Harvey Milkman Powerpoint

TASMANIAN YOUTH CONFERENCE
20 May, 2011
Working With Youth At-Risk of AOD Abuse and Criminal Conduct

Tramsheds Conference Centre Launceston
Harvey Milkman, Ph.D.

Professor, Department of Psychology Metropolitan State College of Denver email: milkmanh@mscd.edu Tel: 303 556-4445
PREVENTION AND TREATMENT FOR ADOLESCENT SUBSTANCE ABUSE AND CRIMINAL CONDUCT
Part I Adolescent Development Pathways to Delinquency, Substance Abuse and Crime The Cognitive-Behavioral Revolution Evidence-Based Practices for Treating Adolescents Working with Female Adolescents Dealing with Gangs Co-Occurring Disorders Exemplary Treatment Approaches
Adolescent Psychological Development

From: (Pediatrics in Review. 2008;29:161-168. doi:10.1542/pir.29-5-161) 2008 American Academy of Pediatrics, Hazen,E., Schlozman, S., Beresin, E
Although adolescence is widely believed to be an inevitable time of turbulence and trouble, most teenagers progress through this period of life with few obvious emotional or behavioral difficulties.
Given a great deal of individual and cultural variability (e.g., an Asian youth who begins to question his or her parents values may be viewed by the West as healthy and normal adolescent development, and by his parents as pathologic and dangerous), the most useful definition of adolescence is not by age norms, rather by the developmental tasks characteristic of this age.
Although we can describe specific domains of adolescent development (i.e., physical, cognitive, psychological, and moral) such constructs exist in constant flux, interacting with each other, and do not occur in isolation (e.g., physical changes have a major impact on the social and emotional functioning and the boundaries between developmental domains are not always distinct). Brain development during adolescence corresponds to the development of new cognitive capabilities that, in turn, are involved in shifts in emotional regulation and processing.
TASKS OF ADOLESCENT DEVELOPMENT

Physical
Growth spurt Growth of pubic and body hair Growth and maturation of reproductive organs Boys: Increased muscle mass Onset of sperm production Girls: Development of female body shape, including breast development Menarche
Social and Emotional

Emotional separation from parents Greater sense of personal identity Identification with a peer group Exploration of romantic relationships and a sense of one's sexuality
Cognitive
Increased capacity for abstraction and advanced reasoning Greater impulse control More effective assessment of risk versus reward Improved use and manipulation of working memory Improved language skills Increased capacity to self-regulate emotional states
Moral
Usually a shift from preconventional to conventional level of morality in Kohlberg's theory Greater ability to take others perspectives Morality less concrete and rule-based, more focused on role obligations and how one is perceived by others May question values of parents and institutions
Physical Development
Physical changes in puberty are attributed to an increased pituitary sensitivity to gonadotropin- releasing hormone, leading to increased gonadal androgens and estrogens, thus bringing about rapid changes in height, weight, body shape and genital development. Girls in the US typically begin the physical changes of puberty between 8 and 13, with the development of breast buds, followed by additional breast development; enlargement of the ovaries, uterus, labia, and clitoris; and thickening of the vaginal mucosa. Menarche typically follows 2 to 2 years after breast buds with a mean age of 13. Boys in the US typically lag behind girls in most noticeable physical signs of puberty. Testicular enlargement usually begins around 12 and is followed by the growth of pubic hair and growth of the penis. For both sexes rapid growth in weight and height follows the onset of puberty, usually beginning distally in the hands and feet before moving proximally to the arms and legs and finally to the trunk. Height can outpace the growth of muscle mass, thus contributing to period of awkwardness for some teens. On average, girls meet their peak in growth velocity around 12, two years before boys.
Physical Development (cont.)

The timing of puberty is influenced by: Health and nutritional status (e.g., obesity has been shown to correlate with earlier onset of puberty in girls and delayed onset in boys; onset of menarche before the age of nine is rising in the US as is the average age of puberty compared to 30 years ago. Ethnicity (e.g., African American girls enter puberty slightly earlier than European American girls). The psychological impact of variations in the timing of puberty differs by sex: Early developing males have greater self-confidence and are likely to have greater academic, athletic and social success than their peers and especially when compared to late developing males. Early pubertal development in girls is correlated with lower self-esteem and heightened concern over body-image. Adequate sleep is essential for health development during adolescence: About 9 to 9 hours per night. Several factors contribute to inadequate sleep during adolescence: hormonal changes, including melatonin secretion, cause a relative sleep phase delay, with a natural tendency toward later onset of sleep and later waking times. Such biological changes correspond to increased academic and social demands. In addition to fatigue and impaired performance in class inadequate sleep may increase the risk of health problems such as obesity.
Emotional and Social Development

Epigenetic Model Erik Erikson
Emotional development is a series of crises where individuals must complete difficult, sometimes conflicting tasks in order to maintain a developmental trajectory.
Developmental challenges are binary crises that force the individual to choose a more adaptive (desirable) emotional stance (e.g., infancy is described as trust versus mistrust -- if infants do not learn to trust the world to care for them, they will develop a suspicious and paranoid stance when moving along the developmental trajectory).
Adolescence is a period of identity formation and role diffusion: An incoherent sense of self and values will result in the lack of as sense of identity.
A second separation from adult caretakers -- first separation occurs when the younger child attains the motor and cognitive ability to move away from the parents constant watch.
Emotional and Social Development (cont.)

From: Theory of Psychological Belonging : Noam G. The psychology of belonging: reformulating adolescent development. Adolesc Psychiatry. 1999;24 :49 68
Adolescence is less concerned with identity formation that group cohesion ( e.g., the middle school child places a high priority on popularity is in the midst of a normal developmental stage.
Successful membership within groups sets the stage for later confidence to move throughout different groups. Healthy early adolescence is characterized by identity with specific group values and norms. Healthy later adolescence is characterized by increasing comfort with one's capacity to choose among many different groups and to endorse selectively the values that have particular relevance to the individual. Clinical implications: Any attempt to counsel younger adolescents must take into account increased susceptibility to peer pressure as a means of maintaining group identity; older adolescents generally respond more readily to challenges to resist peer pressure for the sake of forming their own unique sense of identity.
Horizontal Conformity
The Deviant Career

Role of Parents
As adolescents develop increasing autonomy from parents, they occasionally regress and need more nurturance and caretaking. Although they may appear aloof, they are strongly influenced by values and attitudes of parents and other trusted authorities. It is extremely important for adults to open lines of communication and be mindful of the values and behaviors they are demonstrating to youth. Teens are often likely to accept parental values after having gone through periods of rebellion and rejection.
During periods of separation, teens may look to other adults as role models (e.g., teachers, coaches, friends parents).
During early adolescence teens may romanticize relationships with other adults and develop a crush on an idealized authority figure. Healthy parenting facilitates identity formation and separation from parents.

Development of a Healthy and Stable Self-Image
One of the major goals of psychological development in adolescence. Poor self image correlates with: difficulties in peer and family relationships; depression; unsafe sex; risky or acting out behaviors; poor school performance; and substance abuse. Parents and other authority figures can promote a health self-image by setting an example in their own lives and by demonstrating acceptance of the teenager. Parents should take note of positive qualities that they admire and express praise for these qualities.

The Impact of Physical Illness
Physical illness can have a tremendous impact on self-esteem during adolescence for both visible manifestations (e.g., deformity) or less visible conditions (e.g. diabetes). At the height of importance of group cohesion physical illness can bring on feelings of being flawed or alienated from his peers.
Illness can lead to a greater reliance on parents during a time of struggle to gain a sense of independence.
Psychotherapy, adolescent support groups and similar programs, such as diabetes camps, can reduce the sense of isolation often triggered by physical illness.

Impulsivity and Risk Taking
Younger adolescents have a sense of grandiosity and invulnerability, coupled with limited capacity to foresee ramifications of risky behaviors and to take long-term consequences into account.
Advances in physical maturity, sex drive, intellectual ability, earning potential, and mobility may heighten risk potential. Risk experimentation may include: sexual behavior; use of alcohol or other drugs; and going to dangerous places.
Much adolescent risk-taking has a neurologic basis as the brain is a work in progress.
Clear expectations and firm limits are required from parents, teachers, counselors, and other adult role models. Teenagers may not like what they hear but can perceive such limits as signs of love and protection.
Although limits need to be set on unsafe behavior, experimentation (in everything from hair style to political world view) is seen as essential to the assemblage of healthy self-image.

Common Childhood Risk Factors Predisposing Adolescents to Delinquent Behavior Parental psychiatric illness Learning disabilities History of serious head trauma Severe behavioral problems (e.g., fire setting or cruelty to animals) School problems Family dysfunction Alcohol or Drug Abuse Delinquent peers Emotional distress Criminal activity
Cognitive and Brain Development

Piagets Cognitive Theory
Current perspectives on cognitive development during adolescence are rooted in the work of Jean Piaget (1896 1980). A shift from the rule bound, concrete methods of problem solving during childhood (concrete operations) to more abstract thinking and more flexible problem solving (formal operations). Starting at around 11 years of age the adolescent begins to think hypothetically and to generalize from empiric observations, and to develop abstract concepts (e.g. fairness to all people) that guide future decisions and actions.
Brain Development During Adolescence

Structural brain imaging studies conducted during the past decade challenges earlier concepts that most brain development is complete by early childhood. There are significant increases in white matter (which represents fiber growth and myelination) during adolescence that continues into the early 20s.
Myelination occurs caudal-to-rostal (back to front), thus pathways originating from sensory and motor regions mature earlier than prefrontal areas associated with executive functions (i.e., reasoning and judgment).
There a decrease in gray matter density in the frontal and parietal lobes; this also occurs in a caudal-to-rostal pattern.
Decrease in gray matter is thought to be due to a process of pruning - an experience-driven maturational process in which active neuronal connections are strengthened and idle ones are lost, with subsequent apoptosis (cell death) of inactive neurons.
FRONTAL LOBE DEVELOPMENT The executive region of the brain is not always functioning fully in teenagers This would suggest that teenagers arent thinking thorough the consequences of their behaviors.
Brain Development During Adolescence (cont)

Implications of Brain Imaging Studies
Major changes in brain structure are definitively known to occur through early adult years. These data may provide a basis for understanding how adolescent thinking differs from adult cognition. The ventromedial prefrontal cortex, for example, is associated with the capacity to evaluate risk and reward to guide decision making. Imaging studies suggesting that this area is one of the last brain regions to mature is consistent with observations from behavioral studies involving activities such as gambling, in which adolescents are substantially more likely to take greater risks than are adults.
Recklessness may be related to a lesser ability during adolescence to utilize brain regions best equipped to assess risk and benefits. Maturation of other regions of the prefrontal cortex are consistent with observed gains in working memory, emotion regulation, and the capacity for long-term planning.
SUBSTANCE ABUSE AND THE ADOLESCENT BRAIN

Impulsivity, shortsightedness, and risk-taking behavior are, at least in part, biologically driven.
Attempts designed to change adolescents thinking (in the larger sense cognitivebehavioral treatment), such as antismoking campaigns, may not be sufficiently effective on their own, but need to be bolstered by measures that enforce behavior, such as parental supervision and laws against the sale of cigarettes to minors.
In addressing risky behaviors during teen years (by parents, counselors or health care practitioners), it is important to view these behaviors in a developmental context rather than attributing them to simplistic explanations, such as peer pressure. Understanding (and modifying) these behaviors requires some understanding of the cognitive (including neuro-psychological), social, and emotional development of the individual.
AMYGDALA
This area of the brain is associated with emotional and gut responses.
New imaging studies suggest that teenagers, when asked to interpret emotional information, use this reactive part of the brain rather than the more thinking region the frontal cortex . Scientists speculate that this may be why teens have trouble moderating their emotional responses

Brain studies shed light on the heightened role of emotions during adolescence.
Because of the social and cultural milieu context of adolescence, many important decisions are made by teenagers in emotionally charged settings. The dare, for example, to drink more alcohol or to drive too fast often is presented when the teenager is in a hotly emotional state.
Decisions that stem from these emotionally charged moments may be considered hot cognitions. The intense emotionality of these moments relies on more fully developed limbic brain regions, and as a function of the incomplete myelinations in cortical regions, these decisions do not benefit from proportionately similar consideration from executive brain regions. Attempts designed to change adolescents thinking (in the larger sense cognitive-behavioral treatment), such as antismoking campaigns, may not be sufficiently effective on their own, but need to be bolstered by measures that enforce behavior, such as parental supervision and laws against the sale of cigarettes to minors.
In addressing risky behaviors during teen years (by parents, counselors or health care practitioners), it is important to view these behaviors in a developmental context rather than attributing them to simplistic explanations, such as peer pressure.
Understanding (and modifying) these behaviors requires some understanding of the cognitive (including neuropsychological), social, and emotional development of the individual.

