ALCOHOLISM/ADDICTION:ADULT/ADOLESCENT RELAPSE PREVENTION
CAREGIVING: BURDEN ON ONE FAMILY MEMBER
DISCHARGE PLAN, NEED FOR, ADOLESCENTS LEAVING RESIDENTIAL INSTITUTIONS
DOMESTIC VIOLENCE: BATTERED WOMEN
Substance abuse may be defined by continued use of alcohol or other drugs despite adverse consequences. Adverse consequences for adults or adolescents may include one or more of the following: family or work disruption, health threats, engaging in high risk behaviors, such as, driving while intoxicated, and poor school performance or failure (Barker, 1995; American Psychiatric Association, 1994). The leading causes of deaths among youths are accidents and suicides. These types of death are highly correlated with substance abuse. Research has suggested that substance abuse begins at an earlier age than in previous generations; and that in youth, substance use progresses into poly-substance abuse more quickly than in adults (Nowinski, 1990).
Although it may be useful in work with substance abusing clients generally, this task planner is oriented toward those who have made progress in treatment but who face risk of relapse. Relapse is considered to be the resumption of drug use after a period of abstinence. Generally relapse is accepted as a frequent part of the substance abuse/recovery process (N.I.D.A., 1994). In one large-scale study the only predictor of relapse was severity of drug and alcohol use at admission (McLellan, Alterman, & Metzer, 1997).
Literature: Catalano et al., (1991); Collier & Marlatt (1995); Curtis (1989); Fischer (1992); Kaminer (1994); Marlatt & Gordon (l985); Marlatt. & VandenBos (1997); McLellan, Alterman, & Metzer (1997); National Institute on Drug Abuse (1994); Nowinski (1990); Smyth (1998).
Task Menu
For Person with Substance Abuse Problem
1. Construct a "relapse plan," which includes actions that you will take to prevent relapse if one is imminent (Curtis, 1989) and actions you will take if relapse occurs (e.g., inpatient treatment, increasing relapse prevention efforts, or extended residential placement).
Practitioner’s Role: Provide information on inpatient and other appropriate treatment programs. Assist client in identifying appropriate actions to take to prevent relapse or if relapse should occur. For instance, a distinction between a "lapse" and a "relapse" can be made. A lapse is a single incident of drug use and may or may not result in relapse (i.e., returning to previous levels of substance abuse (National Institute on Drug Abuse ,1994).. Therefore, a lapse may be appropriately addressed by increasing relapse prevention efforts, while relapse may require admission to inpatient treatment.
2. Participate in drug-free recreation activities, (e.g. sports, clubs, creative pursuits, hobbies).
Practitioner’s Role: Provide client with information about drug-free programs and activities in the community. Assist client in identifying interests and suggest possible related activities the client may pursue.
3. Develop a recovery support system, comprised of persons who understand your problem and support your abstinence.
Elaboration: Identify supportive relationships and maintain regular contact with support system via phone calls and shared activities (Nowinski, 1990).
Practitioner’s Role: Assist client in identifying supportive persons in their families, peer group, school and community. If needed, assist client in finding additional members of support system by suggesting social opportunities for meeting friends.
4. Learn and practice refusal skills.
Practitioner’s Role: Obtain materials on refusal skills and provide training to the client by using such techniques as role-playing.
5. Identify triggers as well as risky situations that might cause a relapse.
Practitioner’s Role: Assist the client in identifying high risk situations that may lead to substance use as well as relapse triggers he or she may not be aware of (e.g. feelings such as anger, loneliness, fatigue, anxiety, places or activities that remind client of substance use).
6. Identify strategies and alternatives to using alcohol or drugs should relapse triggers occur (Curtis, 1989).
Practitioner’s Role: Provide client with helpful strategies, as needed. For example, have client notice how he or she is feeling, rather than use substances. If a client is anxious, recommend slow diaphragmatic breathing or applied relaxation.
7. Identify cognitions that have led to relapse in the past and develop alternative cognitions that help you remain free of alcohol and other substances.
Practitioner’s Role: Through use of cognitive restructuring, help client assess which cognitions led to relapse, then work with client to develop alternative cognitions that assist the client in remaining free of alcohol and other substances. For example, a client might say, "If I go past our old hang-out, I might as well go in and talk to my old friends." Work with client to develop alternative cognitions that assist him or her in remaining free of substances -- e.g., "Although I go by the old hang-out daily, I know I shouldn’t go inside. If passing by it continues to tempt me, I should go another way until I have the ability to resist going in. I should also hang out with my new friends that are cool and avoid substance use."
