Co-occurring Disorders Treatment. Bob Werstlein PhD Training Director Daymark Recovery Services

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1 Co-occurring Disorders Treatment Bob Werstlein PhD Training Director Daymark Recovery Services

2 Co-occurring Disorders Definition Co-occurring disorders refers to co-occurring Substance Abuse(SA) and Mental Health (MH) disorders Clients can have one or more SA disorders and one or more MH disorders Clients must have at least one disorder of each type established independent of the other and not a cluster of symptoms resulting from the other disorder

3 Co-occurring Disorders Prevalence Approximately 4 million adults meet criteria for both serious mental illness(smi) and Substance dependence or abuse 10 million adults and youth in the US have COD on any given year Among adults with SMI, 20-25% abused or were dependent upon alcohol or illicit drugs vs % among adults without SMI

4 Prevalence Epidemiologic studies-varying rates(dsm IV)% ETOH Conduct Disorder 25.3(abuse)-41.6 (Dep) men Any antisocial beh. 8.8(abuse)-24.5 (Dep) men ASPD 6.1(abuse)-16.9(Dep) men Conduct Disorder 13.5(abuse)-22.8 women Any antisocial beh. 8.0(abuse)-13.9 (Dep) ASPD 2.1(abuse)-7.8(Dep)

5 Prevalence 7.8 % lifetime prevalence Ob-Comp PD vs. 1% for Ob-Comp PD alone Men with Ob-comp PD have higher lifetime rates of SA compared to women(68.7 vs 47.8(ETOH), 43.5% vs. 28.2% (all drugs)

6 Post Traumatic Stress Disorder(PTSD) and Substance Abuse(SA) Rate of PTSD and SA in clients in SA treatment % Rate of PTSD and SA in female clients in SA treatment-30-59% Attaining Abstinence from SA in clients with PTSD can result in increased PTSD symptoms Treatment outcomes for PTSD/SA client are worse than for SA alone and other DD

7 Post Traumatic Stress Disorder(PTSD) and Substance Abuse(SA) People with PTSD and SA often abuse hard drugs, are vulnerable to repeated traumas, have a more severe clinical profile, more complicated life problems Women with PTSD and SA often have experience childhood trauma(physical or sexual) Perpetrators of assault often have used substances at the time of the assault

8 Prevalence in Borderline Personality Disorder 12 month 24.2%(ETOH) 50.7% Drug Lifetime 57.3% (ETOH) 72.9% (Drug) Prevalence with other Cluster B D/O 49.2% Risk of onset from WHO study Cluster A 12 months odds ratio(or) 2.8, Cluster B 14.5 OR, Cluster C 3.2 OR

9 Prevalence and Risk of SUD and PD Alcohol D/O Cluster A 5.8%, Cluster B 26.7% Cluster C 5.4% Drug D/O Cluster A 2.3%, Cluster B 12.9% Cluster C 2.7% Strong Association between externalizing disorders and SA, risk greatest with Cluster B disorders

10 Adolescent Co-occurring Disorders Over 50% in SUD Rx have 3 or more MH disorders CD, ADHD, Mood, and trauma related disorders are most common 33% endorsed depressive symptoms in the year prior to SUD Rx 50% under age 15 had ADHD and SUD

11 Adolescent Co-occurring Disorders After Rx, co-morbidity predicted early relapse, conduct problems, depression, and more persistent course of SA in 1 yr. follow up

12 What increases risk for Development of SUD Psychiatric symptoms increase the need to use drugs for relief(self medication) Genetic loading and developmental and environmental factors work together to increase risk Interaction of the two above

13 Self Medication Considered a natural response when people become dysphoric In the context of PD(i.e. borderline) this is not the same as Major Depression Likely related to affective instability and rapid shifts in mood Symptoms of non SA D/o typically onset prior to SA

14 Self Medication Symptoms like impulsivity. affective dysregulation, and emotional instability have onset typically years prior to other behaviors or traits that come to be associated with PDs Impulsivity is related to Cluster B PDs in several ways. Antisocial-impulsivity and failure to plan ahead, Histrionic-suggestibility and need for excitement, Borderline-impulsivity due to affective instability

15 Self Medication Risk for developing SUD greater in Cluster B, increased risk also found in Dependent (greater anxiety), Schizotypal(cannabis may correct an imbalance in the endocannabinold system with Schizophrenia), and Avoidant though not as robust as Cluster B Self medication for anxiety is highly prevalent especially with Opioids and tranquilizers

16 Self Medication Increasing inability to cope and to tolerate negative affect Increasing comorbidity is associated with increasing use of drugs to relieve anxiety especially for the use of multiple substances and with Diagnoses of Personality Disorders

17 Risk of PD and SUD Risk for development of PD and SUD are both genetic and environmental with genetic stronger and more influential later in life Risk is high for PD and SUD among those with HX of Childhood Disruptive Disorders Environmental experiences (trauma, neglect) heighten the risk Relapse to SA for PD is increased due to environmental and lifestyle and neurological changes due to SA

