Title: Nurturing and Supporting Clients Who Need More Than Shelter A look at: CoOccurring Disorders, Domest
1Nurturing and Supporting Clients Who Need More
Than ShelterA look at Co-Occurring Disorders,
Domestic Violence and Trauma
- Roland Williams, MA, NCACII, CADCII, SAP
- President, Free Life Enterprises,
- Director, VIP Recovery Coaching
- www.rolandwilliamsconsulting.com
www.rolandwilliamsconsulting.com
2Domestic Violence
3Violence Against Women
- Approximately 4.4 million adult American women
are abused by their spouse or partner each year - 30 of women in the United States experience
domestic violence at some time in their lives. - Women are 7-14 times more likely to suffer a
severe physical injury from an intimate partner
than men.
4Young Women at Risk
- Women ages 16-24 are the group most likely to be
victims of intimate partner violence. - Women in the high-school years to their mid-20s
are nearly three times as vulnerable to attack by
a husband, boyfriend or former partner as those
in other age groups. - Sixteen out of every 1000 women between ages of
16 and 24 were attacked by an intimate partner in
2007, the highest rate of any age group.
5Domestic Violence During Pregnancy
- Women often experience the start of escalation of
violence during pregnancy. - A review study found that an average of 4-8 of
women had experienced domestic violence during
pregnancy. - Abused pregnant women are at higher risk for
infections, low birth weight babies, smoking,
substance abuse, maternal depression and suicide.
6Effects of Domestic Violence
- Symptoms of domestic violence may appear as
injuries or chronic conditions related to stress.
- Women who experience domestic violence are more
often victims of nonconsensual sex. - They also have higher rates of smoking, substance
abuse, chronic pain symdromes, depression,
anxiety and Post Traumatic Stress Disorder.
7Domestic violence programs do not usually deal
with the substance abuse problems of the women
they serve
- The primary focus of domestic violence programs
for women are safety and shelter. - There is a concern that focusing on the substance
abuse of female victims might encourage victim
blaming. - Resources are typically very limited within
domestic violence programs. - Programmatic expertise in substance abuse
treatment usually does not exist in domestic
violence programs.
8Substance Abusing Victims
- Another option for dealing with the substance
abuse problems of female domestic violence
victims within domestic violence programs is
referral to substance abuse programs. This
option, however, is often not pursued for some of
the above reasons and because of philosophical
differences between the two program types.
Domestic violence programs sometimes view the
treatment philosophy of substance abuse programs
as inappropriate for their clients because victim
safety and empowerment are not emphasized.
9Treatment Issues
- Treatment programs for batterers do not usually
provide substance abuse treatment. In fact, there
is often explicit resistance to the inclusion of
substance abuse treatment as a part of treatment
for batterers because of the strong emphasis on
batterer accountability, a high priority in
batterer treatment. There is a concern that
inclusion of the substance abuse component with
its emphasis on alcohol and drug abuse as a
disease or disorder might shift attention away
from the idea that battering is voluntary
behavior, and offenders should be held strictly
accountable for their violent behavior.
10- An Introduction to Co-Occurring Disorders
11Substance Abuse and Mental Illness
- A dual diagnosis or co-occurring disorder
occurs when an individual is affected by both
chemical dependency and mental illness. Both
illnesses may affect a person physically,
socially, psychologically, and spiritually. Each
illness has symptoms that interfere with a
persons ability to function effectively. The
illnesses may affect each other, and each
disorder predisposes to relapse in the other
disease. At times the symptoms can overlap and
even mask as each other, making treatment and
diagnosis difficult. To fully recover, a person
needs to treat/address both disorders.
12How Common is a Dual Diagnosis?
- It is challenging to determine conclusively how
many people have a dual diagnosis because
existing studies examine different populations
and utilize different screening tools. - Further, people with dual disorders are
frequently misidentified, as diagnosis can be
more difficult because one disorder can mimic
another. Varying sources of information have
found that - 37 of alcohol abusers and 53 of drug users also
have at least one serious mental illness
13How Common is a Dual Diagnosis?
- Of all people diagnosed as mentally ill, 29
abuse either alcohol or drugs. - In 1993, as many as 50 of the mentally ill
population were reported to have a substantial
abuse problem. - In 2002, depending on the setting, prevalence
rates for the co-occurring disorders (dual
diagnosis) ranged from 20 to 80 - Relapse rates for substance use are higher for
people with a concurrent mental disorder, as are
the chances that symptoms of mental illness will
return for those with a concurrent substance use
problem.