8. If relapse occurs, identify precipitating events, feelings, and triggers and record this information in a journal.
Elaboration: Keeping a journal increases awareness and helps prevent future relapses.
Practitioner’s Role: Read client's journal and utilize information to help client prevent relapse from similar circumstances that occur at a future time. For instance, if client has certain patterns, such as being able to go to a former place or type of party and abstaining from substances for the first four or five times, but then relapses after the fifth or sixth visit, then that place or type of party is not safe for him or her even though the initial successful visits seem to suggest that it is. The journal showing such a pattern suggests the course of action needed to prevent relapse.
9. [If adolescent] Identify school and career related goals and take action to prepare for the world of work (Kaminer, 1994).
Elaboration: Do any or all of the following: meet with an academic advisor to discuss academic plans, problems and future goals; learn more about career aspirations by talking to a career counselor; seek out a mentor; obtain a part time volunteer position; work at a paid career related job to gain work experience to apply toward career goals; look into vocational training, learn how to network.
Practitioner’s Role: Provide referrals to, mentor, vocational training, and job/volunteer programs, as well as career counselors in community. Teach client how to do networking.
10. Learn and practice communication and problem solving skills.
Elaboration: Use family members and other relationships to work on communication and problem solving skills. Participate in family meetings, etc., to practice using listening skills and "I messages" (Gordon, 1976).
Practitioner’s Role: Train client in communication and problem solving skills through role-plays and family work. Provide written materials to facilitate understanding.
11. Identify stress reduction activities that work for you and utilize them when under stress, (e.g. exercise, progressive relaxation, meditation).
Practitioner’s Role: Books, such as, Reaching New Highs: Alternative Therapies for Drug Addicts (Heggenhougen, 1997) and Life After Psychotherapy (Davison, 1997) contain information on meditation, as well as, other topics to help maintain recovery through the reduction of stress.
12. Participate in self-help groups, such as, Alcoholics Anonymous (AA), Narcotics Anonymous (NA) or Alateen.
Elaboration: Attend meetings, obtain and work with a sponsor, learn about and utilize coping and relapse prevention strategies suggested by fellow members.
The following information on locating self-help groups may be useful:
(For adults)
Alcoholics Anonymous P.O. Box 459, Grand Central Station, New York, New York 10163 (212) 870 3400; online contact http://www.alcoholics-anonymous.org/econtent.html Online directory by states enables one to locate AA group in any given community.
Rational Recovery Systems, P.O. Box 800, Lotus, CA 95651. Call (916) 621-4374 or 800-303-2873. Online Contact: http://rational.org/recovery/
Narcotics Anonymous: International P.O. Box 9999, Van Nuys, CA 91409. Call (818) 773-9999; FAX: (818) 700-0700. Online Contact: http://www.wsoinc.com or mailto:info@wso.com
SMART Recovery Self-Help Network (Self-Management And Recovery Training. SMART is an abstinence program based on cognitive-behavioral principles, especially those of rational-emotive-behavior therapy. Contact: SMART, 24000 Mercantile Rd., Suite 11, Beachwood, OH 44122. Call (216) 292-0220 (day) or (216) 951-0515; FAX: (216) 831-3776. Online Contact: mailto:srmail1@aol.com or http://www.smartrecovery.org/
(For adolescents)
Alateen International. Contact Alateen, c/o Al-Anon Family Group Headquarters Inc., 1600 Corporate Landing Parkway, Virginia Beach, VA 23454-56127. Call (757) 563-1600 or 800-344-2666;Online Contact:[nogood] http://www.al-anon.org or http://www.alateen.org
Practitioner’s Role: Provide meeting lists, but be aware that some clients are uncomfortable with 12-step programs for various reasons. If client is an adolescent, often the members are older than the adolescent client and he or she may be unable to relate to perceived differences in personal experiences or perspectives. Some communities have young people's groups, which would be preferable for an adolescent client under these circumstances. See Alateen above.
13. Discuss with partner ways partner can help you stay sober.
Practitioner’s Role: Meet with client and partner to develop plan that partner can use.