When challenges are presented to adolescents in less emotionally hot settings, they make safer decisions and presumably use higher brain structures more effectively.
Attempts to help adolescents to maintain their own safety also must focus on removing some of the affective energy that adolescents might feel when contemplating risky behavior. An important aspect of adolescent treatment is to anticipate some of the difficult decisions that adolescents are likely to face, such as getting into a car driven by a friend who is drunk, and helping them think through the process before it occurs, outside of the emotional pressures of the moment.
In general, discussions about an adolescent's risk-taking behaviors, both past and future, might be most productive in moments of relative calm.
Kohlbergs Theory of Moral Development

Based on interviews with large numbers of people across a broad age-span about moral dilemmas, Kohlberg described six stages of moral development, grouped into three basic levels.
Preconventional: Person is grounded in and individualistic perspective, guided by selfinterest in following rules to avoid punishment. This is the level of most children prior to the age of 9, many adolescents, and adult criminals.
Conventional: During adolescence most people move to the level where moral thinking is
guided by interpersonal relationship and social roles. Others perspectives are considered and moral actions are guided by social role expectations and the need to be seen as a good person. Cognitive development (i.e., abstract thinking, taking others perspective, concern of how one is viewed by peers) is necessary but not sufficient for progression to the conventional level. Most adolescents and adults remain in the conventional level of moral maturity.
Postconventional: The minority of people who progress to the more principle-based

postconventional level do so after the age of 20 years.
Gilligan views Kohlbergs theory as too focused on a male perspective of morality based on justice. She proposes an alternative view based on caring for others.
What is Normal?
During times of stress adolescents frequently regress to earlier stages of development (e.g., reading books from an earlier period of childhood; organizing or assessing a doll collection). When this type of regression is short lived (i.e., less than a few weeks) it does not warrant particular clinical attention.
Becoming increasingly engrossed in regressed activities does not necessarily represent significant problems but is a marker for additional attention.
Adolescents often experiment with edgy topics and behaviors but it behooves the clinician to have an understanding of teen pop culture to assess the degree of pathology associated with a particular form of interest or behavioral manifestation. Sexual behavior is a huge part of adolescence, ergo experimentation is normal and expected.
Clinicians are encouraged to assist teens to understand the risks of their behavior and to serve as a non-judgmental source of information and guidance.
Adolescent Problem Behavior vs. Normal Adjustment

Principles to help distinguish severe problems of adjustment in adolescence from common transitory difficulties of growth (Steinberg): Be aware of the distinction between intermittent experimentation vs. enduring patterns of problem behavior. Investigate whether problem behavior began in adolescence. Keep in mind that most of the problems experienced in adolescence will be resolved by early adulthood. Understand that problem behavior does not result from adolescence itself. Distinguish adolescents that display only one type of problem behavior from adolescents who display co-morbidity. Determine if an adolescents behaviors are defined as problems by parents but not peers, or by both parents and peers.
Summary of Adolescent Development

Adolescence is a complex developmental process with great variation across individuals and cultures. During the past 20 years neuroscience has shown dramatic biologic changes in the brain which underlie major cognitive, emotional and behavioral shifts during this period of life. Successful adolescent development results in biological maturity, a sense of an independent self, the capacity to form close peer and group relationships, and the cognitive and psychological resources to face the challenges of adult life.
Historically, many discussions of maturation end with the completion of adolescence, however modern developmental theorists view development as process that occurs throughout the lifespan.
Young adulthood presents a series of new challenges including: the capacity to form stable relationships based on the principles of mutuality and respect; search for a fulfilling career. Healthy adolescence sets the stage for additional growth in the decades to come.
Part I Adolescent Development Pathways to Delinquency, Substance Abuse and Crime Evidence-Based Practices for Treating Adolescents Working with Female Adolescents Dealing with Gangs Co-Occurring Disorders Exemplary Treatment Approaches
THEORETICAL FRAMEWORK FOR UNDERSTANDING JUVENILE DELINQUENCY
Social Learning Theory SLT Problem Behavior Theory PBT Theory of Planned Behavior TPB Social Norms Theory SNT Theory of Transitional Teens - TTT Cognitive-Behavioral Therapy - CBT Acquired Preparedness Model APM Social-Community Responsibility Theory - SCRT
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Social Learning Theory - SLT

Three core principles of SLT: 1. Observing behavior; 2. Adopted behavior strengthened when it leads to desirable outcomes; 3. Behavior integrated when there is a CB connection with the observer. Risk: Adolescents adopt behaviors, cognitions (e.g., beliefs) and emotions modeled by peers and adults related to substance use and criminal conduct.
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PROBLEM BEHAVIOR THEORY - PBT

PBT holds that all behavior emerges out of the interaction of three systems: personality behavior environment Risk: When personality features of poor self-control, impulsivity, risk taking, rebellion results in such problem behaviors as substance abuse and criminal conduct ; risk increases with exposure to environments where these behaviors are rolemodeled/normalized.
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THEORY OF PLANNED BEHAVIOR (TPB)

Behavioral intention based on beliefs that: the outcome will be positive; others want them to do it (subjective expectation); perceived self-control succeed at the behavior.
Risk: Intention to use drugs and commit crimes combined with the expectation that others expect this are reinforced by the perception that one can successfully engage in the behavior.
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SOCIAL NORMS THEORY (SNT)

Engaging in a behavior is determined by what the person thinks their peers are doing/thinking and then conforms to what they believe is the norm often, the perception is incorrect (overestimated) and the consequences are underestimated
Risk: Adolescent perceives, e.g. everyone uses drugs or everyone in their hood belongs to a gang, sells drugs, commits crimes its the norm
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TRANSITIONAL TEEN THEORY (TTT)

TTs (15-17 year-olds) are moving away from parent/home structure/supervision facilitated by the rites of passage associated with growing up, e.g., alcohol or other drug abuse, drunk driving, gang membership. Risk: Decrease in parental supervision and increase risk of involvement in drinking, risk taking behavior (e.g., sexual, criminal conduct); risk increases when affinity group has deviant norms
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COGNITIVE-BEHAVIORAL (CB) STRATEGIES

CB holds that cognitive structures (beliefs, thoughts) and social interactions determine disturbances in emotions and behavior; delinquent acts are selfreinforced (strengthened) when: outcomes reinforce the behavior; outcomes strengthen the thoughts that lead to the behavior
Risk: Lack of cognitive skills to manage and control thoughts and beliefs that lead to delinquency; and deficits in social skills to manage relationships that put the person at risk for substance abuse and crime.
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ACQUIRED PREPAREDNESS MODEL (APM)

Combination of personality trait cluster of disinhibition/impulsivity/behavioral undercontrol (that may have genetic loadings) with environmentbased learning factors that set the stage for acquired preparedness for teenage crime and substance abuse. Risk: When constitutional (genetic factors associated with behavioral undercontrol) are combined with the expectation of positive outcomes of substance abuse and criminal conduct, delinquent acts are more likely to occur.
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SOCIAL AND COMMUNITY RESPONSIBILITY THEORY (SCRT)

SCRT holds that engaging in irresponsible and harm behavior towards others is based on cognitive deficits and cognitive skills that determine moral reasoning and moral and community responsibility, i.e., empathy. Risk : egocentric thinking and empathy deficits causing difficulty seeing how AOD abuse or property crime can cause harm to others and the community; deficits in moral reasoning and values that prevent engaging in responsible behavior in the community.
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FROM THEORY TO PRACTICE

SLT: Adolescents adopt behaviors, cognitions (e.g., beliefs) and emotions modeled by peers and adults related to substance use and criminal conduct.
PBT: When personality features of poor self-control, impulsivity, risk taking, rebellion results in such problem behaviors as substance abuse and criminal conduct ; risk increases with exposure to environments where these behaviors are rolemodeled/normalized. TPB: Intention to use drugs and commit crimes combined with the expectation that others expect this are reinforced by the perception that one can successfully engage in the behavior. SNT: Adolescent perceives, e.g. everyone uses drugs or everyone in their hood belongs to a gang, sells drugs, commits crimes its the norm. TTT: Decrease in parental supervision and increase risk of involvement in drinking, risk taking behavior (e.g., sexual, criminal conduct); risk increases when affinity group has deviant norms. CB: Lack of cognitive skills to manage and control thoughts and beliefs that lead to delinquency; and deficits in social skills to manage relationships that put the person at risk for substance abuse and crime. APM: When constitutional (genetic factors associated with behavioral under control) are combined with the expectation of positive outcomes of substance abuse and criminal conduct, delinquent acts are more likely to occur. SCRT: Egocentric thinking and empathy deficits causing difficulty seeing how AOD abuse or property crime can cause harm to others and the community; deficits in moral reasoning and values that prevent engaging in responsible behavior in the community.
THE COGNITIVE-BEHAVIORAL REVOLUTION

CBT Past and Present What is Cognitive-Behavioral Treatment for Criminal Justice Clients? What Works? SCRAM: Core Components of Criminal Conduct and Substance Abuse Treatment
THE COGNITIVE-BEHAVIORAL REVOLUTION IS BASED ON THE IDEA THAT:
Control over our feelings and actions can be achieved by learning skills to become aware, manage and change underlying patterns of thought and belief.
WE HAVE REACHED THE EVOLUTIONARY JUNCTION OF SELF- REGULATION!
BASIC PRINCIPLES OF CBT

The fundamental principles of CBT have been linked to ideas that were first described thousands ago years ago.
CBT is a commonsense approach that is based on two central ideas:

Our thoughts have a controlling influence on our emotions and behavior;
We can learn skills to change or manage negative thoughts thereby regulating feelings and actions to achieve desired outcomes.
Taoism and Buddhism

In Eastern philosophical traditions cognition is regarded as a primary force in determining human behavior.
Men are disturbed not by the things which happen, but by the opinions about the things.
- Epictetus
The cognitive elements of this viewpoint were recognized by Greek philosophers two thousand years before the introduction of CBT.
AARON BECK Beck identifies two primary levels of cognitive processing:
1.
The highest level of functioning is Consciousness CBT therapists encourage the development and application of rational thinking and problem solving.
The therapist helps patients recognize and change pathological thinking on two levels: Automatic Thoughts cognitions that stream rapidly through our minds when we are in the midst of situations (or recalling events). This talk is boring; get me out; I cant take it anymore. Schemas core beliefs that give meaning to information from the environment. Academics no nothing about the real world.
2.
There is an emphasis on techniques designed to help clients detect and modify their inner thoughts, especially those that are associated with emotional symptoms such as depression, anxiety or anger.
One of the most important clues that automatic thoughts might be occurring is the presence of strong emotions.
Ethics for the New Millennium

Dalai Lama (1999)
If we can reorient our thoughts and emotions, and reorder our behavior, not only can we learn to cope with suffering more easily, but we can prevent a great deal of it from starting in the first place.
CBT AND BUDDHISM

Aaron Beck, Gteborg, June 13, 2005
Goals Serenity, Peace of Mind, Relief of Suffering
Values Importance of Acceptance, Compassion, Knowledge, Understanding Altruism vs. Egoism Universalism vs. Groupism: We are one with all humankind. Science vs. Superstition Self-responsibility
Causes of Distress: Egocentric biases leading to excessive or inappropriate anger, envy, cravings, etc. (the toxins) and false beliefs (delusions) Underlying self-defeating beliefs that reinforce biases. Attaching negative meanings to events. Methods: Focus on the Immediate (here and now) Targeting the biased thinking through (a) Introspection, (b) Reflectiveness, (c) Perspective-taking, (d) Identification of toxic beliefs, (e) Distancing, (f) Constructive experiences, (g) Nurturing positive beliefs Use of Imagery Separating distress from pain Mindfulness training

What is CBT?
CBT [in offender treatment] targets the thoughts, choices, attitudes, and meaning systems that are associated with antisocial behavior and deviant lifestyles.
It uses a training approach to teach new skills in areas where offenders show deficits, such as interpersonal problem awareness, generating alternative solutions rather than reacting on first impulse, evaluating consequences, resisting peer pressure, opening up and listening to other perspectives, soliciting feedback, taking other persons well-being into account, and deciding on the most beneficial course of action. The CBT therapist acts as a teacher or coach and lessons are typically taught to groups in classroom settings.
The lessons may include group exercises involving role-play, rehearsal, intensive feedback, and homework assignments and generally follow a structured curriculum with detailed lesson plans.
Lipsey and Landenberger, 2005, p. 1
THE BASIC PRINCIPLES OF COGNITIVE THEORY

The cause of dysfunctional behavior is dysfunctional thinking Thinking processes are shaped by underlying beliefs
Therefore, unless beliefs change behavior will never change
The Iceberg
Above the surface BEHAVIOR
Beneath the surface:

THINKING; FEELING; ATTITUDES & BELIEFS
How does CBT apply to judicial clients?

A sociocentric approach is taken so that offenders are guided to consider and develop their responsibility toward others and the community. Attitudes and skills are built for moral responsibility, empathy, and concern for the welfare and safety of others.
THE COGNITIVE BEHAVIORAL VIEW

Offenders are not necessarily sick
Cognitive groups are not traditional therapy Thinking is a learned behavior/process

If we teach new thinking skills there will be new social behavior
Cognitive and Behavioral Techniques Based on Social Learning Theory (SLT)

Effective modeling Effective reinforcement Effective disapproval Self-regulation and self-management skills Relapse prevention & planning
Example of a Thinking Report

Situation:
___________________________________ Thoughts: Feelings: Core beliefs, mindsets: Outcomes:
Offender Thinking Report

Situation: I skipped my piss test (UA) today! Thoughts:
Im tired of this B.S.! Im not goin in! Ill figure out an excuse.
Feelings:
Angry, nervous, frustrated Defiant, pissed, powerful Deceitful
My PO doesnt give a damn anyway.
Frustrated, depressed, tired
Even if I get caught, it was worth it Indifferent, resentful, trapped to get high.
Core Belief: No ones gonna control my life! Outcome: Parole Violation
ELEMENTS OF CBT PROGRAMS FOR OFFENDERS

Cognitive skills: Training on general thinking and decision-making skills such as to stop and think before acting, generate alternative solutions, evaluate consequences and make decisions about appropriate behavior. Cognitive restructuring: Activities and exercises aimed at recognizing and modifying the distortions and errors that characterize criiminogenic thinking. Social skills: Training in prosocial behaviors, interpreting social cues, taking other persons feelings into account, etc. Anger control: Training in techniques for identifying triggers and cues that arouse anger and maintaining self control. Moral reasoning: Activities designed to improve the ability to reason about right and wrong behavior and raise the level of moral development.
Victim impact: Activities aimed at getting offenders to consider the impact of their behavior on their victims. Substance abuse: Application of any of the typical CBT techniques specifically to the issue of substance abuse.
Behavior modification: Behavioral contracts and/or reward and penalty schemes designed to reinforce appropriate behavior. Relapse prevention: Training on strategies to recognize and cope with high risk situations and halt the relapse cycle before lapses turn into full relapses. Individual attention: Any individualized one-on-one treatment element that supplements CBT group sessions, e.g., individual counseling. (Lipsey et al., 2007)
CRIMINAL THINKING
One of the most notable characteristics of judicial clients is distorted cognition: Self-justificatory thinking Misinterpretation of social cues Displacement of blame Deficient moral reasoning Schemas of dominance and entitlement
Such distorted thinking may lead offenders to misperceive benign situations as threats (e.g., be predisposed to perceive harmless remarks as disrespectful or deliberately provocative), demand instant gratification, and confuse wants with needs. Criminal thinking is often linked to a victim stance with offenders viewing themselves as unfairly blamed, even hated, and cast out from society. These thought patterns may be supported through entrenchment in an antisocial subculture (e.g., prison or street codes) where dysfunctional assumptions may be adaptive, e.g. violence = respect.
(Beck; Dodge; Walters & White; Yochelson & Samenow; Lipsey, Landenberger & Wilson)
What do the prominent CBT programs have in common?

