Treating Co-Occurring Disorders. Stevie Hansen, B.A., LCDC, NCACI Chief, Addiction Services

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1 Treating Co-Occurring Disorders Stevie Hansen, B.A., LCDC, NCACI Chief, Addiction Services

2 Implementing SAMHSA Evidence-Based Practice Toolkits Integrated Dual Diagnosis Treatment (IDDT) Target group: The IDDT Toolkit is designed to assist persons with both a severe mental illness and a serious substance abuse problem. No materials in the Toolkit focus on older adults or youth or other subpopulations such as those with extensive criminal justice histories or persons who are homeless. The Toolkit is not diagnosis specific, though studies in the evidence-base do focus on particular diagnostic subgroups.

3 Practice Components Integrated treatment basically means that both psychiatric and substance abuse treatment are provided at the same time, at the same place, and by the same team. Specific IDDT components are listed in the fidelity scale and include: 1a. Multidisciplinary Team: Case managers, psychiatrist, nurses, residential staff, and vocational specialists work collaboratively on mental health treatment team 1b. Integrated Substance Abuse Specialist: Substance abuse specialist works collaboratively with the treatment team, modeling IDDT skills and training other staff in IDDT

4 Practice Components 2. Stage-Wise Interventions: Treatment consistent with each persons stage of recovery (engagement, motivation, action, relapse prevention) 3. Access for IDDT People to Comprehensive DD Services: Includes residential supported employment, illness management and recovery and ACT or ICM. 4. Time-Unlimited Services: Unlike many substance abuse programs, services are intended to be on-going. 5. Outreach: Assistance in the community with housing, medical care, crisis management and legal aid. 6. Motivational Interventions: Clinicians who treat IDDT people use techniques to increase motivation to change and reduce resistance.

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6 Practice Components 7. Substance Abuse Counseling: People who are in the action stage or relapse prevention stage receive substance abuse counseling that include: Teaching how to manage cues to use and consequences to use; teaching relapse prevention strategies; drug and alcohol refusal skills training; problemsolving skills training to avoid high-risk situations; challenging clients beliefs about substance abuse; and coping skills and social skills training. 8. Group DD Treatment: DD people are offered group treatment specifically designed to address both mental health and substance abuse problems 9. Family Education and Support on DD: Clinicians provide family members (or significant others) education, coping skills training, collaboration with the treatment team and support.

7 Practice Components 10. Participation in Alcohol & Drug Self-Help Groups: People in the action stage or relapse prevention stage attend self-help programs in the community 11. Pharmacological Treatment: Psychiatrists for IDDT people prescribe psychiatric medications despite active substance use. 12. Interventions to Promote Health: Examples include: Teaching how to avoid infectious diseases; helping people avoid high-risk situations and victimization; securing safe housing; encouraging clients to pursue work, medical care, diet, and exercise.

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9 Practice Components 13. Secondary Interventions for Substance Abuse Treatment Non-Responders: Program has a protocol for identifying substance abuse treatment non-responders and offers individualized secondary interventions, such as clozapine, naltrexone, or disulfiram; long-term residential care; trauma treatment; intensive family intervention; and intensive monitoring. 14. High intensity services. Although not in the SAMHSA toolkit, a low client to staff ratio is included by Mueser, Drake et al. in their textbook version of the fidelity scale.2

10 SUDS Stage-Wise Individual Counseling Stage Treatment Needs Strategies for Clinician Precontemplation Contemplation He needs information linking his problems and potential problems with his substance abuse. He should explore feelings of ambivalence and the conflicts between his substance abuse and personal values. Establish rapport, ask permission, and build trust. Raise any doubts/concerns about his substance-using patterns. Normalize ambivalence. Help client tip the decisional balance scales toward change. Preparation He needs work on strengthening commitment. Treatment options from which to choose: 12step, outpatient Clarify his own goals and strategies for change. Offer a menu of options for change or treatment.

11 SUDS Stage-Wise Individual Counseling Stage Treatment Needs Strategies for Clinician Action Maintenance Relapse Client requires help executing an action plan and may have to work on skills to maintain sobriety. Client needs help with relapse prevention. Client has experienced a recurrence of symptoms and must cope with consequences and decide what to do next. Engage the client in treatment. Change through small steps. Acknowledge difficulties. Identify high-risk situations. Help the client identify and sample drug-free sources of pleasure. Support lifestyles changes. Affirm the client s resolve and self-efficacy. Help the client reenter the change cycle and commend any willingness to reconsider positive change. Assist the client in finding alternative coping strategies.