14. Imagine positive aspects of not drinking and negative aspects of drinking.
For Parents or Caregivers [If client is an adolescent]
1. Learn about adolescent substance abuse, relapse, and relapse prevention strategies and read articles and books about substance abuse recovery, adolescents and parenting.
Practitioner’s Role: Educate parents about adolescent substance abuse, relapse, and relapse prevention strategies. Provide reading materials and suggest relevant books. (Suggested books: Nowinski (1990) and Hawkins & Catalano (1992), on adolescent substance abuse.
2. Participate in ALANON or Families Anonymous program.
Elaboration: Attend meetings and obtain and work with a sponsor. Practice the coping skills suggested and ask for support from other members.
The following information may be useful in locating a group:
Al-Anon Contact Al-Anon Family Group Headquarters Inc., 1600 Corporate Landing Parkway, Virginia Beach, VA 23454-56127. Call (757) 563-1600 or 800-344-2666;Online Contact: http://www.al-anon.org
Families Anonymous: National. Contact: Families Anonymous, P.O. Box 3475, Culver City, CA 90231-3475. Call 800-736-9805 or (310) 313-5800; Online Contact: email to: famanon@earthlink.net or http://www.earthlink.net/~famanon.ondex.html
Practitioner’s Role: Provide meeting lists. Suggest the book, Alcohol Problems Among Adolescents (Boyd, Howard, & Zucker, 1995)
3. Work with adolescent to identify risky behaviors and together plan reasonable consequences for behaviors.
4. Provide appropriate supervision.
Practitioner’s Role: Educate and provide parent(s) or caregiver(s) with information and strategies as to what is appropriate supervision for an adolescent with a substance abuse problem. The Handbook of Parenting, Volume 4: Applied and Practical Parenting (Bornstein, 1995) should prove useful with this task.
5. Whenever possible, keep household drug/alcohol free.
6. Provide transportation to drug-free activities and 12-step meetings.
7. Assist adolescent with school and career related goals, help with decision making, be supportive and praise efforts to avoid substance use (Kaminer, 1994).
8. Work collaboratively with school system to organize (1) recovery assistance program for adolescents in recovery, as an alternative to drug culture at school; (2) weekend and summer drug-free recreation programs for adolescents, as part of the recovery assistance program.
Patricia Brescia, Lorn Gingerich, Pamela Zettergren
Even under the best circumstances, caregiving is a physically and emotionally demanding task. When it becomes the primary responsibility of one family member it can be overwhelming. The responsibilities impact family life, leisure time, work life, personal finances, and in some cases physical and mental health. Emotional burdens of caregivers include grief, anger, anxiety, guilt, depression, embarrassment, and altered family dynamics (Mellins, Blum, Boyd-Davis, & Gatz, 1993; National Alliance for Caregiving, 1997). As the care recipient declines and providing care becomes more involved, the situation tends to become increasingly tense for the care provider. One study of caregiving daughters showed that having roles in addition to caregiving, specifically those of worker and mother, was clearly associated with feelings of overload. However, resentment, in the caregiving role was highest for those who had fewer roles apart from eldercare, especially when they had to quit work to provide care, and they did not have a partner to talk with. Life satisfaction was higher for partnered and working caregivers (Murphy, Schofield, Nankervis, Bloch, Herrman, Singh, 1997).
Primary caregivers frequently cite that they need time for themselves, though many do not utilize services. Service utilization rates were lowest among Asian caregivers. Blacks and Hispanics were more likely than Whites or Asians to cite caregiving as a financial hardship (National Alliance for Caregiving, 1997). Compared with white caregivers, nonwhite caregivers are more likely to be an adult child, friend, or other family member rather than a spouse. Nonwhite individuals also report lower levels of caregiver stress, burden, and depression and endorse more strongly held beliefs about filial support. Nonwhite caregivers use prayer, faith, or religion as coping mechanisms (Connell & Gibson, 1997).
In one study (Cotrell, 1996), home respite was found to be greatly preferred over daycare by spouses whether or not they had used respite services. The majority of spouses saw overnight family care as appropriate only for emergencies, while adult children saw overnight care as appropriate for social and recreational activities.. Adult children, who resided with the care recipient, reported employment and caregiver stress and their resulting exasperation as an impetus for utilizing services.
Studies of interventions for caregiver burden suggest that individual intervention may be more effective than group intervention. (Knight, et al 1993; Toseland & Smith, 1990).