14Addressing Substance Abuse and Mental Health
Barriers to Providing Services
- Co-Occurring Mental Health and Substance Abuse
creates unique challenges regarding screening and
assessment, service coordination, treatment
capacity, and funding for services. - Identifying and assessing rclients with substance
abuse and mental health problems are first steps
in dealing with these barriers to employment. - Types of practices that can facilitate accurate
screening and assessment include staff training
on substance abuse and mental health issues, and
the use of appropriate screening instruments. - Once problems are identified, referral to
treatment and providing support services can
improve recipients social functioning and
employment outcomes. Access to treatment can be
difficult, however, because service delivery
systems are often fragmented. - Referring clients to treatment may also bring to
light service capacity problems, particularly for
programs designed to serve women with children. - Limited funding for treatment services and
limited coverage of these health-related problems
through MediCal may be further obstacles to
treatment.
www.rolandwilliamsconsulting.com
15Diagnosis 1
16What is Mental Illness
- Mental Illness Facts
- Mental illnesses are medical conditions that
disrupt a persons thinking, feeling, mood,
ability to relate to others, and daily
functioning. Just as diabetes is a disorder of
the pancreas, mental illnesses are medical
conditions that often result in a diminished
capacity for coping with the ordinary demands of
life.
17Serious mental illnesses
- Include
- major depression
- schizophrenia
- bipolar disorder
- obsessive compulsive disorder (OCD)
- panic disorder
- post traumatic stress disorder (PTSD)
- borderline personality disorder
18In Addition to Medication Treatment
- Psychosocial treatment such as
- cognitive behavioral therapy,
- interpersonal therapy,
- peer support groups,
- and other community services can also be
components of a treatment plan that assist with
recovery. - The availability of transportation, diet,
exercise, sleep, friends, and meaningful paid or
volunteer activities contribute to overall health
and wellness, including mental illness recovery.
19Diagnosis Specific Signs and Symptoms
20Major Depression
- Dysphoric mood
- At least 4 of the following
- Changes in appetite and sleep patterns,
agitation, loss of interest in pleasurable
activities, fatigue, worthlessness, guilt,
inability to concentrate, ruminating negative
thoughts, feeling helpless and hopeless,
recurrent thoughts of death
www.rolandwilliamsconsulting.com
21Signs and Symptoms of Depression
- Tearful
- Changes in sleeping patterns
- suicidal ideation
- changes in appetite
- loss of pleasure
- isolation
- sudden outburst of anger
www.rolandwilliamsconsulting.com
22Signs and Symptoms of Depression
- Difficulty concentrating
- Ruminating thoughts
- Feeling helpless
- Feeling hopeless
- Feeling like life is not worth living
- Ruminating on negative thoughts
- Emotional numbness
www.rolandwilliamsconsulting.com
23Bipolar Disorder
- Bipolar disorder, also known as manic depression,
is a brain disorder that causes unusual shifts in
a person's mood, energy, and ability to function.
Different from the normal ups and downs that
everyone goes through, the symptoms of bipolar
disorder are severe. They can result in damaged
relationships, poor job or school performance and
even suicide.
www.rolandwilliamsconsulting.com
www.rolandwilliamsconsulting.com
24Bipolar Disorder Manic
- One of more distinct period with a predominantly
elevate, expansive or irritable mood - Duration of at least one week during which most
of the time at least 3 have been present - Increase in activity, hyper verbal or pressured
speech, flights of ideas, grandiosity, decreased
need for help, distractibility, buying sprees,
sexual indiscretions, foolish business
investments, reckless driving
www.rolandwilliamsconsulting.com
www.rolandwilliamsconsulting.com
25Post Traumatic Stress Disorder
- Diminished interest in activities
- Feeling detached or estranged from others
- Sleep disturbances
- Hyper alertness
- Exaggerated startle response
- Survival guilt
- Memory impairment, difficulty concentrating
- Intensification of symptoms by exposure to events
that symbolize or resemble the traumatic event
www.rolandwilliamsconsulting.com
26Personality Disorders
- Each of us has a personality or group of
characteristics (traits) which influence the way
we think, feel behave and makes us a unique
individual. - Someone may be described as having a 'personality
disorder' if their personal characteristics cause
regular and long term problems in the way they
cope with life and interact with other people.
Some people with these disorders never come into
contact with the mental health services. - APA when personality traits are inflexible
and maladaptive and cause either significant
impairment in social or occupational functioning
or subjective distress.
27Personality Disorders
- Approximately 10-13 of the population have a
personality disorder. Personality disorders are
more common in younger age groups (25-44 year age
group) and are equally distributed between males
and females.
