parents
Created for children of parents with AOD
Improves Parenting Skills, Child Social
Behavior, and Family Relationships
• Decreases Parent/Child Substance Use, Child
Behavior Problems, Parent/Child Depression
• Up to 2-year longitudinal
Evidence-based Practices Treatments
Strengthening Families Program
• Adapted: African American, Asian/Pacific
Islander, Hispanic, Native American, Rural
Families
• Adapted to 10-14 year olds ( V.Molgaard)
• Three Part Curriculum – Parenting Skills, Child
Skills, Family Life Skills – 14 sessions
• Separate Parent and Child Groups
• Combined Parent and Child Group
• Training - $2,700-$3,700+
• Karol Kumpfer PhD – University of Utah
Evidence-based Practices
Brief Strategic Family Therapy
• Targets child/adolescents 8-17 years exhibiting,
or at risk of behavior problems including
substance abuse
• Promising Practice
• Improve Child’s Behavior by Improving Family
Interactions
Evidence-based Practices - Family Therapy
Brief Strategic Family Therapy
• Severe Conduct Disorder and Substance Abuse
= 24-30 Sessions
• Implementation : Three Day Training, Two Day
Booster, Monthly Phone/Video Consult (1 yr) -$18,000
• Jose Szapocznik PhD - Spanish Family
Guidance Center, Center for Family Studies,
University of Miami
Evidence-based Practices - Family Therapy
Multidimensional Family Therapy
• Targets Adolescents (11-18 years) with drug and
behavior problems.
• Effective/Promising Practice
• Outcomes include improvements in:
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Rates of drug Use {42%-70% abstinent at followup}
Behavior Problems
School Performance
Family Functioning
Evidence-based Practices - Family Therapy
Multidimensional Family Therapy
• Superior outcomes to CBT, Family Group
Therapy, Peer Group Therapy, and Residential
Treatment
• Superior outcomes to Residential Treatment for
Adolescents with Co-Occuring Conditions at 1 yr
follow up
• Howard Liddle PhD – University of Miami
Evidence-based Practices
Functional Family Therapy (FFT)
• Targets Youth 11-18 yrs at risk/
presenting behavior problems, substance
abuse, conduct disorder
• Effective Practice
Evidence-based Practices
Functional Family Therapy (FFT)
• Average duration of service is 3-4 months
• Cost effective
– On average costs $2,100 per youth
– 8-30 sessions of direct service
• Full time therapist will serve 12-15 families at
one time
• Site certification and training
– Teams of 3-8 interventionists - $25,000+
• James Alexander PhD – University of Utah
Evidenced Based Treatment
Aggression Replacement Training
(ART)
• Promising Practice / Proven Approach
• Assumes aggression is related to
– Weak or absent personal, interpersonal and social-cognitive skills
for pro-social behavior
– Impulsive and over reliance on aggressive means to meet daily
needs
– More egocentric and concrete moral reasoning
• Consists of three coordinated components
– Skillstreaming - Anger control training - Moral reasoning
Evidenced Based Treatment
(ART)—Skillstreaming
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Arnold Goldstein, Ph.D.
Procedures to enhance pro-social skill levels
Small group instruction
50 pro-social skills
Modeling “expert” use of the behaviors
Guided opportunities to practice and role-play
Provided performance feedback; praise, reinstruction and feedback
• Transfer training; encouraged to practice and use
in real world situations
Evidenced Based Treatment
ART-Anger Control Training
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Eva Feindler, Ph.D.
Teaches youth alternatives to aggression
An emotion oriented component
Involves modeling, guided practice, performance
feedback, and homework
• Youth are taught to respond to provocations
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Triggers
Cues
Reducers
Reminders
Use of appropriate skillstreaming alternatives
Self evaluation
Cognitive Behavioral Therapy:
ART—Moral Reasoning Training
• Group discussion of moral dilemmas
• Group rules
• Group process
– Introduce the problem situation
– Cultivate mature morality
– Remediate moral development delays
– Consolidate mature morality
Anger Management for
Substance Abuse and
Mental Health Clients
• Outcomes for Consumers with Substance Dependence,
Many of Whom had PTSD
– Significant reductions in self-reported anger and
violence
– Decreased substance use
– Positive impacts across ethnicities and gender
• Successful with Consumers w/o substance abuse, who
have mood and thought disorders.
• Studies for youth younger than 18 in process.
Anger Management for Substance
Abuse and Mental Health Clients
• Patrick M. Reilly & Michael S. Shopshire PhD
San Francisco Treatment Research Cntr
• Center for Substance Abuse Treatment,
SAMHSA
• Promising Practice (Probably) / Proven
Approach
• Bargain Basement Award - It’s Free!
http://www.kap.samhsa.gov/products/manuals/p
dfs/anger1.pdf
Evidence-based Practices –
Multidimensional Treatment
Foster Care
• Effective Practice
• Targets Adolescents with Delinquency and
their Families.