18 Co-occurring Disorders Prevalence Among adults with substance dependence, 20.4% had SMI vs.. 7% among adults without SA Compared to MH or SA alone, clients with COD are 20X more likely to be hospitalized than SA only and 5X more likely than MH only

19 12 Step Assessment Process Engage the Client Identify and contact collaterals to gather additional information Screen for and detect COD Determine quadrant and locus of responsibility Determine level of care Determine Diagnosis

20 12 Step Assessment Process Determine disability & functional impairment Identify strengths and supports Identify cultural/linguistic needs and supports Identify problem domains Determine stage of change Plan treatment

21 Therapeutic Relationship Guidelines Develop and use a therapeutic alliance to engage the client in treatment Maintain a recovery perspective Manage countertransference Monitor psychiatric symptoms Use supportive and empathic counseling Employ culturally appropriate methods Increase structure and support

22 Effective Techniques Overall Provide motivational enhancement consistent with the client s specific stage of change Design contingency management techniques to address specific target behaviors Use Cognitive Behavioral Therapeutic techniques Use Relapse Prevention Therapy(RPT) techniques

23 Effective Techniques Overall Use repetition and skills building to address deficits in functioning Facilitate client participation in mutual selfhelp groups

24 Effective Evidence-based Treatments Motivational Interviewing(MI) Cognitive Behavioral Therapy(CBT) Dialectical Behavior Therapy DBT) 12 step Facilitation Therapy Contingency Management(CM) Combining Case Management services with above increases effectiveness

25 Motivational Interviewing A Client centered therapy that focuses on helping clients resolve ambivalence Based on taking an empathic stance and asking open ended question, providing affirmations, using reflective listening, and allowing for self determination MI is best early in therapy and does not assume client want to discuss SA

26 Motivational Interviewing MI is a style of relating, decreasing resistance and establishing a strong alliance MI works better with angrier clients

27 Guiding Principles of Motivational Interviewing Express empathy Develop discrepancy Roll with resistance Support self-efficacy

28 Cognitive Behavioral Therapy Works best with clients who have made progress in resolving ambivalence about SA CBT works to cope with thoughts or cravings CBT uses distraction techniques that focus on shifting away from internal stimuli

29 DBT An area of mindfulness in DBT that is helpful is the creative way cognitions are used to help clients control their impulses Cravings to use drugs are changed through emphasis on cognitive restructuring, clients learn to substitute the target of their addiction with a healthier choice(i.e. craving something else they enjoy( self soothing techniques help regulate emotions)

30 CBT and DBT CBT and DBT were developed for other conditions(i.e. depression and BPD) They can be effective but it is less the model as a whole than specific techniques that are used as addiction therapies DBT therapist must adjust to treating SA clients as they are not as responsive tin forming a therapeutic alliance

31 DBT for PD and SUD: A CBT Technique DBT focuses on how reducing or stopping SA leads to healthier lifestyle SA is another harmful behavior and it detracts form the quality of life DBT recognizes self determination of goals(e.g. abstinence vs. controlled use DBT suggests there is a low% of PD clients who can successfully control SA

32 DBT for Relapse Prevention DBT recognizes the importance of expecting abstinence only as long as the client believes they can maintain it While abstinence is the goal, lapses can be helpful to provide insights onto how to improve chances for staying abstinence longer

33 12 Step Facilitation 12 Step Facilitation works best as an adjunctive therapy for addiction It emphasizes content related to 12 Step philosophy and includes getting clients to attend AA/NA meetings Recovery = Abstinence + Lifestyle change

34 12 Step Facilitation Help the client locate an appropriate group Help the client find a sponsor Help the client prepare to participate appropriately in the group Help overcome barriers to group participation Debrief with the client after attendance

35 Contingency Management(CM) CM is best as another adjunctive treatment It works through use of behavior therapy by pairing completion of a target behavior with an incentive Effective in methadone maintenance programs targeting compliance with treatment Effective in reducing addictive behaviors in clients with and without PD

36 Contingency Management Effective to increase attendance and lowering psychosocial impairment with ASPD clients in methadone treatment Reduced drop out among very severe comorbid psychiatric and SUD clients compared to TAU Reduced cocaine use in ASPD clients over CBT Increased attendance in PH/SAIOP with CM

37 Checklist for designing Contingency Management Programs Choose a behavior Choose a reinforcer Use behavioral principles Prepare a behavioral contract Implement the contract

38 Common Elements to Relapse Anticipate problems Prevention Models Label them as high risk situations for resuming substance use Help clients to develop effective strategies to cope with those high risk situations

39 Repetition and Skills Building to Address Deficits Be more concrete and less abstract in communicating ideas Use simple concepts Have briefer discussions Repeat core concepts several times Present information in multiple formats Role play real life situations

40 COD Group Treatment Recommendations Reduce the emotional intensity of interpersonal interaction Provide stronger direction Provide co-leaders if possible Keep duration to an hour or less Groups should run regularly without cancellation Group size should be smaller

41 COD Group Treatment Recommendations Be tolerate for levels of participation depending upon client functioning level Be brief, simple, concrete and repetitive Affirm accomplishments Amend negative behavior with positive learning experiences Be sensitive and responsive to client needs