They are highly structured treatment services that are typically delivered to groups of 8 12 in a classroom-like setting.
They assist judicial clients in four tasks: defining the problems that led into conflict with authorities, selecting goals, generating new alternative prosocial solutions, and implementing the solutions.
CBT Treatment Goals for Substance Abuse / Criminal Justice Clients
THE COGNITIVE-BEHAVIORAL MAP

Why a manualized treatment curriculum?

A written guide will provide:
A clear outline of the purpose of the treatment. Definition of the goals of the treatment. The appropriateness of the content of the therapy to change behavior.
The ability of the treatment staff to work with offenders. Continuity of services can be achieved even with staff absences or turnover. Program managers can have an objective means to assess treatment progress.
Studying the effects of CBT

Lipsey et al. (2007) assert that there are too many moderating variables (e.g., staff training, length of contact in treatment, aftercare provisions, quality control and staff supervision) to identify a specific CBT program as superior in achieving measurable treatment outcomes. However there has been a preponderance of evidence to demonstrate the effectiveness of standardized CBT curricula.
WHAT SCIENCE KNOWS

On the basis of a meta-analysis including 58 outcome studies that compared the effects of CBT to a matched comparison group, the general CBT approach is found to be responsible for the overall positive effects on recidivism. No significant differences were found in the effectiveness of the different types or brand names of CBT (e.g. Moral Reconation, Thinking for a Change,, Reasoning and Rehabilitation, Aggression Replacement Therapy, Interpersonal Problem Solving Therapy)
Recidivism is .4O (4 out of 10) in the first 12 months after the control intervention vs. .30 (3 out of 10) in the treatment group), a 25% decrease. The most effective configurations of CBT produced odds ratios nearly 2x as large as the mean, corresponding to about .19 (about 2 out of 10) in the treatment group vs. .40 (4 out of 10) of the average control group.
Interpersonal problem solving and anger control components increase positive program effects (victim
impact and behavior modification components appear to diminish success). High quality programs are characterized by few treatment dropouts, close monitoring of the quality and fidelity of the quality and fidelity of the treatment implementation, and adequate CBT training for the providers.
Treatment effects are greater for offenders with higher risk of recidivism when more intensive services target criminogenic needs (e.g., criminal thinking) using CBT and social learning approaches.
CBT is as effective for juveniles as for adults. Treatment setting is not related to treatment effects (i.e., offenders treated in prison, generally close to the end of their sentence showed recidivism decreases comparable to those of offenders treated in the community, e.g., while on probation, parole, or in transitional aftercare). (Lipsey et al., 2007)
Elements of CBT Programs and Strongest Effect Sizes

Recidivism Risk Rating Sessions per week (minimum of 2x per week) Hours per week Total hours of treatment logged Individual Attention Anger Control Cognitive Restructuring The strongest relationship appeared for individual attention, followed by anger control and cognitive restructuring.
Implementation
The devil is in the details!
QUALITY IMPLEMENTATION IS CRITICAL FOR PROGRAM SUCCESS!

Assessing needs (agency, client, system) Cost and availability Initial Ongoing Facilitator training Agency overview training Quality control Program integrity Outcome evaluation
Maintain program integrity (dont adapt/alter)
EFFECTS OF COGNITIVE-BEHAVIORAL PROGRAMS FOR CRIMINAL OFFENDERS
Citation: Lipsey MW, Landenberger NA, Wilson SJ. Effects of cognitive-behavioral programs for criminal offenders. Campbell Systematic Reviews 2007:6 DOI: 10.4073/csr.2007.6
Harvey Milkman, PhD Kenneth Wanberg, PhD May 2007
National Institute of Corrections www.nic.org NIC Accession Number 021657

Stages of Change
SCRAM: GENERIC TREATMENT MODELS
Cognitive-Behavioral Treatment Relapse Prevention

Assessment / Hypothesis Testing
Motivational Enhancement
STAGES OF CHANGE
Entry
Relapse
Permanent Exit
PreContemplation
Maintenance
Contemplation
Action
Determination
Prochaska & DiClementes six stages of change.
STAGES OF CHANGE
Prochaska & DiClemente
Determination Decision
SEARCHING FOR SMUGGLED NOSE POWDER pre-contemplation
Stages of Change

The greatest discovery of my life is that a human being can alter his life by altering his attitude
- William James
THE COGNITIVE-BEHAVIORAL REVOLUTION: HOW TO MANAGE THOUGHTS, FEELINGS, AND BEHAVIORS
Thinking makes it so. The greatest weapon against stress is our ability to choose one thought over another. - William James
ESSENCE OF COGNITIVE -BEHAVIORAL TREATMENT Your thoughts and attitudes and not external events create your moods.
Emotions are experienced as a result of the way in which events are interpreted or appraised. It is the meaning of the event that triggers emotions rather than the events themselves.
The role of the cognitive therapist is to help the individual see the alternative ways of thinking about and appraising a situation and then help the individual identify any obstacles to thinking and acting in this new, more helpful way.
MODEL OF COGNITIVE STRUCTURES AND PROCESSES
Cognitive Processes Automatic Thinking Information Processing
Proximal Structures Expectations Appraisals Attributions Decisions Intermediate Structures Rules, Values, Attitudes CORE BELIEFS AND SCHEMAS Beliefs about the Self and the World
INTERACTION OF DISTAL, INTERMEDIATE AND PROXIMAL STRUCTURES
PROXIMAL STUCTURES AUTOMATIC THOUGHTS Decision GET DRUNK Expectation If I have a drink, Ill feel better; cant cope Appraisal Getting fired is the worst thing that can happen Attribution Its all my fault; It will affect everything that I do
INTERMEDIATE STRUCTURES Rules Do whatever you can to get over Values Peace of mind Attitudes Who cares anyway; life sucks
DISTAL STUCTURES CORE BELIEFS; SCHEMAS Im damaged; life isnt fair; I fall apart under pressure
STRESS loss of employment
Cognitive-Behavioral Map
ERRORS IN LOGIC
Arbitrary inference: drawing a conclusion based on little evidence.
Selective abstraction: focusing on one insignificant detail. Overgeneralization: drawing global conclusions on the basis of a single fact.
Magnification & Minimization: small bad events are magnified and large good events are minimized. Personalization: incorrectly taking responsibility for bad events in the world.
POOHS ERRORS IN LOGIC
Arbitrary inference Selective abstraction Overgeneralization Magnification
Cognitive-Behavioral Restructuring in Everyday Life

The relationship between events, automatic thinking, and emotions in everyday life is illustrated by the example of Susan, a woman who successfully turned her thoughts around after realizing that they were formative to her depressed feelings.
Case Example: Susans Automatic Thoughts Event My father calls and asks why I forgot to call him about going to lunch. Thinking about a termpaper that is due at school. Automatic Thoughts There I go again. Theres no way that I will ever please him. I cant do anything right. I might as well give up. I can' handle it. . Ill never meet the deadline.. I wont be able to face my teacher. Ill get a low grade and screw things up like I do everything else. Hes really on my case. Im not being a good wife. I dont enjoy life. Nobody would like to spend time with me. Emotions Sadness Anger
Anxiety
My husband complains that I'm cranky.
Sadness Anxiety
Automatic Thought Exercise

1. Draw three columns on a sheet of paper and label them:
Event Automatic Thoughts Emotions
2. Recall a recent situation or memory of an event that seemed to stir up emotions such as anxiety, anger,
sadness, physical tension, or happiness.
3 . Try to imagine being back in this situation, just as it happened.

4. What automatic thoughts were occurring in this situation? Write down the event, the automatic thoughts, and the emotions in each column of your record. 5. Try to identify the underlying beliefs that energize these thoughts.
6. What kind of errors in logic might you be using?

7. What alternative cognitive process can you use to alter your emotional states?
AUTOMATIC THOUGHT
Mindfulness Exercise: Floating Leaves on a Moving Stream

Imagine a beautiful slow moving stream. The water flows over rocks, around trees, descends downhill, and travels through a valley. Once in a while, a big leaf drops into the stream and floats away down the river. Imagine you are sitting beside the stream on a warm, sunny day, watching the leave float by.
Now become conscious of your thoughts. Each time a thought pops into your head, imagine that is is written on one of those leaves. If you think in words, put them on the leaf in words. If you think in images, put them on the leaf as an image. The goal is to stay beside the stream and allow the leaves on the stream to keep flowing by. Don't try to make the stream go faster off slower; don't try to change what shows up on the leaves in any way. If the leaves disappear, or if you mentally go somewhere else, or if you find that you are into the stream or on a leaf, just stop and notice that this happened. File that knowledge away, and then once again return to the stream, watch a thought come into your mind, write it on a leaf and let the leaf float away down the stream. Continue doing this for at least five minutes. Keep a watch or clock close by and note when you start the exercise. This will be useful in answering some the questions below. If the introduction are clear to you now, go ahead and close your eves and do the exercise.
How long did you go until you got caught by one of your thoughts?
If you got the stream flowing and then it stopped, or if you went somewhere else in you mind write down what happened just before that occurred.
If you never got the mental image of the stream started, write down what you were thinking while it wasn't starting.
Stages of Change

Marlatts Relapse Prevention Model
CORRECTIONAL PRACTITIONER
Balance Between Accountability
& Rehabilitation
Essential Facilitator/Staff Qualities

Empathetic
Effective problem solving skills
Above average social skills Well-developed communication skills

Logical reasoning abilities Open-minded & non-judgmental Ability to motivate offenders & roll with resistance
Essential Facilitator/Staff Qualities

Ability to coach/teach high-risk offenders Knowledge of group dynamics
Strength-based/positive approach Challenge/confront without demeaning Firm, fair, and consistent Solid understanding of behavior change strategies (i.e. Stages of Change, Motivational Interviewing, SLT, Cog, etc.)
CULTURAL MINDFULNESS
Mindfulness encourages tuning in to our own socialized cultural scripts and expectations.
3 ELEMENTS OF MINDFULNESS
UNDERSTANDING
By empowering members in their own identities clients RESPECTING become more open to developing an in-group identity aligned with the SUPPORTING goals of treatment.
CBT FOR SPECIFIC POPULATIONS

CBT has become the predominant modality for treating a broad spectrum of social problem behaviors including substance abuse, criminal conduct and mental disorder. Carte blanche endorsement of a generic CBT approach, however can lead to ineffective programming with disappointing treatment and rehabilitation outcomes.
The new generation of CBT programs are tailored to the special attributes of target populations.
TREATMENT OF ADOLESCENTS WITH SUBSTANCE USE DISORDERS
CSAT Tip 32
MOST ADOLESCENT PROGRAMS ARE DESIGNED FOR ADULTS
Adolescent Users Differ From Adults In Many Ways

Their drug and alcohol use often stems from different causes. They have even more trouble projecting the consequences of their use into the future. In treatment, adolescents must be approached differently than adults because of their unique developmental issues, differences in their values and belief systems, and environmental considerations (e.g., strong peer influences). At a physical level, adolescents tend to have smaller body sizes and lower tolerances, putting them at greater risk for alcohol-related problems even at lower levels of consumption. The use of substances may also compromise an adolescent's mental and emotional development from youth to adulthood because substance use interferes with how people approach and experience interactions.
The treatment process must address the nuances of each adolescent's experience, including cognitive, emotional, physical, social, and moral development. An understanding of these changes will help treatment providers grasp why an adolescent uses substances and how substance use may become an integral part of an adolescent's identity.
Regardless of which specific model is used in treating young people, there are several points to remember when providing substance use disorder treatment:
GUIDELINES FOR ADOLESCENT TREATMENT

Take into account gender, ethnicity, disability status, stage of readiness to change, and cultural background. Treatment for adolescents should identify delays in cognitive, and social-emotional development and their connections to academic performance, self-esteem, or social interactions.
Make every effort to involve the adolescent client's family because of its possible role in the origins of the problem and its ability to change the youth's environment. Using adult programs for treating youth is ill-advised. It should be done only with great caution and with alertness to inherent complications that may threaten effective treatment for these young people.
Because many adolescents are coerced into treatment, providers should be sensitive to motivational barriers to change at the outset of intervention. Several strategies can be used for engaging reluctant clients to consider behavioral change.
General Program Characteristics