• Alternative to Group Home Placement and
Incarceration
Evidence-based Practices –
Multidimensional Treatment
Foster Care
• Patricia Chamberlain PhD – Oregon
Social Learning Center
Evidence Based Practices for
Adolescents Substance Use
Disorder Treatment
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Motivational Interviewing (MI)—Explain
Adolescent Portable Therapy
Behavioral Therapy for Adolescents
Brief Strategic Family Therapy
Multidimensional Family Therapy *
Multisystemic Therapy *
Seeking Safety *
Evidence-Based Preventative
Programs for Substance Use
Disorder
• Integrated Dual Diagnosis Treatment Model
(IDDT)
• Seeking Safety *
• Strengthening Families*
• Dialectical Behavior Therapy (DBT)*
• Trauma Affect Regulation: (TARGET)*
• Trauma Recovery and Empowerment Model
(TREM)*
Manualized Brief Interventions
Cannabis Youth Treatment
Series
Resource for substance abuse treatment
professionals that provide a unique perspective
on treating adolescents for marijuana use.
These volumes present effective, detailed,
manual-based treatment resources for teens
and their families.
These brief treatments can be transposed easily to
the mental health setting
Cannabis Youth Treatment
(CYT) Series
• Motivational Enhancement Therapy and Cognitive
Behavioral Therapy for Adolescent Cannabis
Users: 5 Sessions, Vol. 1. Sampl, S., & Kadden, R.
– Uses both motivational enhancement therapy and
cognitive behavioral therapy
Cannabis Youth Treatment
(CYT) Series
• Motivational Enhancement Therapy and
Cognitive Behavioral Therapy Supplement: 7
Sessions of Cognitive Behavioral Therapy for
Adolescent Cannabis Users, Vol.2. Webb, C.,
Scudder, M., Kaminer, Y., & Kadden, R.
– Uses cognitive behavioral therapy and Motivational
Enhancment –7 sessions
• Family Support Network for Adolescent
Cannabis Users, Vol.3. Hamilton, N.L., Brantley,
L.B., Tims, F. M., Angelovich, N., &McDougall, B.
– Provides additional support for families
Cannabis Youth Treatment
(CYT) Series
• The Adolescent Community Reinforcement
Approach for Adolescent Cannabis Users, Vol.4.
Godley, S. H., Meyers, R. J., Smith, J. E.,
Karvinen, T., Titus, J. C., Godley, M. D., Dent,
G., Passetti, L., & Kelberg, P.
– Outlines 12 individual sessions for adolescents and
their parents or caregivers
• Multidimensional Family Therapy for Adolescent
Cannabis Users, Vol.5. Liddle, H. A.
– Integrates family therapy and primary substance
abuse treatment
Cannabis Youth Treatment
(CYT) Series
References & More Info
• SAMHSA, Substance Abuse Mental
Health Services Administration.
• www.samhsa.gov
• CYT—Website
Section Five:
Recommendations
Recommendations
It is clear that there are enormous mental
health needs for adolescents with CoOccurring Disorders.
Recommendations
Assessment:
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Comprehensive biopsychosocial
assessment
Assess Mental Health Issues using standard
mental health intake process/evaluation
Assess for SUD using a brief screening tool
for substance use disorders in ALL
adolescents entering system
Recommendations
Assessment:
– Follow up with a comprehensive substance
use disorder assessment for adolescents
who have a co-morbid substance abuse
disorder
– Assess for trauma/victimization
– Assess readiness for change
Recommendations
Treatment:
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Implement science based psychotherapies for
co-occurring disorders into routine practice
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Target most common co-morbidities ,i.e.
Depression, ADHD, PTSD, CD
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Target most common substances abused;
marijuana alcohol/cigarettes
Recommendations
Treatment:
• Conceptualize SUD as a process; waxes/wanes,
relapse expectable. Unrealistic to expect total
remission in all cases.
• Medication has a place in treating co-morbid
disorders, particularly the internalizing disorders
Recommended
Programs
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Assessment format that includes standardized
SUD instruments, screening and more
comprehensive when indicated
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Preventive Program
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Strengthening Families
Family program
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GAIN
Sassi
Multisystemic Therapy
Or Family ----free on e
Trauma treatment paradigm
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Seeking Safety
Recommendations
• Substance abuse treatment protocol
– Motivational Enhancement and Cognitive
Behavioral Therapy (5 or 7 sessions)
– Motivational Interviewing.
• Individual Treatment
• Social Skills Treatment
– ART
• Placement
– MTFC