42 Summary Clients with SUD and PD require highly structured treatments consisting of psychotherapy, behavioral interventions and pharmacotherapies Treatment intensity can be reduced with consistent stability in recovery Self determination with regard to goals of treatment must be honored

43 Summary Clients who pursue abstinence are less likely to relapse MI is the best approach for addiction especially early in treatment CBT and DBT techniques can be helpful as clients become more motivated 12 step facilitation is effective for clients wanting to pursue abstinence CM works well as an adjunctive treatment because of it s behavioral foundation

44 Empirical Evidence Outpatient SA treatment can led to positive outcomes for certain clients with COD even when treatment is not tailored to their specific needs Many COD clients who remain in SA treatment at least three months can improve however modifications designed to address MH disorders can enhance effectiveness

45 COD Outpatient Program Design Screening and assessment Centralized intake Reassessment Referral and placement Engagement Discharge planning Continuing care

46 Discharge Planning Housing Case management services Medication management Relapse prevention Positive peer networks Mutual self help groups Advocacy involvement

47 Continuing Care Supports client progress Monitors their condition Responds to a return to SA or symptoms of MH Describes steps for when and how to reconnect with services

48 Adolescent Effective Evidence-based Treatments Cognitive Behavior Therapy Motivational Enhancement Therapy Family Therapies(Family Behavior Therapy(FBT), Multidimensional Family Therapy(MDFT), Multisystemic Therapy(MST), Brief Strategic Family Therapy(BSFT)

49 Cognitive Behavior Therapy Core strategies-challenge irrational thoughts, cognitive restructuring, skill enhancement by modeling and role playing, self monitoring, changing reinforcement contingencies, coping skills training, and relapse prevention DBT focuses on emotional validation and acceptance couples with skills training

50 Motivational Enhancement Therapy MI-Non confrontational, client directed intervention that is empathic, nonjudgmental, develops discrepancy, avoids argumentation, rolls with resistance, and supports self efficacy for change. (i.e. MET/CBT 5)

51 Family Therapies-Family Behavior Therapy(FBT) FBT demonstrated increased retention, reductions in suicidal behaviors, hospitalizations, SA, anger, and behavior problems. It draws on a community reinforcement approach using behavioral contracting, stimulus control, urge control, and communication skills training

52 Family Therapies: MDFT MDFT targets multiple domains of risk, protection, and functioning with the youth, family, and community. Interventions focus on individual problems, goals of the youth, parental issues, parenting, family relationships, and extra-family relationships

53 Family Therapies: MST MST is based on social ecology theorybehavior is multi-determined and linked to the youth, family, peer group, school, and community. Intervention goals are to restructure the youth s environment to promote healthier, less risky behavior

54 Family Therapies: BSFT BSFT is designed to (1) prevent/reduce/treat adolescent behavior problems/drug use/conduct problems, delinquency, sexually risky behavior, aggressive behavior, and association with antisocial peers; (2) improve prosocial behaviors such as school attendance/performance; and (3) improve family functioning, including effective parental leadership and management, positive parenting, and parental involvement with the child and his or her peers and school

55 Suicidality SA is a major risk factor for suicide SA is associated with % of completed suicides Between 5 & 27% of all deaths of individual who abuse alcohol are caused by suicide with a lifetime risk of 15% There is a particularly strong relationship between SA and suicide in the youth

56 Suicidality Comorbidity of alcoholism and depression increases suicide risk The association between alcohol use and suicide may relate to the capacity of ETOH to remove inhibitions, leading to poor judgment, mood instability, and impulsiveness Intoxication is associated with increased violence toward self and others

57 Nicotine Dependence Tobacco dependence is common Screen everyone(ask, advise to quit, assess motivation to quit, assist to quit, arrange follow up Practice guidelines recommend first line pharmacotherapy-6 FDA approved treatments bupropion and 5 nicotine replacement treatments(nrt)

58 Nicotine Dependence Tobacco treatment medications are effective in the absence of psychosocial treatments Adding psychosocial increases outcomes by 50% For COD, use specific coping skills to cope with cravings associated with smoking cues Watch for changes in mental status, med. Side effects, and any need to lower dosage

59 COD/Borderline Personality Disorder BPD clients may use substances in idiosyncratic and unpredictable patterns Polydrug use is common and may involve ETOH and other sedative-hypnotics for self medication BPD clients are skilled in seeking multiple sources of medications

60 COD/Antisocial Disorder(AD) Prevalence of SA and AD is high SA treatment alone is particularly effective Most SA clients are not sociopathic Most AD clients are not true psychopaths Many AD clients use substances in a poly drug pattern(pot, ETOH, Meth., cocaine, heroin) Many AD clients are excited by the illegal drug culture and involved with the law

61 CBT Treatment for COD CBT treatment for SA CBT treatment for anger management CBT treatment for depression CBT treatment for anxiety CBT treatment for panic disorder CBT treatment for PTSD CBT treatment for OCD What is the potential to combine????

62 Bob Werstlein PhD

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