Staff should represent the cultural diversity of the client population. Forms, books, videos, and other materials should reflect the culture and language of the clientele. Innovative and intensive continuing education may be needed to improve cultural competence among staff. Someone on staff should be familiar with disability issues and disability culture:
Staff training should occur periodically throughout the year. This is greatly preferable to training presented in ad hoc situations to address crises or acute situations. Ongoing training should address a range of specialty topics, including the following: Treatment approaches specific to adolescents and their families Family dynamics and family therapy Adolescent growth and development Sexual and physical abuse Gender issues Mental health problems Different cultural and ethnic values Psychopharmacology Referral and community resources Cognitive impairments Legal matters When recovering individuals are hired, they should have the same level of expertise and training required of other staff members in the same position. Recovering individuals must have clear evidence of abstinence from alcohol and drugs for 2 to 5 years
Program Components
Orientation, conducted in a non-confrontational style and tone, clarifies what treatment is, her or his role in treatment, and the concept of program expectations.
Daily scheduled activities of school, chores, homework, and positive recreational activities can help adolescents learn new skills and provide them with an alternative to their substance-using behavior and can help ensure that adolescents remain sober after treatment. Peer monitoring in a group setting can help the client build the strength necessary to override peer pressure and harness the influence of the peer group in a positive manner. Conflict resolution is often necessary. Conflict may arise from a staff member's inexperience or a client's inability or unwillingness to meet program expectations, in which case the treatment plan should be modified. Staff take a proactive stance in resolving conflicts. Client contracts (e.g., behavioral contracts, including substance-free contracts) - signed by both the adolescent and primary counselor - lay out concrete treatment goals, expectations, time frames, and consequences (if not followed) mutually acceptable to client and counselor. They provide a baseline for monitoring change. They also give to adolescents a sense of control in going through treatment and a degree of investment in their well-being. Schooling focuses on substance use and basic education, is one of the most important factors in an adolescent's recovery. On or off site, it should be fully integrated into the program. Teachers are part of the treatment team. For adolescents who attend public schools, a liaison between the school and treatment program should be designated. Vocational training should be part of treatment. Interventions include prevocational training, career planning, and job-finding skills training. Without these skills, illegal activities and relapse are more likely. The level of intensity of these components will vary considerably from outpatient to residential treatment .
Essentials of Treatment Planning

Problems of the client and the family, including substance use, psychosocial, medical, sexual, reproductive, and possible psychiatric disorders Goals that are attainable and help clients to recognize their involvement with substances and to acknowledge responsibility for the problems resulting from substance use. Strengths and resources of the individual and the family and ways to apply them to address treatment goals.
Objectives that are realistic and measurable steps for achieving each goal. Interventions such as treatment strategies and services that are needed to achieve the objectives, e.g., structured CBT curriculum for criminal conduct and substance abuse treatment. Educational, legal, and external support systems The treatment plan includes pre-established times for evaluation and adjustment of goals as necessary. Programs work closely with other entities such as school systems, child welfare, and juvenile justice agencies. Interagency agreements should describe payment policies, funding problems, mutual goals for clients, and intra- and interagency contracts. An established practice of exchanging signed releases of information from each shared client, so client agrees to the sharing of information, so that the involved staff members can more freely exchange confidential information about the client's progress.
Adjunct Providers Guide for Female Adolescents in Correctional Settings
Harvey Milkman, B. Gagliardi & K. Wanberg
Adjunct Providers Guide for Female Adolescents in Correctional Settings

SECTION I: ADOLESCENT GIRLS AND DELINQUENCY: THE ROUTE INTO CORRECTIONAL SETTINGS
SECTION II: GENDER SPECIFIC STRATEGIES AND MODELS FOR TREATMENT SECTION III: GENDER SPECIFIC ADAPTATIONS FOR FEMALE ADOLESCENTS IN CORRECTIONAL SETTINGS APPENDIX Summary of Relaxation and Stress Management Skills Script for a 10-Minute In-Session Grounding Demonstration Reflection Poems Stories
APA Guidelines for Treating Girls and Women

The American Psychological Association (2007)has outlined the following guidelines for treating females:
1. strive to be aware of the effects of socialization, stereotyping, and unique life events on the development of girls and women across diverse cultural groups. 2. recognize and utilize information about oppression, privilege, and identity development as they may affect girls and women.
3 .to understand the impact of bias and discrimination on the physical and mental health of those with whom they work. 4. use gender sensitive and culturally sensitive, affirming practices in providing services to girls and women. 5. ...recognize how their socialization, attitudes, and knowledge about gender may affect their practice with girls and women. 6. use interventions and approaches that have been found to be effective in the treatment of issues of concern to girls and women.
7. strive to foster therapeutic relationships and practices that promote initiative, empowerment, and expanded alternatives and choices for girls and women.
8. strive to provide appropriate, unbiased assessments and diagnoses in their work with girls and women. 9. strive to consider the problems of girls and women in their sociopolitical context.
10. strive to acquaint themselves with and utilize relevant mental health, education, and community resources for girls and women.
11. understand and work to change institutional and systemic bias that may impact girls and women.
THE KEY PRINCIPLE

CONTEXTUAL AWARENESS
Biology and social learning experiences are critical to gender differences in substance abuse and criminal conduct, including: motivation patterns of expression and abuse toxic manifestations preferred treatment approaches
PTSD population statistics

About 8% of the population will have PTSD symptoms at some time in their lives.
Approximately 5.2 million adults have PTSD during a given year; however, this is only a small portion of those who have experienced a traumatic event. About 60% of men and 50% of women experience a traumatic event at some time in their lives.
Women are more likely to experience sexual assault and child sexual abuse. Men are more likely to experience accidents, physical assault, combat, or disaster or to witness death or injury.
About 8% of men and 20% of women who experience a traumatic event will develop PTSD.
Sexual assault is more likely than other events to cause PTSD.
Approximately 30% of men and women who served in war zones experience PTSD symptoms. An additional 20% to 25% have had some symptoms. Specific to the Vietnam War, research shows that of those who served, over 30% of men and 26% of women experienced PTSD symptoms at some time during their lives. As many as 10% of Gulf War (Desert Storm) veterans, 6% to 11% of Afghanistan (Enduring Freedom) veterans, and 12% to 20% of Iraq (Iraqi Freedom) veterans are expected to have experienced PTSD.
Those Most Likely to Develop PTSD

were directly exposed to a traumatic event as the victim or as a witness were seriously injured during the event experienced a trauma that was long lasting or very severe believed their lives were in danger believed that a family member was in danger had a severe reaction during the event such as crying, shaking, vomiting, or feeling separated from the surroundings felt helpless during the trauma, not being able to help oneself or family member(s) had an earlier life-threatening event, such as being abused as a child had another mental health problem had family members with mental health problems had minimal support from family and friends recently lost a loved one, particularly if it was unexpected had recent, stressful life changes drink alcohol in excess women, poorly educated, or younger
Differences in susceptibility
Behavioral scientists are unable to predict or measure the potential effect of a traumatic event on different people, but certain variables seem to have the most impact, including:
The extent to which the event was unexpected, uncontrollable and inescapable; The level of perceived extent of threat or danger, suffering, upset, terror, or fear;
The source of the trauma: human-caused is generally more difficult than an event of nature; Sexual victimization, especially when betrayal is involved;
An actual or perceived responsibility for the event; and Prior vulnerability factors including genetics or early onset as in childhood trauma.
Symptoms of PTSD
Re-experiencing the trauma Emotional numbing Avoidance Neurobiological changes Physical manifestations
Headaches Stomach or digestive problems Immune system problems Asthma or breathing problems Dizziness Chest pain Chronic pain or fibromyalgia
Psychological outcomes
Depression, major or pervasive Anxiety disorders such as phobias, panic, and social anxiety Conduct disorders Dissociation Eating disorders
Social manifestations
Interpersonal problems Low self-esteem Alcohol and substance use Employment problems Homelessness Trouble with the law Substance abuse Suicidal attempts Risky sexual behaviors Reckless driving Self-injury
Self-destructive behaviors

Recovery from trauma

Recovery from traumatic events unfolds in three stages: Establishing safety Establishing safety includes allowing the victim to regain control. Tasks of remembrance and mourning Retelling the story must be repetitive; eventually, the story no longer will arouse such intense feelings (Herman, 1997). Eventually, it becomes only a part of the survivors experience rather than the focus of it Reconnection with ordinary life Victims must create a new self and a new future. As quoted by Herman (1997), psychiatrist Michael Stone describes this task (specific to his work with incest survivors) thusly:
All victims. . . have, by definition, been taught that the strong can do as they please, without regard for convention. . . Re-education is often indicated, pertaining to what is typical, average, wholesome, and normal in the intimate life of ordinary people. Victims . . . tend to be woefully ignorant of these matters, owing to their skewed and secretive early environments. Although victims in their original homes, they are like strangers in a foreign country, once safely outside. - Michael Stone
Seven criteria for the resolution of trauma

The physiological symptoms of PTSD have been brought within manageable limits; The survivor is able to bear the feelings associated with traumatic memories; The person has authority over the memories, e.g., she can either remember the event or put it aside; The memory is coherent and linked with feeling; The survivors self-esteem has been restored; Important relationships have been reestablished; and A coherent system of meaning and belief concerning the trauma has been constructed
TREATMENT OUTCOMES
Treatment Outcomes Are Enhanced Through Gender-Specific Programs lower rates of relapse and recidivism; lower rates of inpatient care; greater job constancy; better parenting relationships resulting in higher rates of child custody.
Protector (NOT!)
When I was a child She taught me to fear the wild You need a protector Need a protector You need a protector From the BIG BAD WOLF. And when I was bad (or not) I was punished be the dad (or what) Hes our protector Hes our protector But hes also the BIG BAD WOLF. And when I was grown I wanted out on my own.. Not without a protector You need a protector Need a protector From the BIG BAD WOLF. And so I was married And tradition carried I had a protector... Had a protector I had a protector Who turned into the BIG BAD WOLF LEARN TO PROTECT YOURSELF. - Ree H.
TREATING GANG INVOLVED OFFENDERS
any serious attempt to provide treatment programs for juvenile offenders must consider the reality of gangs, gang activities, and whether they can be addressed successfully in the treatment context.
From: Treating Gang-Involved Offenders, Parker, R., Negala, T., Haapanen, R., Miranda, L., Asencia, E., p. 171 in Treating the Juvenile Offender, Hoge, R., Guerra, N. Boxer, P., The Guilford Press, 2008.
Oregon Youth Authority

Prevention: Helping youth see the disadvantage of being gang-involved before their choice is made.
Intervention: Helping youth that are ganginvolved/designated to redirect their lives and get out of gangs. Participants will address criminogenic risk factors and risky thinking processes that lead to destructive behaviors and criminality. Pro-social Empowerment (Treatment): Empowering youth through an intensive treatment process to take responsibility and gain control of their lives to become productive, law-abiding citizens of their communities. By utilizing education and skill development in a Social Learning Milieu, youth will be better prepared to make healthy life choices, hence reducing recidivism and promoting positive community citizenship.
CO-OCCURRING SUBSTANCE ABUSE AND MENTAL DISORDER
From: Treating Adolescents with Co-Occurring Disorders Holly A. Hills, Ph.D. Florida Certification Board/Southern Coast ATTC Monograph Series #2, August 2007
EPIDEMIOLOGY OF MENTAL HEALTH AND SUBSTANCE USE DISORDERS IN ADOLESCENCE

Over one in five children has a diagnosable mental health disorder, with some major mental illnesses having an onset as early as 7-11 years of age 7. The MECA Study (Methodology for Epidemiology of Mental Disorders in Children and Adolescents) estimated that: almost 21% of U.S. children ages 9 to 17 had a diagnosable mental or addictive disorder associated with at least minimum impairment. Estimates dropped to 11% when diagnostic criteria required the presence of significant functional impairment, translating to a total of 4 million youth who suffer from a major mental illness that results in significant impairments at home, at school, and with peers.
When extreme functional impairment is the criterion, the estimates dropped to 5%.
EPIDEMIOLOGY OF MENTAL HEALTH AND SUBSTANCE USE DISORDERS IN ADOLESCENCE

Mental health disorders can be found disproportionately in children/ adolescents involved with child welfare or the juvenile justice system. Putnam reports that approximately 30% - 40% of the children in out-of-home care have a serious emotional disorder and as many as 75% - 80% of the population in out-of-home care need mental health services.
Likewise, approximately 70% of youth in the juvenile justice system are thought to meet criteria for one or more mental health disorders. Research has shown that youth with mental health disorders in these systems are more likely to require/receive restrictive or expensive treatment. Access to the appropriate mental health care is a significant issue. Most of the children and youth with mental health disorders (75-80%) do not receive services.
Whether insured or not, over 75% of children who could benefit are considered to have unmet mental health needs.

Conduct Disorder
Aggression to people or animals; destruction of property; lying and theft; serious rule violations; bullying or intimidation; initiation of fights.
Childhood onset (before age 10) may have more aggression, family history of antisocial behavior, early temperamental difficulties.
In males, more evidence of direct behaviors; in females, more relational or indirect forms may be observed.
Strong association with development of substance use disorders in adolescence.

