Beverly Fox MS, CAADC, LPC Clinical Supervisor at Rehab After Work
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By the end of this course participants should be able to: List the biological, psychological and social components of co-occurring disorders Describe the key elements of integrative treatment List some evidence-based treatment interventions that work well with this population
Questions to consider: Is your background in mental health or drug and alcohol treatment? Which populations do you work with? (e.g., adults, adolescents, specific genders or ethnicities) What type of treatment setting do you work in? (e.g., inpatient, residential, outpatient, urban vs. rural) What theoretical model(s) do you operate from? (e.g., CBT, therapeutic community, etc) What are the strengths vs. weaknesses of that model? What do you wish you could change about how you work with clients?
Drug and alcohol abuse masks mental health symptoms so it is often difficult or impossible to tell what is really going on until the client has achieved some period of sobriety. Clinical history is often unobtainable due to clients tendency to drop out of treatment, not sign releases of information, and provide an incomplete history when self-reporting past treatment and/or previous diagnoses, Assessments conducted by treatment providers often miss key questions about co-occurring symptoms, making it more likely that information needed to make an accurate diagnosis will be missed. Clients rarely offer information that is not explicitly asked about. Lack of knowledge on the part of treatment providers prevents them from diagnosing issues: we only see that which we understand.
SAMHSA s 2002 report to Congress defines cooccurring disorders as: Individuals who have at least one mental disorder as well as an alcohol or drug use disorder. While these disorders may interact differently in any one person (e.g., an episode of depression may trigger a relapse into alcohol abuse, or cocaine use may exacerbate schizophrenic symptoms), at least one disorder of each type can be diagnosed independently of the other. Other terms include dual-diagnosis, co-morbid, mentally ill chemical/substance abusers (MICA/MISA), mentally ill chemically dependent (MICD), chemical/substance abuse and mental illness (CAMI/SAMI), etc.
An estimated 4.2% of adults (10 million) and 10.7% of adolescents (2.6 million) suffer from serious mental illness An estimated 6.6% (17.3 million) of persons aged 12 or older suffer from alcohol abuse or dependence An estimated 2.6% (6.9 million) of persons aged 12 or older suffer from illicit drug abuse or dependence This leads to an estimated 8.9 million individuals suffering from co-occurring disorders Source: Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: United States, 2014. HHS Publication No. SMA-15-4895. Rockville, MD: SAMHSA 2015
For a long time, individuals in treatment for substance abuse have spoken of self medicating, meaning that they abuse drugs and alcohol in order to alleviate symptoms of their mental illness. Anyone in recovery will attest to the fact that chemicals are a fast and effective treatment for almost any issue including depression, anxiety, mood swings, ADHD, PTSD, insomnia, social phobias and plain old bad days (e.g., boy, I could use a drink ).
New research into the biochemistry of both mental illness and addiction explains the reason: Substances of abuse work on the same neurons that are affected by mental illness. An individual suffering from a neurochemical deficiency can adjust that deficiency by using chemicals that stimulate the release of that neurochemical, thereby adjusting the system to a balanced level. PET scan of an ADHD diagnosed individual showing lower dopamine levels than control subject Image from NIDA for teens: http://teens.drugabuse.gov/blog/post/prescription-stimulants-affectpeople-adhd-differently
However, long-term abuse of drugs depletes the brain of these neurochemicals by creating a demand that the brain cannot meet, thus making the initial imbalance worse and escalating the symptoms of the mental illness. It is a progressive disease. Decreased dopamine transporters in a methamphetamine Abuser Image from NIDA: Volkow ND, Chang L, Wang GJ, Fowler JS, Leonido-Yee M, Franceschi D, Sedler MJ, Gatley SJ, Hitzemann R, Ding YS, Logan J, Wong C, Miller EN. Association of dopamine transporter reduction with psychomotor impairment in methamphetamine abusers. Am J Psychiatry 158(3):377-382, 2001.
Most mental illnesses begin to emerge during adolescence. Most individuals begin experimenting with drugs and alcohol in early adolescence and many are already abusing substances by later adolescence. This makes answering the question of which came first impossible to answer But in the end, it doesn t really matter- when both are present in the individual, both must be treated.
Both mental illness and addiction contribute to the development of negative behavioral coping tools (isolation, avoidance, negative interpersonal relationships) which exacerbates symptoms of both disorders. Individuals suffering from mental illness and addiction are significantly more likely to present with a trauma history than the general population. Individuals in this population are more likely to experience more severe and/or chronic medical conditions than those in the general population. Issues of socioeconomic disadvantage (especially homelessness and lack of health insurance), veteran s challenges, cultural adaptation and legal complications all apply. Stigma affects this population more than individuals suffering from either disorder alone.