28Personality Disorders
- Prominent characteristics
- Tx of problematic relationships
- Blames difficulties on others or bad fortune
- Doesnt learn from mistakes
- Generate and perpetuate existing problems
- Lack of control over emotions
- Distorted thinking
www.rolandwilliamsconsulting.com
www.rolandwilliamsconsulting.com
29Types of Personality Disorders
- Divided into 3 Clusters
- A) odd/eccentric paranoid, schizoid
- B) dramatic/erratic antisocial, borderline,
histrionic, narcissistic - C) anxious/inhibited dependent, avoidant,
obsessive-compulsive
www.rolandwilliamsconsulting.com
www.rolandwilliamsconsulting.com
30Antisocial Personality Disorder
- Current age of at least 18
- Onset before 15 as indicated by 3 or more
- Truancy, expulsion, delinquency, running away
from home, arrested, persistent lying, repeated
sexual intercourse, repeated drunkenness or
substance abuse, thefts, vandalism, low school
grades, chronic violations of home rules,
initiation of fights
www.rolandwilliamsconsulting.com
www.rolandwilliamsconsulting.com
31Antisocial Personality Disorder
- At least 4 of the following since age 18
- Inability to sustain consistent work behavior
- Lack of ability to function as a responsible
parent - Failure to accept social norms with respect to
lawful behavior - Inability to maintain enduring attachment to a
sexual partner
www.rolandwilliamsconsulting.com
www.rolandwilliamsconsulting.com
32Antisocial Personality Disorder
- Irritability and aggressiveness
- Failure to honor financial obligations
- Failure to plan ahead or impulsivity
- Disregard for the truth
- Recklessness
- A pattern of continuous antisocial behavior in
which the rights of others are violated
www.rolandwilliamsconsulting.com
www.rolandwilliamsconsulting.com
33Borderline Personality Disorder
- At least 5 of the following
- Impulsivity or unpredictability in at least 2
areas that are potentially self
damaging-Spending, sex, gambling, shoplifting,
AOD use, etc - A pattern of unstable and intense interpersonal
relationships - Inappropriate, intense anger or lack of control
over anger - Identity disturbances
- Affective instability
- Intolerance of being alone
- Physical self damaging acts
- Chronic feelings of emptiness and boredom
34Post Traumatic Stress Disorder
- The person has been exposed to a traumatic event
in which the person experienced, witnessed, or
was confronted with an event or events that
involved actual or threatened death or serious
injury, or a threat to the physical integrity of
self or others and the person's response involved
intense fear, helplessness, or horror. The
disturbance, which has lasted for at least a
month, causes clinically significant distress or
impairment in social, occupational, or other
important areas of functioning. - The traumatic event is persistently reexperienced
in one or more of the following ways
35Post Traumatic Stress Disorder
- Recurrent and intrusive distressing recollections
of the event, including images, thoughts, or
perceptions. - Recurrent distressing dreams of the event.
- Acting or feeling as if the traumatic event were
recurring (includes a sense of reliving the
experience, illusions, hallucinations, and
dissociative flashback episodes, including those
that occur on awakening or when intoxicated).
36Post Traumatic Stress Disorder
- Intense psychological distress at exposure to
internal or external cues that symbolize or
resemble an aspect of the traumatic event - Physiological reactivity on exposure to internal
or external cues that symbolize or resemble an
aspect of the traumatic event
37Post Traumatic Stress Disorder
- The individual also has persistent avoidance of
stimuli associated with the trauma and numbing of
general responsiveness (not present before the
trauma), as indicated by 3 or more of the
following - Efforts to avoid thoughts, feelings, or
conversations associated with the trauma - Efforts to avoid activities, places, or people
that arouse recollections of the trauma - Inability to recall an important aspect of the
trauma - Significantly diminished interest or
participation in significant activities
38Post Traumatic Stress Disorder
- Feeling of detachment or estrangement from others
- Restricted range of affect (e.g., unable to have
loving feelings) - Sense of a foreshortened future (e.g., does not
expect to have a career, marriage, children, or a
normal life span)
39Post Traumatic Stress Disorder
- Persistent symptoms of increased arousal (not
present before the trauma), as indicated by 2 or
more of the following - Difficulty falling or staying asleep
- Irritability or outbursts of anger
- Difficulty concentrating
- Hypervigilance
- Exaggerated startle response
40The Good News About Mental Illness
- Is that recovery is possible.
- Mental illnesses can affect persons of any age,
race, religion, or income. - Mental illnesses are not the result of personal
weakness, lack of character, or poor upbringing. - Most people diagnosed with a serious mental
illness can experience relief from their symptoms
by actively participating in an individual
treatment plan.
41Diagnosis 2
42The Three Cs of Addiction
- Control
- Early social/recreational use
- Eventual loss of control
- Cognitive distortions (denial)
- Compulsion
- Drug-seeking activities
- Continued use despite adverse consequences
- Chronic Condition
- Natural history of multiple relapses preceding
stable recovery - Possible relapse after years of sobriety
43Addiction A Dog with a Bone
- It never wants to let go.
- It bugs you until it gets what you want.