Attention-Deficit/ Hyperactivity Disorder (ADHD)
Two core categories:1. inattention (difficulties in sustaining attention, listening, following instructions, attending to details, forgetfulness, impaired organization, and 2.Hyperactivity/Impulsivity (squirming or fidgeting, running and climbing excessively, difficulty in playing quietly, talking excessively. Impairment must be observed in two or more settings; Typically diagnosed in school years; features of motor activity may diminish in late adolescence/early adulthood. Consistently found more often in males. Co-occurring association with CD or Bipolar disorder predicts substance use in adolescence. Focus on immediate over delayed gratification may increase substance use risk.
CO-OCCURRING SUBSTANCE ABUSE AND MENTAL DISORDER Major Depression (MD)

Sad or irritable mood, changes in sleep, appetite, or body movement;
Not interested in previous activities;

Guilt or worthlessness, decreased energy; Frequent thoughts of death or suicide; difficulty concentrating;
Rates of death by suicide, especially in early adolescence (ages 10-14)have increased in recent years. Lesbian and gay youth thought to be 2-6 times more likely to make a suicide attempt than other youth.
Substance use may occur as an attempt to reduce or modify symptom experience or may be associated with peer group influences.

Dysthymia General unhappiness, pessimism, negativity, hypersensitivity to criticism, dissatisfaction, may be hard to please, always remember feeling this way;
Majority of children / adolescents with dysthymia (70%) go on to develop MD; Appears to interfere more with normal development than does MD.

Bipolar Disorder
Cycling of manic and depressive episodes;
manic symptoms include irritability and agitation, sleep disturbance, distractibility/impaired concentration, grandiosity, reckless behavior, suicidal thoughts ;
Presentation in youth may be characterized by very rapid, brief, recurrent episodes lasting hours to a few days; Early onset appears to have greater frequency in males; Stronger association with co-occurring SA, anxiety and CD than with unipolar depression

Schizophrenia (Childhood Onset)
Little range of emotion, few facial expressions;
Poor eye contact, delays in language, unusual motor behaviors, odd speech, both in content and tone; May hear voices, see things, problems with abstraction;
May demonstrate confusion, suspicion, paranoia; unusual fears; May have few friends or be withdrawn from peers;
Onset of full disorder before age 6-7;

Difficulty in school functioning may be an early sign; Substance use may facilitate otherwise impaired peer group interactions.
30 25 20 15 10 5 0
ADHD CD ODD MDD MANIA G. ANX OCD SAD PTSD S. PHOB
ADM N-ADM
Diagnostic Prevalence Rates for the 10 most common disorders for ADM and non - ADM service sectors
TIME
INTOXICATION WITHDRAWAL MENTAL DISORDER
SEPARATING SUBSTANCE ABUSE AND MENTAL DISORDER
Separating Substance Abuse and Mental Disorder

When clients are actively abusing drugs, their symptom picture is apt to be that of intoxication or toxicity. Alcohol intoxication can occur, and severe intoxication can lead to stupor and even coma. With cocaine intoxication, a range of mental states can occur, from euphoria and hyperactivity to paranoia. As blood levels of the abused drug drop, withdrawal symptoms begin to dominate the clinical presentation. With alcohol, these are minor or major (for instance, delirium tremens) withdrawal syndromes. There are similar problems with benzodiazepines and barbiturates. With cocaine, a crash and craving ensue. Acute withdrawal from chemicals of abuse can extend from days to weeks, depending on the agent(s) used. Severe and chronic abuse of potent psychoactive agents such as alcohol and cocaine may produce more subtle withdrawal problems that last for several months. As recovery proceeds, and as toxic and withdrawal states abate, underlying Axis I and II disorders become more evident. Examples of this process include a manic illness that emerges as drug abuse symptomatology wanes and a panic disorder that expresses itself after all depressant drug abuse has ceased.
TIME
INTOXICATION WITHDRAWAL MENTAL DISORDER
SEPARATING SUBSTANCE ABUSE AND MENTAL DISORDER
Screening for Co-Occurring Disorders

Structured diagnostic interviews available for use in assessment of youth include:
Childrens Interview for Psychiatric Syndromes (ChiPS; Weller, et al.64), Adolescent Diagnostic Interview (www.wpspublish.com), Mini-International Neuropsychiatric Interview (M.I.N.I.- Kid; www.medicaloutcomes.com), Diagnostic Interview Schedule for Children-Revised (DISC-R; Shaffer et al.), Global Appraisal of Individual Needs (GAIN; www.chestnut.org/li/gain).
A detailed overview of a subset of these measures can be found in the Adolescent Screening and Assessment Instrument Compendium for Substance Abuse and Mental Health Disorders (available at www.scattc.org.). Grissom and Underwood also review a range of interview and self-report measures for screening and assessment in youth, with special emphasis on those that have been used with juvenile justice populations (www.ncmhjj.com).
Guiding Principles for Treating Co-Occurring Disorders

Building a strong relationship and motivating clients to attend treatment; Creating a treatment plan that centers on client-generated goals;
Applying empirically supported treatments, focused on interventions specific to the clients diagnostic presentation; Using culturally and developmentally sensitive content;
Focusing on client strengths, with an emphasis on impulse control, communication, problem solving, and regulation of affect; Designing goals and objectives focus on change that is sustainable over the long term; Monitoring motivation, substance use and medication compliance, if utilized; Increasing intensity if the intended response is not achieved; Using relapse prevention strategies; Fostering peer group influences; Conducting psychoeducation for parents.
Developing a Treatment Plan

Riggs proposes the following paradigm:
Step 1. Integrate all assessment info, including patients goals, into a problem list.
Step 2. Engage the adolescent in treatment, initially through collaborating on goals.
Step 3. Determine medication need, requiring at least weekly therapy appointments, emphasizing motivational techniques, cognitive-behavioral interventions in early treatment.
Step 4. If substance use or symptoms of psychiatric illness do not significantly improve in a 2 month period: 1) reassess diagnosis; 2) consider changing medication; and/or 3) increase the intensity or frequency of treatment.
Step 5. Convey from the beginning, an understanding of the need for long term monitoring of psychiatric disorder, and continued attention to factors related to substance use relapse.
Exemplary Treatment Practices
MOTIVATIONAL INTERVENTION (MI)

Individual Approach F FEEDBACK R PERSONAL RESPONSIBILITY A ADVICE M MENU OF OPTIONS E EMPATHY S SUPPORT SELF-EFFICACY

Often used in the emergency room after a teen has been brought in due to an automobile accident, overdose, assault, or simply intoxication.
The counselors initial goal is to engage the adolescent and to gather information concerning the persons AOD habits. The second goal of MI is to attempt to motivate the adolescent. In order to increase the teenagers awareness of their patterns of destructive behavior, three steps are taken:
Personalized and comparative feedback based on assessment instruments; Provide educational information concerning alcohol and its effects; Ask teenagers to describe his or her possible future should he or she decide to change or not.

All brief interventions must end with a plan for the teenagers next steps.
In addition to goal setting, these should include the anticipation of barriers to success, such as peer pressure to drive after drinking. The adolescent should be made to feel capable and confident about being successful in implementing the plan.
Reinforcement of the motivation process can be made via future contact between the counselor and the teen.
PROBLEM-SOLVING SKILLS TRAINING (PSST)
Individual Approach
PSST is based on the idea that juvenile justice clients often exhibit disruptive behaviors that are representative of cognitive deficits and distortions, which can lead to aggression and violence. Youth usually work on an individual basis with a licensed therapist to learn appropriate skills to use in interpersonal situations. PSST training may consist of up to 20 weekly sessions, each lasting 40-50 minutes. Pro-social solutions are fostered through modeling, role-playing, coaching, practice and direct reinforcement.
PROBLEM-SOLVING SKILLS TRAINING (PSST) Individual Approach

The primary focus of treatment is on the thought processes rather than on the behavioral acts that result, teaching adolescents a step-by-step approach to solving problems.
First, emphasis is on how children approach situations, primarily focusing on the thought processes that dictate their behavior.
Second, youth are taught to use a step-by-step approach to solve interpersonal problems. Using personal statements to directly confront the problem.
Third, treatments usually employ a wide range of games, academic activities and stories to relate problems to real-world situations. Fourth, therapists play an active role in all phases of treatment. Finally, treatment involves several different procedures including modeling and practice, role-playing, and reinforcement.
(PSST) Guiding Principles for Problem Solving

Problems are natural and should be accepted as an inevitable part of life: Accepting problems helps people to be more open and less defensive about them. Think before jumping to a solution: Once a problem is recognized the individual will frequently act on the first solution they come up with. However, many times the first reaction to a problem may not be the best way to solve it. Most problems can be solved: Most people will view a particular problem as unsolvable. Many times they will give up before trying because the problem seems too complex and there is an exaggerated sense of difficulty. However, using a structured means for dissecting the problem will generally get results.
Take responsibility for your problems: Do not blame others for a problem that only you can solve. Encouraging teenagers to recognize their contribution to their own life events creates a sense of ownership and facilitates problem resolution. State what you can do, not what you cant do: Make sure the solution is within the realm of possibility. Do not make promises to yourself or others that are unrealistic and unachievable. The behavior must be legal and socially acceptable: Creating new solutions to solving a problem must fall within societal norms; otherwise new problems will arise from the solutions. Solutions must be within your power and ability: Solutions that try to remedy a problem using techniques beyond your ability are doomed to failure. Only implement solutions that can be used now with current knowledge and skills.
PROBLEM-SOLVING SKILLS TRAINING (PSST) Individual Approach
PSST aims to provide adolescents with several life improving techniques: Alternative Solution Thinking Means-End Thinking Consequential Thinking Causal Thinking Sensitivity to Interpersonal Problems
Decision-Making Problem-Solving
State decision to be made very clearly;
List Pros and Cons; Weigh pros and cons on a scale of (1-5);
Add up numbers for pros and cons separately; The choice achieving the highest weighting should be the one selected.
Means-End Problem-Solving
What is my goal?
What steps do I need to reach my goal?
Did my plan work? Did I reach my goal?
FAMILY THERAPIES
FAMILY THERAPY (Tip 32)

Works with multiple units - individual parents, adolescents, parent-adolescent combinations, and whole families, also target extended systems (e.g.) adolescent's peers, school, and neighborhood all believed to contribute to dysfunctional interactions in families. Intervention aims to change the way family members relate to each other by examining the underlying causes of current interactions and encouraging new (and presumably, healthier) ones. Family members appreciate how differences in values and perspectives do not have to be a source of conflict. By solving problems together in the therapeutic setting , these solutions can be applied with the adolescent in the home. Such maneuvers decrease family conflicts and improve communication.
Family therapists help parents regain their confidence and optimism and motivate them to continue to help their teenager; at the same time helping them improve their parenting skills.
Parents are taught how to provide age-appropriate monitoring of their teenager (e.g., to know their friends, to know how they spend their time), set limits (e.g., negotiate about reasonable curfews, schedules, and family obligations), establish a system of positive and negative consequences, rebuild emotional attachments, and take part in activities with the adolescent outside the home.
FAMILY THERAPY (cont.)

Includes discussion of the effects of the teenager's actions in extra-familial systems--such as skipping an appointment with a probation officer or hanging out with peers late at night on unsafe street corners where drugs are bought and sold. Then the therapist might meet with the probation officer or ask the adolescent to bring a peer to a session to review the problem from the youth's perspective.
Family therapists are aware of the complex of behaviors and systemic interactions associated with recovering from a substance use disorder. They also consider cultural differences in family patterns and typical attitudes toward therapy.
Adolescent substance involvement should be considered within the context of other problem behaviors such as delinquency and school problems, necessitating new frameworks of diagnosis and assessment, as well as treatment. Adolescent clients will benefit when the treatment team, including substance abuse counselors, nurses, and doctors, working in conjunction with family therapists, have a general understanding of family therapy within the substance use disorder treatment setting. When they have this understanding, the treatment team members can best support the efforts of the therapist and coordinate their components of treatment with family therapy. Most important in family therapy is the therapeutic alliance between the therapist and adolescent. It is crucial for the therapist to emphasize to the client and family members that the purpose of the therapy is to help the client.
FAMILY SYSTEMS THEORY AND FAMILY THERAPIES

Having its roots in the 1930s, Family Systems Theory (FST) is based on the recognition that individuals are an interconnected and interdependent part of the family system. Principle of causalitycertain parental practices actually encourage problem behaviors. A multidimensional approach to include all family members as well as the adolescents peers. Coercion by parents or the criminal justice system is typically the reason for teen treatment, hence the family therapists first assignment is to utilize therapeutic tools based on FST to overcome resistance to participation.
Current practice indicates use of Motivational Enhancement techniques as indicated in the FRAMES acronym. Problem solving and negotiating skills (both integral components of the cognitivebehavioral approach) are taught and the concepts of empathy and compromise are encouraged.
The typical problems that arise in families may be exacerbated by extreme parenting styles such as being too coercive, permissive, lenient or simply inconsistent.
BEHAVIORAL THERAPY FOR ADOLESCENTS AND FAMILIES

Incorporates the principle that unwanted behavior can be changed by clear demonstration of the desired behavior and consistent reward of incremental steps toward achieving it. Urine samples are collected regularly to monitor drug use. The therapy aims to equip the patient to gain three types of control:
Stimulus Control Urge Control Social Control A parent or significant other attends treatment sessions when possible and assists with therapy assignments and reinforcing desired behavior.
SPEAKER LISTENER TECHNIQUE

Rules for the Speaker Speak for yourself, dont mind read! Keep statements brief. Dont go on and on. Stop to let the listener paraphrase.
Rules for the Listener Paraphrase what you hear. Focus on the speakers message, dont rebut. Rules for Both The speaker has the floor. Speaker keeps the floor while the listener paraphrases. Share the floor.
MULTIDIMENSIONAL FAMILY THERAPY (MDFT)