Literature: Clark & Rakowski (1983); Connell & Gibson (1997); Cotrell (1996); Gendron Poitras, Dastoor, & Perodeau (1996); Mellins, Blum, Boyd-Davis & Gatz (1993); Murphy, Schofield, Nankervis, Bloch, Herrman, Singh (1997); National Alliance for Caregiving (1997); Toseland et al (1990); Zarit & Edwards (1996).
Task Menu
1. Communicate problem of being overburdened to other family members.
2. Express feelings about providing care to other family members.
3. Identify better ways to balance caregiving role with other family members.
4. Designate other responsible caregivers.
Elaboration: Asserting oneself is particularly important in unbalanced caregiving relationships (Gendron, Poitras, Dastoor, & Perodeau, 1996).
5. Split caregiving tasks among family members.
Practitioner’s Role: Prepare client for increased tension and conflict that will likely result from this task. Have client remind family members that this situation, if handled with a positive attitude, can result in increased closeness, social support, and time spent together among family members (Mellins, Blum, Boyd-Davis, & Gatz, 1993).
6. Set up a family care plan, including who will be responsible for what type of assistance, and establish a process of monitoring the situation to ensure needs of care recipient are being met.
7. Discuss as family (including care recipient) the possibility of requesting outside services, including respite care.
Elaboration Two types of respite currently exist, short term and long term. Short term respite may consist having a person come into the home and watch the elder or temporary placement outside of the home in a structured setting, such as Adult Day Care (Mace & Rabin, 1991). Short term respite may last from one hour to a whole day. Respite has been found to increase caregiver attitudes, decrease caregiver stress as well as minimize depression and health and relationship problems (Cox, 1997). Respite has also been found to decrease the probability of long term care placement (Cox, 1997). In addition, in respite the elder can spend time with others, make friends, increase social behaviors, enhance feelings of self esteem and self worth, and increase independence from caregivers (Cotterill, 1997). Long term respite most often is a structured setting that the elder can stay for a number of days at a time, usually two days to a week (Mace, 1991). Long term respite offers the caregivers an opportunity to rejuvenate his/herself. Respite, at any length has been proven to improve caregiver attitudes, feelings of well being and to enhance ability to care for loved ones (Cox, 1997). The types of places that may offer long term respite include, hospitals, nursing homes, foster homes; also there may be family or friends who will care for the elder for an extended period of time
8. If relevant, designate family member(s) to investigate services available and arrange for an initial contact.
9. Discuss as a family (including care recipient) the possibility of placement in long-term care.
10. If relevant, designate family member(s) to investigate long-term care facilities and arrange initial contact.
11. Explore ways to recover personal time.
Elaboration Set aside blocks of personal time in which caregiving responsibility is covered by someone else (family member, adult day care, respite care).
Matthias Naleppa, Holly Hokanson
A major depressive episode is typified by both a depressed mood over which the individual has no control and a constellation of motor, neurovegetative, and cognitive symptoms that constitute a common psychiatric disorder. Major depression is not only frequently disabling, but also highly correlated with suicidal behavior (Ivanoff & Riedel, 1995). The individual with a clinically significant depression has sustained negative views of the self, of current experiences, and of the future, and these views are products of the enduring cognitive patterns that determine how the individual organizes experiences of the self and the environment (Beck et al 1979; Craighead, Evans & Robinson, 1994). The cognitive patterns are maintained by thinking that excludes alternatives contrary to the cognitive patterns (e.g., use of global versus specific explanations of bad events) ( Peterson & Seligman, 1984).
DSM-IV (American Psychiatric Association, 1994) states that a depressive episode is characterized by a period of at least two weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities, such that the individual experiences great subjective distress or impairment in previous interpersonal, social, and occupational functioning. Symptoms of depression include marked changes in weight or appetite; changes in sleep; changes in sexual activity; psychomotor agitation or retardation; decreased energy; feelings of worthlessness or guilt; difficulty concentrating; and preoccupation with death or suicide.
According to Kessler et al. (1994), approximately 13 percent of women and 8 percent of men in the United States experience a major depressive episode each year. Moreover, about 21 percent of women and 13 percent of men suffer one or more episodes over the course of their lifetimes. Kaplan et al. (1994) observe that women are twice as likely as men to experience major depression. Hypotheses for the sex-based difference in prevalence include hormonal differences, the consequences of childbirth, and social role differences. Kaplan et al. (1994) also point out that race does not have an impact on the prevalence rates of major depression; however, underdiagnoses or misdiagnoses occur when the race or culture of the diagnostician is different from that of the client.