Historically, individuals have been treated by either mental health facilities OR drug and alcohol rehabs. There was little or no communication, sharing of resources or coordination of treatment between involved parties. Furthermore, treatment providers lacked knowledge of other disorders and subsequently misdiagnosed or completely missed them leaving the client untreated, unaware and prone to relapse.
Treatment Origins Culture Psychiatric Efforts at integration Mental Health Drug and Alcohol Earliest treatment sought to address the medical/ psychosomatic elements of disorders Earliest treatment started as grass roots campaign to treat spiritual drought and was adapted by treatment facilities later Care provided by doctors, physicians, psychiatrists and clinicians (i.e., the authoritarian relationship issue) Care provided by peers and individuals within a mentorship approach (i.e., the Are you in recovery? question) Medications have proven effective in controlling symptoms and are highly advocated, but doctors may not be aware of addictive nature of some prescriptions Medications have proven effective in controlling cravings but individuals may face stigma for taking them Seeks to utilize strength-based resources including family, physical health and religion, while appreciating specifics of clients gender, culture and identity Seeks to utilize community supports including family, religion, employer, legal supervision and advanced medical interventions
See handout with above title and consider these questions: In what ways did the treatment provider fail Anita? In what ways did the system work against her? How could this type of outcome be prevented in an integrative model? What would have to change in order for that to happen?
Most experts in the field believe that, as a whole, we must move towards integrated treatment in order to provide appropriate care to individuals in recovery. According to the SAMHSA website: Services Integration refers to the process of merging separate clinical services to meet the individual's substance abuse, mental health, and other needs. Services integration has two levels: Integrated programs are changes within an entire agency that help practitioners provide integrated treatment. Integrated treatment occurs at the individual-practitioner level and includes all services and activities. Truly integrated care requires system reform: treatment programs need to be redesigned from the ground up in order to address all aspects of treatment including staff knowledge, program design, screening and assessment, treatment planning, evidence-based treatment interventions, community involvement (family, physicians, religious supports, legal supervisors) and outcome measurements.
https://www.youtube.com/watch?v=dfwalqrw BaQ
Two measurements have been designed to assess current treatment programs needs to restructure: 1. Dual Diagnosis Capability in Addiction Treatment (DDCAT) for substance abuse treatment providers 2. Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) for mental health treatment providers Both rate programs on structure, milieu, assessment, treatment, continuity of care, staffing and training, and provide specific benchmarks to reach truly integrated care SAMSHA offers the Integrated Treatment for Co- Occurring Disorders Evidence-Based Practices (EBP) KIT for free on their website
System-wide transformation requires the entire system to be involved. Funders (insurance companies, state agencies, etc) need to change their policies regarding reimbursement for services. Accrediting agencies need to revise their policies for program certification. Program administrators need to adapt the model and create new policies within their agencies. Individual clinicians need to be trained in order to become co-occurring competent. Consumers need to learn about available services and establish a voice in order to advocate for themselves. We are heading in this direction- many are already there. We need to lead the charge by starting with ourselves.
Both drug and alcohol and mental health treatment providers are required to obtain continuing education each year in order to maintain licensure, certification and employment within their agencies (thus why we re all here)- why not devote yourself to getting educated on the issues you need to know more about? Screening and assessment Medication-assisted treatment New drugs of abuse Behavioral addictions (gambling, sex, internet, food, etc) Trauma-informed treatment Physical health problems for this population Holistic interventions And many more topics Remember: the strength-based model advocates identifying currently existing resources and building on them (i.e., you don t have to get a 2 nd master s degree to become competent)
Integrated assessment means that mental and substance use disorders are assessed in the context of each other. It consists of gathering key information and engaging in a process with the individual that enables a practitioner to: Establish (or rule out) the presence or absence of a co-occurring disorder Determine the individual's readiness for change Identify the individual's strengths or problem areas that may affect the processes of treatment and recovery Begin the development of an appropriate treatment relationship -SAMHSA Website Specific issues to look for: frequency and amount of use, correlation of mental health symptoms with use, pattern in relation to symptoms and treatment interventions (relapse), specific checklists for mood disorders, anxiety disorders, eating disorders, trauma and behavioral addictions (gambling, sex, internet, shopping, etc). Obtain collateral information from all available supports (all other treatment providers including doctors, significant others, family, friends, legal supervisors, AA/NA supports, religious peers, etc) The BioPsychoSocial model considers familial, cultural, religious, gender-specific, sexual preference, employment, physical health and other factors to allow for an understanding of how all the client's symptoms affect each one of these areas of life.