MDFT is an outpatient, family-based drug abuse treatment for teenagers. Treatment includes individual and family sessions held in the clinic, in the home, or with family members at family court, school, or other community locations.
MDFT is based on adolescent and family development theories and on research concerning the formation of drug use and problem. MDFT is a multi-component, stage-oriented therapy utilizing an organized approach of stepby-step phases, each building upon one another to effect change.
Multisystemic assessment is a critical first step. All aspects of the adolescents life are reviewed with family members, extended relatives, teachers, school personnel, and friends of the family.
Children raised by neglectful or abusive parents seek out negative or aggressive friends.
Not only can positive peer relationships serve as protection from negative behavior, they allow for a healthy expression of emotions, thereby eliminating an additional risk factor for drug or alcohol use.
During initial sessions the teenager and therapist focus on important developmental tasks such as decision making, negotiation and problem solving skills. Parallel sessions are held with family members. Parents examine their particular parenting style, learning to distinguish influence from control and to have a positive and developmentally appropriate influence on their child.
FUNCTIONAL FAMILY THERAPY (FFT)

FFT, a short-term intervention with an average 8 to 12 one-hour sessions and up to 30 hours for more difficult situations, is designed for conductdisordered youth between the ages of 11 and 18. Outcome data suggest that FFT can reduce recidivism between 25% and 60%.
A major goal of FFT is to improve family communication and supportiveness while decreasing intense negativity often experienced in conflictive family situations.
Other goals include: 1) Helping family members adopt positive solutions to family; problems; 2) Developing positive behavior change and parenting strategies. FFT has shown positive effects in multi-ethnic, multicultural contexts with pre-adolescents and adolescents diagnosed with conduct disorders, violent acting out and substance abuse.
FUNCTIONAL FAMILY THERAPY (FFT)

Comprised of three specific and sequential intervention phases: Engagement and Motivation: Utilizing the cognitive techniques of reattribution and reframing, participants develop a sense of hope, purpose, empowerment and entitlement.
Behavior Change: Applies individualized and developmentally appropriate techniques such as communication training, specific tasks and technical aids, basic parenting skills, contracting and response-cost. Generalization: Aims to improve a familys ability to affect the multiple systems in which it is embedded, e.g., school, court system, community, with the ultimate goal of transitioning the family from therapist-care to self-care.
MULTISYSTEMIC THERAPY (MST)

MST is an intensive community based (outpatient) treatment that targets juvenile offenders (ages 12 to 17) and their families. The typical MST youth is 14-16 years of age; has multiple arrests; lives in a single parent home; has major problems at school or does not attend; has deep involvement with delinquent peers; and abuses substances (marijuana, alcohol, cocaine).
There is daily contact with family members and therapy sessions are usually conducted directly in their home.
MST addresses the multiple factors associated with heightened antisocial behavior patterns. These include characteristics of the: Adolescent Family Peers School Neighborhood
Nine principles form the core of MST.
Multisystemic Therapy (MST)

Principle 1: The primary purpose of assessment is to understand the fit between the identified problems and their broader systemic context . Several steps are taken to develop a correct fit assessment between the apparent problem behaviors and future treatment models within the childs life, i.e., Method, Hypothesis Development and Hypothesis Testing. The factors associated with the problem behavior are examined across multiple settings allowing the therapist to acquire a comprehensive plan for integrating treatment approaches. By integrating information received from multiple sources the therapist is able to define a direction for future treatments and objectives. MST is a continuous process that reinvents itself as new problems arise or old objectives are met.

Principle 2: Therapeutic contacts emphasize the positive and use systemic strengths as levers for change. Several steps are taken to insure development and maintenance of the strength focus:
Teach and use techniques of reframing;

Use positive reinforcement liberally; Incorporate and maintain a problem-solving stance; Provide hope; Find and emphasize what the family does well.

Principle 3: Interventions are designed to promote responsible behavior and decrease irresponsible behavior among family members. In order to promote responsible behavior with children, reinforcement theories such as those proposed by social theorists work well: Contingencies articulated clearly; Understanding rationality of rules; Tangible reinforcers for positive action; Aversive discipline; Minor transgressions equal minor sanctions; Physical discipline should be discouraged.

Principle 4: Interventions are present focused and action oriented, targeting specific and well-defined problems.
Emphasis is placed on changing current circumstances; Swift and consistent action is required to enable the family and key players in the social ecology to meet their treatment;
Two types of specific treatment goals are used in MST: 1. Overarching goals represent long-term objectives defined by the family. 2. Intermediate goals are small day-to-day projects usually initiated by the therapist.

Principle 5: Interventions target sequences of behavior within and between multiple systems that maintain the identified problems.
Interventions will vary from family to family; Significant attention is placed on transactions between systems that are associated with identified problems, e.g. school and juvenile probation.

Principle 6: Interventions are developmentally appropriate and fit the developmental needs of the youth.
Particular care must be given to creating effective goals and transactions that reflect the current developmental stage of all parties involved in treatment.
A twenty-year-old single parent with a ten-year-old child using drugs, will have very different needs than forty year-old parents that have a seventeen year old refusing to attend school. Every MST treatment is uniquely designed to fit the specific needs of the individual participants.

Principle 7: Interventions are designed to require daily or weekly effort by family members. Constant effort provides several advantages:
Problems are resolved in a timely manner; Noncompliance of treatment goals becomes apparent; Goals can be assessed on a regular basis and adjusted accordingly; Feedback is continually produced; Families become stronger as more tasks are accomplished.

Principle 8: Intervention effectiveness is evaluated continuously from multiple perspectives with providers assuming accountability for overcoming barriers to successful outcomes.
Constant evaluation of treatment objectives allows the therapist to determine what is working and what is not.
Objectives and tasks from multiple sources (e.g., youth and parents) can be continuously revised depending on the amount of progression or regression encountered. Therapist has the ability to mold the treatment to the individual.

Principle 9: Interventions are designed to promote treatment generalization and longterm maintenance of therapeutic change by empowering caregivers to address family members needs across multiple systemic contexts. The ultimate goals of MST: Emphasize development of skills that family members will use to navigate their social ecology; Develop the capacity of family members to negotiate current and future problems; Delivery primarily by caregivers, with therapists playing primarily supportive and consultative roles;
Accentuate and build family strengths and competencies; Make abundant use of protective and resiliency factors available in the natural environment.
Multisystemic Therapy (MST) Program Evaluation

For serious juvenile offenders, evaluations of MST have demonstrated:
Reductions of 25-70% in long-term rates of re-arrest; Reductions of 47-64% in out of home placements; Extensive improvements in family functioning; Decreased mental health problems for serious juvenile offenders.
EXEMPLARY TREATMENT PROGRAMS

The Adolescent Treatment Model (ATM) funds the manualization and empirical evaluation of treatment programs thought to be exemplary in their efforts to treat adolescents. The ATM program aim is to achieve the following goals: To identify existing, potentially exemplary models of treatment for adolescents; To collaborate with providers to formalize the models and disseminate manuals for replication; To determine how the model has been tested and the services received by adolescents; To evaluate the effectiveness, cost, and cost-effectiveness of the models;
To ensure the models and study findings are disseminated.
Teen Substance Abuse Treatment Program (TSAT)

The CBT program, based on family systems model, is a threemonth intensive (i.e., nine or more hours per week) outpatient program for 12 to 17 year-olds and their families in Maricopa County, AZ. Juvenile probation is the primary referral source. TSAT consists of three components including:
1. In-home family and individual counseling; 2. Teen group therapy; and 3. Multifamily group. All participants receive all three forms of treatment. Treatment goals of the program are: Improved decision making; Improved family functioning; Reduced or eliminated criminal involvement; Reduced out of home placement.

In-Home Program
Combines CBT and FST with techniques to encourage the clients to become aware of their feelings and motives behind their behaviors.
In-home sessions are adaptable to whichever family members are in attendance. For the first month, there are six hours per week of counseling; then, four hours for the second, and two hours for the final month. Counselors must also be alert to drug use by family members and make treatment referrals. Parenting skills may also be taught to help parents regain authority in the family unit.

Teen Group
A group session for the adolescents is held three times a week for three hours. The curriculum consists of the following:
Skill building Anger Management Avoiding Pitfalls Hole in the Sidewalk Coping Strategies Taking Responsibility Substance abuse Decision Making Signs of Substance Abuse and Addiction Addiction: Tolerance, Withdrawal, Cross Addiction Goal Setting Communication Skills Self-Medication Refusal SkillsRole-Play Drug Values Clarification Categories/Physical Effects Tobacco/Nicotine Health Post-acute Withdrawal HIV and Other STDs Drug of ChoiceInteractive Exercise Depression Chemical Addiction and Substance Physical Exercise and Fitness Abuse Workshop Future-Day Fantasy Healthy Boundaries Recovery Healthy Living Cognitive Disorders Positive Feedback Right On Motivation and Willingness to Change Sober Fun/Natural Highs Responsibility Identity and Diversity Relapse prevention Addicted versus Rational Thinking Relapse Cycle Consequences of Substance Abuse Relapse Triggers 12-Step Programs Relapse Warning Signs Support Networks Developing Clean Plans

Multifamily Group Family members share their current progress, solutions, support and resources. One goal of this forum is to decrease the amount of isolation and stigma due to the family involvement in substance abuse. Drug Use Testing Relapses are used as a learning experience regarding triggers and subsequent behaviors. Anyone suspected of being under the influence during the group is taken to the testing site at that time. Teens who refuse testing are taken home. Evaluation Assessment tools include: Global Appraisal of Individual Needs Hispanic Acculturation scale HIV/AIDS knowledge and risk assessment, Environmental Street Inventory Adolescent Relapse Coping Questionnaire Cognitive functioning questionnaire to assess problem solving, abstract reasoning, and knowledge and concepts of disease.
La Caada Adolescent Treatment Program (30 day residential)

Serving ethnically diverse adolescents in five southern counties of Arizona since 1996, La Caada provides a residential, step-down treatment program for adolescent substance abusers. Approximately 87% of the clients have been referred by juvenile county courts. Other health care agencies, families, and adolescents themselves make up the remaining 13% of referrals.
The philosophy of the program is a combination of traditional psychiatric approaches and systems theory. A treatment plan is developed through negotiation among the counselor, family, and adolescent, with abstinence being the goal. This plan is in force throughout a 30-day residential program and two aftercare phases of treatment.
Treatment within the residential phase includes one hour per week of individual therapy, one hour of family therapy, five hours of group therapy, three hours of psycho-educational groups and four hours of case management.
Individual therapy is designed to offer a safe place to discuss sensitive issues such as sexual abuse, trauma, sexual orientation and sensitive family matters.
Motivational Enhancement Therapy/Cognitive Behavioral Therapy for Adolescent Cannabis Users

This outpatient program is designed for treatment of cannabis abuse or dependence and associated problems in youth age 14-18. It encourages but does not demand abstinence.
The treatment protocol offers the following presentation options depending on the level of client involvement and family participation.
1. 2. 3. 4. MOTIVATIONAL ENHANCEMENT THERAPY/COGNITIVE BEHAVIORAL THERAPY--MET/CBT5 MET/CBT5+CBT7 (7 additional CBT sessions) FSN (Family Support Network home visits, parent education, aftercare) ACRA (Adolescent Community Reinforcement Approach 12 individual sessions for parents, caregivers and other concerned members of the support network designed to learn coping skills within the adolescents environment.
U.S. Department of Health and Human Services; SAMHSA, CSAT, www.sanmhsa.gov
THINKING FOR A CHANGE (T4C)

Program onset: Copyright 1997, Revised 1998, Bush, Glick & Taymans Contact: U.S. Department of Justice National Institute of Corrections 320 First Street, NW, Washington, DC 20534 800-995-6423 Target Population A variety of offenders including adults and juveniles, probationers, prison and jail inmates, and those in aftercare or on parole. Participants should be pre-screened and selected after a brief, 15 minute interview. This meeting should set the tone of the sessions, direct and focus the participant to their need for the program, set a tone for positive participation, and an expectation that such participation will enhance their options in the criminal justice setting. Program Goals & Objectives By utilizing a variety of approaches including cognitive restructuring, social skills training, and problem solving, the goal of T4C is to provide offenders with the skills as well as the internal motivation necessary to work through situations without engaging in criminal behavior
T4C PROVIDER QUALIFICATIONS AND QUALITY CONTROL

Provider Qualifications Any staff person may facilitate groups and teach the content. No special credential or level of education is required. Trainers should be caring, like to teach, understand group processes and interpersonal interactions, and be able to control an offender group. Quality Control It is strongly recommended that group facilitators be trained in the content and process of T4C. Training for group facilitators should be included in any management implementation plan for the program. Training should be accomplished within three to five days with two master trainers.
PRESENTATION FORMAT
Small groups of 8-12 individuals facilitate interactive and productive feedback.