12 Principles of Effective Integrated Treatment 1. Observe and give feedback concerning how each disorder affects them and how each disorder can affect the symptoms of the other. 2. The Gestalt concept of foreground and background: Therapist will not intervene with the same intensity with each disorder at a particular time. 3. Develop treatment plan with goals and objectives for both SA and MH disorders. 4. All interventions impact the systems of each of their disorders to some degree, so design the intervention to promote all the goals of the treatment plan and monitor them for both positive and negative effects.

13 Keep a Competency-based Focus Focus your feedback on strengths and competencies instead of their problems. Help person identify a personal strength Example: Person has a cannabis dependence disorder, a cooccurring generalized anxiety disorder, occasional panic attacks, is currently unemployed, and lives in a shelter with no significant relationship in over 10 years. When asked to identify a personal strength during his treatment group intro, he states he has none. You counter that by saying, you are here and that wasn t easy for you to do.

14 Competency-based focus Components 1. Help identify their strengths and skills 2. Help them gain a sense of optimism 3. Integrate the strengths into a treatment plan 4. Make treatment plan goals realistic and achievable 5. Any positive change equals SUCCESS!

15 Standard Interventions 1. Use leverage to promote treatment. 2. Match treatment demands with what is possible. 3. Set clear treatment goals and expectations early for clients mandated to treatment. 4. Provide information for self-diagnosis. 5. Identify and discuss the positive benefits of substance use and psychiatric symptoms with negative life consequences. 6. Connect alcohol and drug use and behaviors resulting from psychiatric symptoms with negative life consequences.

16 Standard Interventions (cont d) 7. Connect how psychiatric symptoms affect alcohol and drug use and how this usage affects psychiatric symptoms. 8. Require them to be abstinent during treatment sessions. 9. Promote medication compliance. 10. Promote skills needed to achieve treatment goals. 11. Use group treatment as much as possible. 12. Promote self-help involvement.

17 Prehistoric Intervention It s something new called an intervention.

18 A Co-Occurring Disorders Psychoeducation Program Session 1 Overview of MH and SUD s Session 2 Concept of Co-Occurring Disorders Session 3 Alcohol and Mental Disorders Session 4 Marijuana and Mental Disorders Session 5 Cocaine and Mental Disorders Session 6 Caffeine and Nicotine and Mental Disorders Session 7 Commonly used Local Drugs and Mental Disorders Session 8 Addiction and Mental Illness Session 9 Effects on the Family Session 10 Overview of Treatment for Co-Occurring Disorders Session 11 Overview of Recovery from Co-Occurring Disorders

19 A Relapse Prevention Curriculum Session 1 MH and SA Recovery Models Session 2 Overview of Relapse Prevention Skills Session 3 Warning Signs and Triggers Session 4 Defense Mechanisms Session 5 Cognitive Distortions and Self-Defeating Attitudes Session 6 Emotional Management Session 7 Anger Management Session 8 Stress Management Session 9 Planning & Problem Solving Session 10 Communication and Assertiveness Session 11 Relationships Session 12 Nutrition and Health

20 Similarities Between SA and MH Recovery Concepts Recovery from MH and SA disorders requires hope the cornerstone of motivation, resilience, and determination; the medication for the will I ever be normal again fear; the step beyond anger at having these disorders. Recovery from MH and SA disorders is defined as a process, not an event. Recovery form MH and SA disorders requires diligence and daily involvement. Recovery from MH and SA disorders involves growing beyond the level of maturation achieved at the time of the onset of the disorder.

21 Differences Between SA and MH Recovery Concepts Very little corresponds in MH recovery with the impact of craving in SA disorder recovery. The term enabling has a very different meaning in MH recovery than it does in SA disorder recovery. The concept of maintenance is very different. In SA it is for a lifetime, in MH it implies limiting services to only medication and case management because of the need to ration services or limit access to more intensive services.

22 Recovery Concept A focus on both MH and SA disorder in a nonsequential manner involves concurrent attention to all disorders present in an integrated manner. Progress in one enhances the other and relapse in one decreases the stability of the other. The need for integration in the process of recovery is as important as integration in treatment.

23 Key Activities for Successful Recovery from Co-Occurring Disorders Having realistic expectations Participating actively Accepting responsibility for change Developing attitudes/behaviors that help with long term recovery Being honest about problems/struggles/feelings Being patient and persistent Making a commitment to recovery Complying with treatment Being self-reflective Knowing when to ask for/accept help Learning new coping strategies Attending support groups Allowing room for mistakes/learning from them Developing inner resources Identifying and building strengths

24 Resources SAMHSA Evidence-based Practice Tool Kits Edward L. Henderson Marilyn S. Schmal Sharon C. Ekleberry Treating Co-Occurring Disorders A Handbook for Mental Health & Substance Abuse Professionals

25 Questions? Thank you for the opportunity to share information with you today. Stevie Hansen, MHMR Behavioral Health Services

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