The etiology of major depression is unclear and very likely results from an as-yet-unknown interaction among biological, psychosocial, and genetic factors. Biological factors include neurotransmitter abnormalities (a target of many anti-depressant medications); psychosocial factors include the extent of psychopathology in the client's family which may affect her or his rate of recovery, and the loss of a spouse or partner (Kaplan et al., 1994).
Assessment of major depression .includes obtaining a history of prior depressive episodes and the extent and severity of current symptoms. Particular attention should be given to the stressors that may have precipitated the depression or that may be maintaining it.
Observation of the client.is also pertinent. (Kaplan et al., 1994) report that the "classic" presentation of a depressed individual includes a "stooped posture, no spontaneous movements, and a downcast, averted gaze" (p. 532). Finally, objective rating scales, such as the Beck Depression Inventory (Beck,1978) may be used .
The concept of depression is broadly applied to various disorders that do not meet the criteria of major depression. These include minor depression, brief recurrent depressive disorder, dysthymia and sub-threshold depression (Badger & Rand, 1998). The task planners below apply to all forms of depression.
Meta-analyses and research reviews of controlled studies of interventions for depression provide support for cognitive-behavioral, cognitive, interpersonal, psychodynamic, and drug therapies but have not established that any one of these methods is superior to any other (DeRubeis & Crits-Christoph. 1998:. Dobson, 1989; Robinson et al., 1990).
Literature Akiskal & Cassano (1997) sets out an overview of chronic depressions and their clinical management; for a cognitive approach to depression see Beck., et al (1979). Thase (1996). Badger & Rand (1998) provides an overview of diagnostic considerations. Barker (1993)offers a self-help guide to managing depression. Cornes (1990) presents the interpersonal model for treating depression..Craighead, Evans & Robins (1992) discuss cognitive-behavioral treatment of depression: Libassi (1995). Nezu, Nezu &. Perri (1989) present a problem-solving approach. O’Connor (1997) a clinician who himself has struggled with depression, provides a useful resource for both practitioners and clients.
Task Menu
1. Consult with psychiatrist to assess need for anti-depressant medication.
Practitioner’s Role If psychotropic medication is prescribed for the client, educate her or him about the role of the medication vis-a-vis depression (Libassi, 1995).. Assist client in monitoring the effectiveness of the medication, as well as unwanted side effects (Libassi, 1995). Advocate for the client with the physician and others (e.g., multidisciplinary treatment team) in relation to factors that have an impact on the client's compliance with the medication schedule and the effectiveness of the medication (e.g., nutrition, supportiveness of other persons significant to the client) (Libassi, 1995). Collaborate with other professionals e.g.,-- provide psychosocial information gleaned from the client and persons significant to her or him (Libassi, 1995).
2. Identify modifiable factors, especially stressors, that might be causing or aggravating your depression
3. Select a stressor that you think you can change and take at least one step to change it.
4. Identify resources and coping mechanisms that can be utilized to alleviate your depression.
Elaboration Develop a task that makes use of one of these resources or coping mechanisms. For example, if discussing your problems with a particular person has helped in the past, try to arrange to have a conversation with this person.
5. Keep track of things you enjoy and accomplish
Elaboration A depressed person may downplay pleasurable or successful activities. In any case it is helpful to determine what is or is not being enjoyed or accomplished.
Practitioner’s Role A tool for recording is the Weekly Activity Schedule (Beck, et al 1979) in which client records his or her activities and rates his or sense or pleasure or mastery associated with them.
6. Undertake an activity that results in mastery or pleasure.
Elaboration Depressed people are often convinced that they can do nothing right, that whatever action they undertake will wind up as a failure, or they may see liitle that they do as bringing them any pleasure.
Practitioner’s Role To challenge these expectancies, graded tasks likely to lead to a successful or pleasurable outcome can be used (Sacco and Beck, 1985). A goal suggested by the client is selected. A series of tasks, graduated from easy to difficult, is set up to bring about step-by-step progress toward the goal. The goal itself may relatively simple accomplishment, such as a home improvement project or joining a social group. However, attainment of the goal itself is secondary to the main purpose of providing the client with a successful or enjoyable experience. The grading of the task permits repeated successes as well as adjustments if difficulties are encountered (Reid, 1992).