Can be used concurrently or consecutively with other treatment programs. Curriculum is divided into 22 one- to two-hour lessons. No more than one lesson should be offered per day; two per week is optimal.
Flexible and meet individualized program needs with little operational concerns.
Role-plays, written homework assignments, social skills checklist, and input from a person who knows the participant well, are all used to create a profile of necessary social skills that become the basis for additional lessons. The authors suggest at least 10 additional lessons be held, utilizing this profile. Lessons are sequential and program flow and integrity are important, however, in situations of high turnover or movement to other facilities, sessions 10 and 16 can be utilized as points to reorganize or combine existing groups, freeing one facilitator to be with a new set of offenders. Materials include the T4C Curriculum binder that includes each of 22 lessons, including a summary and rationale for each lesson. Concepts and definitions and key points of the lesson are also provided. Lesson objectives are outlined, followed by major activities. The content of the lesson is then detailed.
Supplemental materials including overhead transparencies, a course organizer, handouts, and class rules and participant expectations. The course schedule and outline is to be developed by the facilitator. Suggested trainer scripts and trainer notes to embellish the script are also provided. The program is available in several formats: CD-ROM, Online, and Distance Learning tapes. A Spanish version is available on CD-ROM
T4C PROGRAM CONTENT

National Institute of Corrections who has offered the training course, Cognitive Approaches to Changing Offender Behavior in Longmont, Colorado since 1992. Thinking for a Change is based on the core cognitive restructuring intervention methods of Aron Beck (1970s), Albert Ellis( 1970s), Ross and Fabiano (1980s), and Bush (1990s). Integrates into these methods cognitive skills training interventions introduced by Bandura (1970s), Meichenbaum (1980s), Goldstein and Glick (1980s), and Taymans (1990s). The authors synthesized concepts and tools from both methods into one completely integrated, seamless intervention.
Participants learn that cognitive restructuring requires cognitive skills and cognitive skills require an objective, systematic approach to identifying thinking, beliefs, attitudes, and values. Cognitive restructuring concepts are introduced during the first eleven lessons, as are targeted critical social skills to support the restructuring process. Problem solving techniques follow in lessons 16-21, supported by the appropriate social skills.
Goal of the program is that by the 12th lesson, cognitive restructuring techniques are second nature to the participant. By the 22nd lesson, participants can evaluate themselves using a provided skills checklist so that they can develop their personal cognitive skills curriculum.
T4C PROLIFERATION
Since 1997 over 30 sites have delivered T4C. Agencies have included state correctional facilities, local jails, community based corrections programs, and probation and parole departments. Populations include male and female adults and juveniles. More than 600 providers have been trained with 60 participating in a train the trainers program. Five correctional systems are capable of training their own staff.
12-Step-Based Programs
Most 12-Step-based programs focus on the first five steps during primary treatment, while the remaining ones are attended to during aftercare. Below are ways to present the first five steps to adolescents so that their specialized developmental needs can be addressed.
Step 1: We admitted we were powerless over alcohol--that our lives had become unmanageable. With adolescents, the primary goal of this step is to assist them in reviewing their substance use history and to have them associate it with harmful consequences. Step 2: We came to believe that a Power greater than ourselves could restore us to sanity. To convey this message, allow new clients to interact with those who have been successful in treatment and are leaving the program. Providers must help adolescents with coexisting mental illnesses or cognitive disabilities to understand that Step 2 refers to obtaining help to stop drug seeking and use behavior. Step 3: We made a decision to turn our will and our lives over to the care of God as we understood Him. This step can be simplified by saying, "Try making decisions in a different way; take others' suggestions; permit others to help you." Using the phrase "Helping Power" instead of "Higher Power" can benefit some. Step 4: We made a searching and fearless moral inventory of ourselves; Step 5: We admitted to God, to ourselves, and to another human being the exact nature of our wrongs. Steps 4 and 5 provide an opportunity to be accepted by another person in spite of one's past behaviors and to take a "personal inventory" of those past behaviors.
Therapeutic Communities (TC)

Typically used to treat youth with the severest problems and for whom longterm care is indicated. TCs have two unique characteristics: 1. The use of the community itself as therapist and teacher in the treatment process. 2. A highly structured, well-defined, and continuous process of self-reliant program operation. The community includes the social environment, peers, and staff role models. Treatment is guided by the substance use disorder, the person, recovery, and right living.
Job functions, chores, and other facility management responsibilities that help maintain the daily operations of the TC have been used as a vehicle for teaching self-development. The Part Is highly structured, with time designated for chores and other responsibilities, group activities, seminars, meals, and formal and informal interaction with peers and staff. The use of the community as therapist and teacher results in multiple interventions that occur in all these activities. For the adolescent, the community may be even more crucial than for adults since the TC functions as family. This is an exceedingly significant function, since many youth in TCs come from dysfunctional families.
Part II Envisioning a Juvenile Justice System

Dealing with Diverse Needs and Backgrounds Project Self-Discovery: Artistic and Adventure-Based Alternatives for At-Risk Youth
Cognitive-Behavioral Treatment: Pathways to SelfDiscovery and Change

Natural Highs: A Positive Approach to Mood Alteration
ENVISIONING A JUVENILE JUSTICE SYSTEM THAT SUPPORTS POSITIVE YOUTH DEVELOPMENT

Overarching Goal:
To create a juvenile justice system that seeks to uphold and protect community safety but also offers youth an opportunity for change, restitution, and rehabilitation.
Notre Dame Journal of Law, Ethics & Public Policy [Vol.22],2008Frabutt, J., Diluca, K., Graves, K.
ROLE OF CORRECTIONAL TREATMENT TO REDUCE RISK OF RECIDIVISM

Treatment programs that follow the risk-need-responsivity principles have the largest effect size and are more likely to be effective in reducing recidivism. Official sanctions tend to have a negative effect on recidivism.
The risk principle states that treatment is most effective when it is applied to those who
have an appreciable risk of offending; that is, treat high risk rather than low risk offenders.
The need principle states that criminogenic needs (the dynamic or changeable
characteristics that contribute to an individuals criminal activities such as criminal attitudes and criminal associates) must be assessed, identified and targeted in order for treatment to be effective.
The responsivity principle states that treatment effectiveness can be maximized if the
delivery of treatment is adjusted to accommodate the clients idiosyncratic characteristics such as cognitive abilities, level of motivation, readiness for treatment, cultural background and so forth. (Andrews & Bonta, 2003; Wong & Hare, 2005)
Leverage Points for a Positive Youth Development Orientation

Engaging a system-wide focus and commitment to treatment, rehabilitation, and restoration;
Proactively addressing the mental-health issues of court involved youth; Granting specialized attention to the facility-tocommunity transition process for incarcerated youth;
Investing fiscal, social, and human capital in the power of prevention, relying on a network of evidence-based, cost effective, community-based programs.
LINKING POSITIVE YOUTH DEVELOPMENT WITH JUVENILE JUSTICE

Move beyond simple risk-avoidance;
Capitalize on building resilience through competency development.
"While service programs based 'on deficit' or 'medical model' assumptions have come to dominate the youth policy landscape, most people become conventional adults as they gain experience in responsible institutional roles at work, in the family, and through key community networks.
Bazemore, G. and Clinton, W. (1997). Developing Delinquent Youth: A Reintegrative Model for Rehabilitation and a New Role for the Juvenile Justice System. Child Welfare, 76, 5, 665-716.
Therefore
It is imperative to cultivate youth competencies across cognitive, social, moral, emotional, and behavioral domains such as: interpersonal social skills positive identity development academic competency personal contentment social engagement
Frabutt, J., Diluca, K., Graves, K., 2008
Encapsulating the Process of Positive Youth Development

Community Youth Development Model underscores the importance of community institutions to foster opportunities for youth engagement (Villarruel et al., 2003);
Search Institute focuses on forty developmental assets (Bensen and Scales, 2005):
External assets are the positive experiences received from peers, adults, parents, and social/educational settings. Focused on support and empowerment, boundaries and expectations, and constructive use of time. Internal assets are the characteristics possessed by individual youth that elicit positive growth and development. Focused on positive values, social competencies, and commitment to learning.
Integrative Approach focuses on youth-environment interactions and highlights attributes among youth known as the five Cs -competence, confidence, connection, caring, and character (Lerner, 2006).
Common Elements
Reliance on youth strengths instead of deficits; Clear acknowledgement that youth are shaped by (and have the ability to shape) multiple social contexts beyond their family (schools, neighborhood organizations, churches, and social programs); Understanding that youth pro-social development is greatly fostered through high-quality relationships with caring adults. It is time to more fully integrate the tenets of positive youth development with juvenile justice: Embracing the principles of positive youth development remains our best hope for creating a future that welcomes the majority of our children.
Juvenile Justice and Positive Youth Development, (Schwartz, 2004)
The North Carolina Model

One example from a system that is equally focused on public safety and youth rehabilitation can be observed in new approaches to secure confinement in North Carolina. A serious movement toward juvenile justice reform in North Carolina began during the 1990s with changes to the state juvenile code. In 2000, then-Governor Jim Hunt created a cabinet-level department to carry forth the new code, entrusted to the new Department of Juvenile Justice and Delinquency Prevention (DJJDP). Since that time, North Carolina has completely revamped its approach to juvenile prisons in the state. These facilities-called Youth Development Centers (YDCs) - used to be large institutional facilities much like adult prisons. DJJDP recommended that small, community-connected facilities replace large, custodial, YDCs. Originally there were only five such facilities to serve the entire state; new plans called for the construction of thirteen smaller, more geographically dispersed facilities. With the backing of the state legislature, the DJJDP adopted a new model featuring YDCs that are markedly different on several levels: size, design, campus layout, schedule, staffing patterns, and an array of on-site services and supports. All of those changes were conceived, with one goal in mind: creating a therapeutic environment to break the cycle of criminal offenses. More than just a buzzword or the latest fad, creating a "therapeutic environment" represents a paradigm shift in treating youthful offenders. To cast a therapeutic environment in a state's most secure facilities, reserved for the most challenging juvenile offenders, requires a commitment that transcends environmental space, resources, and time allocation. As described by the DJJDP, "The environment is the treatment;. therefore, every part of every Part Is planned and implemented to support treatment and development."
Focusing on Treatment
Youth receive a thorough assessment of strengths and needs at intake. Prior to entering a YDC, each youth spends time at the Assessment and Treatment Planning Center to derive an individualized service plan. A four-to-one staffing ratio within the YDC. Through regular, consistent, one-on-one interactions, staff uphold high expectations for youth along with support and firmness to reach them. Since youth admitted to YDCs are, on average, three to four grade levels behind their peers in reading and mathematics, the educational needs of the juveniles are addressed through developmentally appropriate approaches to instruction. On any given day, youth will spend seven hours in a structured, school-like instructional environment.
Every youth in a YDC receives intensive services such as counseling, therapy, and instruction in critical life skills. Depending on the needed services outlined in their individualized plan, youth may receive treatment for substance abuse, serious emotional disturbance, and/or sexual behavior problems. Intensive case management supports the proper array of programming to ensure efficacy.
Focusing on Treatment (cont.)

YDCs are purposely being built in closer proximity to the population centers that have typically had the most youth in treatment. More community connectedness means that the facilities are open to parent and family involvement in the rehabilitation process. Parent and family involvement may take the form of parenting groups, family therapy, and programs to enhance family communication and discipline practices.
Caregivers are encouraged to commit to ongoing involvement in their child's treatment through regular visits, participation in service team meetings, and frequent phone contact with staff.
Planning for release from the YDC begins on the day that a youth arrives. Community reintegration is not viewed as a discrete, culminating event. Instead, progress toward goals is monitored all along with an eye toward the transition from secure confinement to one's home community. Advance planning is crucial to making sure that necessary services and supports are in place in the designated discharge environment.
Focusing on Treatment (cont.)

In addition to the highlighted points, the YDC programming continuum provides health services, a recreation program, gender-specific programming for females, and a commitment to delivering services in a way that is culturally competent. While our discussion of North Carolina's emerging model of secure facilities for juveniles is not exhaustive, the central point is clear:
YDC staff commits on a daily basis to reduce the risk factors in a child's life and to build on the protective factors that will keep that child crimefree for the long-term.
JUVENILE OFFENDING AND MENTAL HEALTH

Between 40% and 90% of children and adolescents involved in the juvenile justice system also suffer from a mental illness compared to 18-22% of the general youth population; More than 50% of offending children have co-occurring substance use problems; One study indicated that two-thirds of juvenile detainees had one or more alcohol, drug, and/or mental disorders. The vast majority of youth in the juvenile justice system have multiple mental health diagnoses - with one large multi-state, multi-system study reporting that 60% of youth had three or more co-occurring mental health diagnoses (Skowyra, et al., 2007); Given the astounding prevalence of mental health issues, it is likely that children's mental health and substance abuse problems play major roles in their offending behaviors.
Specific Mental Health Diagnosis

Disruptive behavior disorders such as conduct disorders are often the first to be diagnosed. However, other more "hidden" disorders also are common. Anxiety disorders may impact as many as 41% of the juvenile justice population.
Other estimates indicate that 84-94% of juvenile offenders reported a history of trauma, with girls being more likely to meet criteria for post-traumatic stress disorder (PTSD) than boys. A history of trauma increases the risk of arrest by 59% and of committing a violent crime by 30%.
Strength-Based Assessments
If a traditional deficit-based paradigm is utilized, deficits (e.g. school failure, family dysfunction) will be the highlight of both assessment and treatment, preventing the recognition and utilization of strengths.
In contrast, strengths-based paradigms shift the focus away from deficits by devoting attention to the strengths and resources within the child, and family, and then incorporate those strengths into treatment planning (e.g., artistic, musical or athletic ability, social skills). An ecological approach is used to obtain a comprehensive picture of youth and, their surroundings. These ecological factors can include person-level factors (e.g., anxiety, depression, inattention, trauma history), family-level factors (e.g., caregiver strain, history of parental violence), and school-level factors (e.g., attendance, academic performance, extracurricular activities). Clearly there is a need for cross-system service planning in which juvenile justice personnel can participate in mental-health treatment planning through the creation of child and family teams, and mentalhealth staff can be housed within juvenile justice facilities.
ADDRESSING OFFENDER REENTRY