Cognitive Behavioral Therapy (CBT): both disorders lead to the development of distorted thinking and their continuation is largely caused by these patterns of thought. CBT seeks to directly challenge and change these distorted thoughts, thereby changing the associated behaviors. Thought records and journals are required in the beginning to teach the individuals how to track and challenge their thoughts with in-session thought challenging to encourage identification of associated physical responses and behaviors (see mindfulness). With time and practice, individuals learn to do this process internally, thereby interrupting the thought process before it leads to the problematic behavior. Recommended reading: Cognitive Behavioral Therapy: Basics and Beyond by Judith S. Beck, Feeling Good: The New Mood Therapy by David D. Burns
Seeks to initiate change by meeting the client where they re at (i.e., individuals do not have to believe that the behavior is a problem, they just have to identify some aspect of it they would like to change) Operates off of stages of change model which is universally applicable to both addiction and mental health issues Classic example: an individual does not wish to stop abusing marijuana, but they agree that they need to in order to stay out of jail. Or a person does not want to eat, but agrees that they need to in order avoid more invasive treatment. Recommended reading: Motivational Interviewing: Helping People Change by William R. Miller and Stephen Rollnick, Motivational Interviewing for Concurrent Disorders by Carolynne Cooper and Wayne Skinner
Mindfulness training seeks to teach individuals to utilize their senses to become more aware of bodily reactions to emotions (including cravings) and change those physical sensations to remove the urgency of those emotions It s about separating the triggering thoughts from the associated response so that you can let go of them (goes hand in hand with CBT) Meditation allows individuals to self-soothe and calm down their autonomic response thereby enabling clearer thinking and better problem-solving Recommended reading: Mindfulness for Beginners: Reclaiming the Present Moment and Your Life by Jon Kabat-Zinn, Mindfulness and Psychotherapy by Christopher K. Germer, Ronald D. Siegel and Paul R. Fulton
As a universal rule, human beings need other human beings in order to live healthy, productive lives- regardless of different diagnoses or problems. As such, any treatment MUST involve the individual's support team. Remember: it is the individual s definition of family, not the traditional one. Treatment includes education, coordination in treatment planning, family therapy, community involvement and WRAP planning (see relapse prevention). Recommended reading: Substance Abuse Treatment and Family Therapy (TIP No. 39) by SAMHSA
The Wellness Recovery Action Plan (WRAP) can be utilized for co-occurring diagnosed individuals as it seeks to get a comprehensive picture of what wellness looks like Completed while a client is doing well in recovery it teaches them to look for the signs and symptoms of recovery maintenance the same way they look for triggers and objective signs that they are heading into relapse Clients identify specific behaviors, scheduling requirements and treatments to be used as part of their recovery Utilizes support involvement by tasking the individual to identify specific steps for their supports to take and actively involving them in the planning process (this includes treatment providers, family/friends, and all other supports we ve discussed) Recommended reading: Wellness Recovery Action Plan (WRAP ) for Addictions by Mary Ellen Copeland
Integrative treatment requires systematic change which must involve all parties- funders, administrators, accrediting agencies, individual treatment providers and informed, empowered clients Individual clinicians can start the change within themselves and make system-wide transformations from the bottom up by following practical steps for professional growth Tools are available from a variety of resources invested in helping with this change- SAMHSA is a wonderful resource, but each state/agency/clinician can utilize what is right for them We must use the same strength-based approach we employ with our clients to identify and build upon what we already have rather than reinventing the wheel
SAMHSA: http://media.samhsa.gov/cooccurring/ DDCAT: http://www.samhsa.gov/cooccurring/topics/ddcatddcmht/pdf/ddcat_instrument.pdf DDMHT: http://www.samhsa.gov/cooccurring/topics/ddcatddcmht/pdf/ddcmht_instrument.pdf Integrated Treatment for Co-Occurring Disorders Evidence-Based Practices KIT: http://store.samhsa.gov/product/sma08-4367
Drexel University College of Medicine offers free, fully-accredited CEUs to clinicians: http://drexel.edu/medicine/academics/conti nuing-education/behavioral-healthcare- Education/Regional-Course-Information/ The American Counseling Association offers free online trainings: http://www.prolibraries.com/counseling/ Ask your agency for assistance in finding/funding continuing education