7. Increase your social activities.
Elaboration Withdrawal from social contacts is a common feature of depression. Simple tasks, such as attending a church event, may provide ways to begin to enhance the client’s social life.
8. Identify thoughts and beliefs that may add to your depression
Elaboration A person prone to depression tends to have an unrealistically negative view of self, the external world, and the future (Beck 1967; Sacco and Beck 1985). Distortions toward the negative are maintained by errors in processing information (see cognitive restructuring). With a depression-prone individual, these errors over-emphasize the negative. Thus, negative details about a situation are focused upon, the significant negative events are magnified and over-generalized, events are given a negative twist and personalized, and black or white thinking usually favors the black side (Reid, 1992).
Practitioner’s Role Useful client self-monitoring tools are the Daily Record of Negative Automatic Thoughts and the Daily Record of Dysfunctional Thoughts" (Sacco & Beck, 1985) . With the aid of such client self-recording, help the client identify cognitive distortions (e.g., personalization, dichotomous thinking) that may add to his or her depression. Using cognitive restructuring, help the client correct these distortions and generate rational responses to events and situations.
9. Identify underlying beliefs and assumptions that underlie depression.
Practitioner’s Role Help client extract from automatic thoughts and affective responses to situations the assumptive rules by which she or he organizes experiences. For example, Leonard may believe that he is basically unattractive to women. Thus he avoids initiating relationships with the opposite sex, a factor in his depression. Use cognitive restructuring to help client examine and challenge such assumptions and to replace them with more rational appraisals
10. Learn social skills to improve interpersonal relationships, including assertion and conversational skills.
Practitioner’s Role Help client identify and learn appropriate social skills through use of methods of social skills training (Craighead, Evans, and Robins, 1992).
11. Set realistic, attainable goals.
Elaboration Depressed persons often attempt to attain perfectionistic goals or standards; failing to live up to these expectations can aggravate depression.
12. Identify "messages" from important figures in the past that may be contributing to depression and attempt to act in ways that would modify these messages
Elaboration For example, Joan may have acquired the message from her parents that "you need to give in to get along," which has contributed to a pattern of submissive behavior, leading to feelings of self-contempt and resentment at others. Acting in a more appropriately assertive way could increase self-esteem and lead to more satisfying interpersonal relations (Jensen, 1994).
Practitioner’s Role Help client identify such messages including their dysfunctional components and to plan corrective tasks.
13. Identify role disputes and role transitions that may be contributing to depression (Cornes, 1990).
Elaboration Interpersonal role disputes --e.g. conflict with marital partner, employer -- and role transitions -- e.g. loss of job --can lead to depreciated self-esteem and demoralization and hence can be factors in depression.
Practitioner’s Role Help client carry out identification process, develop understanding of the problem, and devise plan of response. For example, client may have to mourn loss of cherished role before he or she can replace it. (Other task planners may relate to role problems. See, for example, COUPLE PROBLEMS: COMMUNICATIONS and PARENT-ADOLESCENT CONFLICT: PROBLEM SOLVING.)
14. Identify difficulties in establishing satisfactory interpersonal relationships, attempt to understand factors contributing to these relationships, and take steps to resolve them.
Elaboration Interpersonal deficits, with related problems such as loneliness and unstable relationships, can lead to depression (Cornes, 1990).
Practitioner’s Role Help client carry out processes of identification and development of understanding; help client develop tasks to improve interpersonal relationships.
15. Express your feelings.
Elaboration "Depression is an effort to avoid feeling" (O’Connor, 1997). It is better to experience painful feelings than to ward them off. Try to express them to others who will be accepting and provide you with support.
Kathyrn Baraneckie
Discharge from residential placement is a critical period in an adolescent’s treatment (Durrant, 1993). Many times mandatory clients do not follow through on their aftercare programs and relapse into preplacement behaviors. This is especially true with conduct disordered clients, who often show minimal improvement immediately on discharge but may improve over the long term (Pyne, 1985; Wells, 1993; Brown, 1994). As conduct disordered youth often suffer from a myriad of comorbid disorders, especially substance abuse, the task planners for their specific problems should also be consulted in the discharge process.