According to the state-mandated 2001 recidivism study, in North Carolina, nearly three-and-a-half years after release from the juvenile system, 88.5% of juveniles received subsequent adult criminal charges.
CORE, a pilot re-entry enhancement project was developed to improve participants' transitions from YDCs back into their home communities. CORE is designed to include services such as employment training and placement, education, medical care, housing assistance, and intensive case management. A Community Support Coordinator (CSC) assumes a case manager role as youth exit the YDC and continues to engage the family and community in support of that youth. The CSC maintains contact with youth and families for up to two years, assisting youth and families in connecting with the community resources they need to support successful transitions for youthful offenders.
Re-entry (cont.)
Preliminary recidivism findings over a three year period indicate that of the fortyfour youth who participated in the CORE program, the recidivism rate for all participating youth across the juvenile and adult systems was 36% vs. 85% in the 2001 study. The nature of their initial recidivating offenses was almost always less severe than that of their commitment offenses. Additionally, the decrease in weapons-related recidivating offenses was notable. The severity of recidivating offenses tended to increase, however, with further offenses over time, indicating the importance of a constant monitoring of these youth that allows for immediate response to any criminal behavior. Recommendations from the pilot study include implementing appropriate training for Community Support Coordinators (CSCs), standardizing documentation for tracking, formalizing community partner roles and obligations, and implementing clear organizational management of the collaborative partnerships. With these recommendations at the forefront of developing juvenile reentry support programming, successful impacts are attainable, cost effective, and often require coordination of community-based efforts that are already underway.
PREVENTION
Juvenile justice systems must commit to maintaining legislative and fiscal support for a continuum of community-based prevention and intervention efforts.
Maintaining a system of graduated sanctions ensures that the course of treatment is appropriate to the offense. By design, graduated sanctions progress from the least restrictive environments (e.g., community-based mentoring programs) to the most restrictive environments (e.g., secure confinement for serious, violent, chronic offenders).
In the vast majority of juvenile delinquency cases, alternatives to incarcerationfamily counseling, restitution, mentoring, structured day programs - should take place in the home community of the youth.
One way to ensure a broad, community-based continuum of services and placements is to allow prevention and intervention decisions to be made at the local level, but with fiscal support from the state.
North Carolina requires by statute that each of its 100 counties creates a Juvenile Crime Prevention Council (JCPC).
Juvenile Crime Prevention Council

The purpose of each JCPG is to galvanize local community support and input for, creating a range of dispositional alternatives for at-risk and court-involved youth.
JCPC membership, appointed by the County Board of Commissioners, must include local law enforcement leaders, judges, child attorneys, faith community members, juvenile court staff; service providers, and interested citizens.
Representatives are charged with the following responsibilities: a) conducting an annual assessment of juvenile risks and needs as well as available community resources; b) determining the scope and array of prevention and intervention services needed; c) developing a written solicitation for providers of those services; d) funding programs and ensuring adherence to program guidelines; and e) evaluating program performance.
JCPCs should "work to increase public awareness of the causes of delinquency and of strategies to reduce the problem; develop strategies to intervene and appropriately respond to and treat the needs of juveniles at risk of delinquency; and provide funds for services for treatment, counseling, or rehabilitation for juveniles and their families.
Juvenile Crime Prevention Funding & Service Utilization

Although the amount varies from year to year, the state allocation to Juvenile Crime Prevention Council totals approximately $20-$30 million. Those funds are distributed to each JCPC, which then disperses funds directly to each respective service provider. The broad, general categories of programming funded by JCPCs are:
Assessment programs (e.g., clinical evaluation and psychological assessment programs);

Clinical treatment programs (e.g., sex offender assessment and counseling, homebased family counseling, individual counseling programs; Community day programs (e.g., juvenile structured day programs); Residential programs;
Restorative programs (e.g., mediation/conflict resolution, restitution, and teen court); Structured activities programs (e.g., skill building and mentoring programs).
NCs Comprehensive Strategy for Juvenile Delinquency

Problem Behavior > Noncriminal Misbehavior > Delinquency > Serious, Violent, and Chronic Offending
Target Population: At-Risk Youth

Programs for All Youth
Prevention
Target Population: Delinquent Youth

Intermediate Sanctions
Graduated Sanctions
Community Training Schools
>
Programs for Youth at Greatest Risk
> Intervention >
Immediate
> Confinement >
>
Aftercare
Preventing youth from becoming
Improving the juvenile justice
delinquent by focusing prevention

programs on at-risk youth
system response to delinquent

offenders through a system of
graduated sanctions and a

continuum of treatment
alternatives


Youths With Distinctive Treatment Needs

Young people who have distinct concerns related to coexisting psychiatric conditions, sexual orientation, involvement with the criminal justice system, physical health, or displaced living conditions may not do well in traditional treatment programs.
Therefore, treatment providers should offer individualized treatment, paying particular attention to the events and circumstances that contributed to the client's current situation.
Problems that often accompany substance use disorders include illegal activity, homelessness, shame surrounding sexual orientation, and coexisting physical and mental disorders.
Coexisting Disorders
Any adolescent who is being treated for substance use disorders and is also taking psychoactive medications for a coexisting psychiatric disorder requires careful psychopharmacological management. These adolescents should also be given routine urine testing as part of their treatment plan. Close scrutiny of adolescents with ADHD is particularly important for those who are receiving substance use disorder treatment. Treatment providers and mental health authorities should develop programs together to treat youth with coexisting disorders.
Cross-training can help staff of both programs develop the sensitivity and the clinical skills to understand coexisting disorders and to identify the presence of either problem or both. Youths who have coexisting disorders and are not on psychoactive medications do better in programs that provide both substance use disorder and mental health treatment together than in separate programs.
Homeless Youth
Street outreach workers should focus on developing trusting relationships with youths that, over time, can influence a young person to access treatment services for substance use disorders.
Service providers must meet with, talk to, and develop relationships with young people on the street to engage them in treatment. Returning homeless or runaway youth to their homes is not always in their best interest because less than optimal conditions may exist in these homes. Treatment providers should explore the appropriateness of other transitional living options for homeless youth if necessary. Once a homeless youth has entered the system, the next step is establishing a case management plan that is based on a thorough assessment of her needs. Possible services should include finding housing, dealing with family problems, entering substance use disorder and/or HIV-related treatment, and providing schooling, sexual and reproductive health care, and job training.
It may be necessary to prioritize the needs for services according to the individual's problems.
Homosexual, Bisexual, and Transgendered Youth

Adolescence is a very lonely, high-risk time for many youths who have sexual identity issues.
Many gay, bisexual, and transgendered youths have no one in whom they can confide, and most communities lack gayidentified services.
Gay-specific services are likely to be more sensitive to the importance of not divorcing the issues of sexual identity from substance use problems during the treatment process. Effective treatment for these youths involves helping them to feel comfortable with, and to take pride in, their sexual identity.
Youth in the Juvenile Justice System

Every young person involved in the juvenile justice system should undergo thorough screening and assessment for substance use disorders, physical health problems, psychiatric disorders, history of physical or sexual abuse, learning disabilities, and other coexisting conditions.
Juvenile probation officers can be helpful partners in the system of care. For their part, providers should educate the local juvenile justice system about the importance of early intervention and the resources available to it.
It is almost impossible to intervene here unless the youth is removed from the environment that brought him into conflict with the juvenile justice system in the first place (e.g., the home, neighborhood). Early intervention is critical in working with adolescents who have come into contact with the juvenile justice system.




Participants Workbook
32 youth focused CBT treatment sessions
Visual and written record of treatment objectives Comic strips and stories from teen perspective
Interactive exercises Role playing, modeling Reflective assignments
Short and long term goal planning emphasis Active discussion about thoughts, feelings and actions which underlie patterns of delinquency, crime and drug abuse


SECTION I: THE UNIVERSAL DESIRE TO FEEL GOOD The experience of pleasure is derived from stimuli, originating outside or inside the body, that increase the concentration of dopamine in the nucleus accumbens, the primary reward center of the human brain.
SECTION II: FINDING RELIEF AND LETTING GO

I do not think that anyone completely understands its mechanism, but it is a fact that there are foreign substances which, when present in the blood or tissues, directly cause us pleasurable sensations; and they also so alter the conditions governing our sensibility that we become incapable of receiving unpleasureable impulses. - Sigmund Freud, Civilization and Its Discontents
Finding Relief and Letting Go

Neurochemical and psychosocial similarities exist for a range of stress dampening activities, e.g., alcohol, eating, cigarettes and heroin. Hey, Whats in This Stuff Anyway? Alcohol can trigger addiction yet their are health benefits (cardiovascular). Also there are potential risks from even moderate drinking. The Great Psychiatric Tavern provides a setting where a host of psychological and social needs are managed by a surrogate mental health treatment team. A wide variety of licit and illicit psychoactive chemicals - including inhalants, stimulants, cigarettes and heroin are used to self-medicate. Nicotine is the worlds antidepressant. Both men and women often abuse these substances in attempt to control psychological pain Food may also serve as a drug to alter mood.
SECTION III: THE THRILL OF EXCITEMENT AND RISK Security is mostly a superstition. It does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure or nothing. Helen Keller
Cocaine in the brain. The amount of neurotransmitter in a synapse depends on the balance between the rate at which neurotransmitter is released into the synapse (from vesicles) and the rate at which neurotransmitter is removed from the synapse by the reuptake pump (left panel). By blocking the reuptake pump, cocaine increases the concentration of neurotransmitters which, in turn, occupy more receptors and cause hyperexcitation (right panel).
SECTION IV: MENTAL EXCURSIONS:

When I examine myself and my methods of thought, I come to the conclusion that the gift of fantasy has meant more to me than my talent for absorbing positive knowledge. Albert Einstein
SECTION V: CRAVING FOR INTIMACY
To love is to receive a glimpse of heaven. - Karen Sunde
SECTION VI: JOURNEY TO OBLIVION Obsessed by a fairy tale, we spend our lives searching for a magic door and a lost kingdom of peace. Eugene ONeil
SECTION VII. NATURAL HIGHS THE CUTTING EDGE OF MOOD ALTERATION Go to the meadow, go to the garden, go to the woods. Open your eyes.
- Albert Hoffmann (chemist responsible for the discovery of LSD)
SIX TENETS FOR NATURAL HIGHS

THE COGNITIVE-BEHAVIORAL REVOLUTION: How to Manage Thoughts, Feelings and Behaviors
MAINTAINING CLOSE AND INTIMATE RELATIONSHIPS

RELAXATION, MINDFULLNESS AND MEDITATION EATING YOURSELF FIT EXERCISE: THE MAGIC BULLET MEANINGFUL ENGAGEMENT OF TALENTS
ACCUMBENS-STRIATAL-CORTICAL NETWORK The nucleus accumbens forms a critical interface between the motor system (striatum) and the prefrontal cortex that controls thought.
THE EXPERIENCE OF FLOW
Flow is experienced when perceived opportunities for action are in balance with the actors perceived skills.
CHAR-GAR-GA-GAR-MAN-CHAR-GA-GAR-CHUGUNGA-BUNGA-MOG

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TASMANIAN YOUTH CONFERENCE

Working With Youth At-Risk of AOD Abuse and Criminal Conduct

Harvey Milkman, Ph.D.

Adolescent Psychological Development

TASKS OF ADOLESCENT DEVELOPMENT

Social and Emotional

Physical Development (cont.)

Emotional and Social Development

Emotional and Social Development (cont.)

The Deviant Career

Emotional and Social Development (cont.)

Emotional and Social Development (cont.)

Emotional and Social Development (cont.)

Emotional and Social Development (cont.)

Emotional and Social Development (cont.)

Cognitive and Brain Development

Brain Development During Adolescence

Brain Development During Adolescence (cont)

SUBSTANCE ABUSE AND THE ADOLESCENT BRAIN

Brain Development During Adolescence (cont)

Brain Development During Adolescence (cont)

Brain Development During Adolescence (cont)

Kohlbergs Theory of Moral Development

Postconventional: The minority of people who progress to the more principle-based

Adolescent Problem Behavior vs. Normal Adjustment

Summary of Adolescent Development

THEORETICAL FRAMEWORK FOR UNDERSTANDING JUVENILE DELINQUENCY

Social Learning Theory - SLT

PROBLEM BEHAVIOR THEORY - PBT

THEORY OF PLANNED BEHAVIOR (TPB)

SOCIAL NORMS THEORY (SNT)

TRANSITIONAL TEEN THEORY (TTT)

COGNITIVE-BEHAVIORAL (CB) STRATEGIES

ACQUIRED PREPAREDNESS MODEL (APM)

SOCIAL AND COMMUNITY RESPONSIBILITY THEORY (SCRT)

FROM THEORY TO PRACTICE

THE COGNITIVE-BEHAVIORAL REVOLUTION

THE COGNITIVE-BEHAVIORAL REVOLUTION IS BASED ON THE IDEA THAT:

BASIC PRINCIPLES OF CBT

CBT is a commonsense approach that is based on two central ideas:

Taoism and Buddhism

AARON BECK Beck identifies two primary levels of cognitive processing:

Ethics for the New Millennium

CBT AND BUDDHISM

THE COGNITIVE-BEHAVIORAL REVOLUTION

THE BASIC PRINCIPLES OF COGNITIVE THEORY

Therefore, unless beliefs change behavior will never change

Beneath the surface:

How does CBT apply to judicial clients?

THE COGNITIVE BEHAVIORAL VIEW

Cognitive groups are not traditional therapy Thinking is a learned behavior/process

Cognitive and Behavioral Techniques Based on Social Learning Theory (SLT)

Example of a Thinking Report

___________________________________ Thoughts: Feelings: Core beliefs, mindsets: Outcomes:

Offender Thinking Report

My PO doesnt give a damn anyway.

Frustrated, depressed, tired

Core Belief: No ones gonna control my life! Outcome: Parole Violation

ELEMENTS OF CBT PROGRAMS FOR OFFENDERS

What do the prominent CBT programs have in common?

CBT Treatment Goals for Substance Abuse / Criminal Justice Clients

THE COGNITIVE-BEHAVIORAL MAP