Involvement of the family is imperative. Family dysfunction often manifests itself in the acting out of the child or adolescent. Pyne (1985) noted marked family disharmony among 70 percent of his study group, and many studies show a strong correlation between family functioning, involvement in the patient's treatment, and successful outcome (Pfeiffer, 1990; Force, 1985; Brown, 1994).
An after-care plan should specify services adolescent is to receive during the transition from residential care to living at home, who is to provide them, and the processes of referral. The plan should include attention to the client’s school performance. How well the child does in school, both academically and behaviorally, has been found to be a good predictor of outcome (Force, 1985; Kowitt, 1989).
Literature: Brown, Myers & Mott (1994); Durrant (1993); Force & Sebree, J. (1985);. Kowitt et al (1989); Pfeiffer, & Strzelecki (1990); Pyne, Morrison, & Ainsworth, (1985);Wells & Faragher (1993).
Task Menu:
For Adolescents and Parents
(While in residential setting)
1. Identify successes in the program and how changes will translate into home life.
Elaboration Tasks1-4 can be completed as journaling homework and discussed at the next session
2. Identify possible and probable causes of problem behavior at home.
Practitioner’s Role Meet with client and family to review progress and anticipate future obstacles. Ideally, there should be at least 3 joint sessions with the parents and the adolescent in the last month before discharge with one of these sessions occurring on discharge day. During sessions help family and adolescent negotiate rules family will follow when he or she is home on pass. Help them focus on what is to be different when he or she returns home from what it was prior to placement
3. Identify strengths and interests that promote positive behavior at home.
4. Identify home support structures, i.e. helping agencies and individuals
5. Become involved in writing final discharge reports, recommendations, and referrals.
6. Develop plan for home pass.
Elaboration Identify necessary appointments – e.g. with aftercare services -- for the next home pass and make the appointments from practitioner’s office. Identify issues to talk about with parents and others.
Practitioner’s Role :Arrange for home passes with frequency and length contingent upon teenager’s behavior in the residence and at home. Home passes should become much more frequent and of longer duration as discharge nears.
7. Examine feelings about returning home.
(When on home pass)
8. Make contact with home support organizations -- e.g. aftercare service, Alcoholics Anonymous.
Practitioner’s Role Facilitate initial client contacts with outside agencies and helping organizations, including school. Meet with family members to discuss issues identified in Task #7 above.
9. Practice new living skills -- e.g. saying "no" to old "friends" who want to involve you in using substances. See Social Skills
10. Participate in previously identified positive lifestyle choices (work out in a gym, go to a concert, for a walk, a movie, etc.).
11. "Hang out" with a friend who won’t get you into trouble
Elaboration If you don’t have such a friend, try to make one.
12. Take an active part in at least one family activity each week.
Russell Gray
Within the past two decades, a good deal of attention has been given to the problem of women who are physically abused by their husbands or male partners (Webb, 1992; Grusznski, Brink, and Edleson, 1988). According to Stark and Flitcraft (1988) one fifth to a quarter of all women have been abused at least once by their male partners. About 22 to 35 percent of women who receive treatment in emergency rooms of hospitals are there due to symptoms that are related to ongoing abuse. (Randall, 1990). Statistics from the Bureau of Justice Statistics National Crime Victimization Survey estimate that 29 percent all violent crimes against women by single offenders were done by the person with whom they are intimate, namely husbands or boyfriends (Bachman and Saltzman, 1995). Women experiencing abuse often express feeling confused, frustrated, frightened, helpless, hopeless, depressed, angry, downtrodden, and worthless (Webb, 1992; Schumaker, 1985; Walker, 1978). Mistaken beliefs (cognitive distortions) about themselves and others interfere with the woman’s ability to behave in a self-sustaining manner (Webb, 1992). This contributes to difficulty in the woman’s ability to break away from the abusive relationship. Battered women seeking to free themselves of abusive relationships must struggle with a combination of emotional and practical issues. These take different forms depending on the nature of the relationship with the batterer.
Literature Carlson (1997); Petretic-Jackson and Jackson (1996); Dutton (1992); Webb (1992); Wilson (1997).
Task Menu
1.Gain perspective on situation by relating your experience of abuse to others.
Practitioner’s Role: An abused woman should be encouraged to "tell her story" to persons she trusts and who would respond supportively, including the practitioner (Davis and Srinvasan, 1995; Dutton, 1992; Petretic-Jackson and Jackson, 1996). This helps the woman gain perspective and prioritize her issues (Petretic-Jackson and Jackson, 1996).
2. Identify past efforts to control or stop abuse (Carlson, 1997).
Elaboration Taking inventory of past attempts to leave the relationship or control violence and assessing the extent to which prior efforts have proved effective are important in evaluating what future steps to take (Carlson, 1997).
3. Identify reasons/beliefs that you have for continuing the relationship (Dutton, 1992).
Elaboration Look at cognitive distortions about yourself and others. Webb (1992) suggests using a diary to write down these beliefs.
Practitioner’s Role Instruct and encourage client to use self-monitoring to evaluate and record behavior.
4. Identify other concurrent stressors.
Elaboration For example, what other issues might impact on your future decisions and may effect your ability to mobilize resources to address the abuse (Petretic-Jackson and Jackson, 1996)?
5. Develop safety plan (Carlson, 1997).
Elaboration A safety plan may comprise a number of components, depending on whether you plan to leave your partner -- for example, knowing where to go in case of danger, arranging for transportation to get out, having necessary items prepared in one place, for example, ID, medication, birth certificates, Social Security card, drivers license) changing locks on dwelling, obtaining an order of protection, securing an electronic necklace that can be used to summon police if in danger, notifying employers whom to call if absent, and arranging for safe care of children. Petretic-Jackson and Jackson (1996) suggest rehearsing mental-escape drills in session and then a "walk through" at home when the abuser is not there.
6. [If planning to leave batterer] Develop a plan for self-sufficiency -- e.g. income and shelter, including putting money aside prior to break-off.
Practitioner’s Role Explore resources as indicated -- e.g. shelters, support groups, special counseling programs, legal aid.
7. [If planning to leave batterer] Anticipate need to grieve loss of relationship and consider supports that may help with this process.
8. [If planning to leave batterer] Reinforce break-off by doing other new things, as symbolic of starting a "new life." -- e.g. getting new hairstyle, joining a group.
9. [If planning to leave batterer] Make use of help and support that might be provided by friends and family.
10. [If planning to leave batterer] If there are children and partner is father, work out plan for custody and visitation.
11. [If planning to leave batterer] Develop plan for making new relationships.
12. [If planning to leave batterer]. Consider circumstances in which you might be tempted to resume the relationship and devise ways of coping with these circumstances.
13. Learn about causes, dynamics, effects of battering, and services available.
Elaboration It is important you to learn the nature of domestic violence and its effects, how women’s historical oppression in society impact on this social problem, available services in the community, common emotion, physical, and behavioral after-effects. (This can help in "normalizing") In particular it is important for you to learn about cycle of abuse --abuse followed by contrition and reconciliation and then further abuse -- and how it applies to your situation. (Carlson, 1997); Petretic-Jackson and Jackson, 1996; Dutton, 1992). A useful book for victims of domestic violence is Wilson (1997).
14. Enhance coping strategies and modify cognitive distortions (Carlson, 1997; Petretic-Jackson and Jackson, 1996).
Elaboration Look at previous coping strategies and create a new repertoire of coping efforts. Modifying cognitive distortions includes modification of distorted and maladaptive beliefs such as the belief that you can control your partner’s violence or that he will start keeping his oft-broken promises never to hit you again. Consider modifying behaviors that are dysfunctional (e.g., being overly dependent emotionally or economically on the abuser). Cognitive-behavioral techniques that could be used include cognitive restructuring. stress inoculation, and coaching (Carlson, 1997; Webb, 1992).
14. Enhance problem solving and decision making skills (Carlson, 1997).
Elaboration This includes realizing that you have the right to make choices for yourself, and that you have alternatives and options (Carlson, 1997). See problem-solving training.
15. Reduce isolation and increase social support (Carlson, 1997; Petretic-Jackson and Jackson, 1996).
Elaboration Many women who are in abusive situations become socially isolated (Neilsen, Endo, and Ellington, 1992). It is important to increase social skills and social support, while reducing social isolation, as they are important coping resources. Gaining the support of women who were formerly in abusive relationships and have been able to achieve violence-free lifestyles, is very valuable (Carlson, 1997, 1996; Brown and Dickey, 1992).
Practitioner’s Role To help increase social support, you can encourage client to attend battered women’s support groups, reconnect (mobilize) with family and friends (Davis and Strinivasan, 1994; Dutton, 1992).
Miranda Koss