- It never forgets when/where it is used to
getting its bone. - It thinks its going to get a bone anytime I do
anything that reminds it of the bone.
www.rolandwilliamsconsulting.com
44Addiction Defined
- Drug Addiction is a complex illness. It is
characterized by compulsive, obsessive and at
times uncontrollable craving, seeking and use
that persist even in the face of extremely
negative consequences. Denial, minimizing and
rationalizing the use and effects prolong the
illness. For many, addiction becomes chronic,
with relapses possible even after long periods of
abstinence.
45DSM-IV Criteria
- Substance Abuse (need 1 in 12 mo. Period)
- Use leads to impairment or distress by
- Failure to fulfill major roles, obligations
- Use in hazardous situations
- Recurrent legal problems
- Continued use despite problems
- Symptoms never met criteria for substance
dependency
46DSM-IV Criteria
- Substance Dependence (need 3 in 12 mo. Period)
- Use leads to impairment or distress by
- Tolerance
- Withdrawal
- Loss of control
- Failed attempts at control or abstinence
- Much time spent, getting, using or recovering
- Given up or reduced job or recreational activity
- Continued use despite known negative consequences
47Common Sense Assessment
financial
work
spiritual
family
emotional
social
recreational
physical
legal
48When to be Suspicious
- Unexplained changes in appearance, attitude and
overall health - Family concerns or turmoil
- Drug seeking behavior
- Loss prescriptions
- Chronic pain complaints
- Unexplained weight loss
- Missed appointments
- Lying or inconsistencies in self-report
- Increased parenting problems
49- Substance Abuse and Mental Illness Co-Occurring
Disorder
50Current Terminology
- Dual diagnosis is an unfortunate misnomer, as
rarely do people experience ONLY two disorders.
SAMHSA favors the term, co-occurring disorders.
One type of disorder may trigger the other, but
90 percent of the time, according to National Co
morbidity Survey (NCS) data, mental illness
precedes substance use. On average, mental
illness occurs at around age 11 followed by
substance use five to 10 years later. On the
other side of the coin, drug use can produce
psychotic symptoms, result in a relapse of a
psychotic illness, or create a need for
medication adjustments.
51Other names for this condition
- Co-morbid disorders
- Co-occurring disorders
- Concurrent disorders
- Co-morbidity
- Dual disorders
- Dual diagnosis
52Co-Occurring Risk Factors
- Childhood risk factors such as poverty, family
discord, and pre and postnatal complications
appear to be implicated in both mental illness
and substance use. - Between 51 and 97 percent of women with serious
mental illness have been physically or sexually
abused. - 41 to 71 percent of women treated for alcohol or
drug use report being sexually abused.
53Stigmas
- Alcohol and drug abuse have many negative
connotations in our society. For many, drug abuse
is perceived to result from lack of willpower,
laziness, or selfishness. Sadly, these erroneous
perceptions also extend to a group extremely
vulnerable to drug abuse people with mental
disorders.
54Relationship between Substance Abuse and Mental
Illness
- Those with a mental disorder can be very
sensitive to the effects of drug abuse not only
can it be easier to abuse drugs, it can also be
harder to quit. - Like the rest of the population, a person with a
mental disorder is more likely to abuse drugs if
there is a family history of alcohol and drug
abuse. - Environmental factors such as peer pressure,
location, and the availability of the drug also
contribute to a pattern of drug abuse in the
mentally ill.
55Relationship between Substance Abuse and Mental
Illness, cont.
- Drug use can interfere with prescribed
medication, increase symptoms of a mental
condition, and increase relapse risk. - Having difficulty developing social
relationships, some people find themselves more
easily accepted by groups whose social activity
is based on drug use. - Some believe that an identity based on drug
addiction/alcoholism is more acceptable than one
based on mental illness.
56So are we doing to provide more comprehensive and
effective treatment to the Dual Diagnosis Client?
57The Need for Dual Recovery
- A person with a dual diagnosis may sincerely try
to recover from one illness and not acknowledge
the other. - As a person neglects the mental illness, that
illness may resurface. This recurrence may in
turn lead a person to feel the need to self
medicate through drug/alcohol use to combat
symptoms of the mental illness or side effects of
medications.
58The Need for Dual Recovery
- This relief or change is temporary at best and
usually leads to hospitalization. Over time, the
lack of progress towards recovery on both fronts
may - Trigger feelings of failure and alienation
- Lead to trouble with parenting, finding and
keeping employment, housing, and non-tolerance in
rehabilitation or treatment facilities - Lead to loss of support systems and benefits
- Result in frequent relapses and hospital stays.
59How is a Co-Occurring Disorder Treated?
- Programs historically have not addressed the
unique problems of those struggling with both
disorders, instead treating the mental illness
and drug abuse as separate problems. This has not
proved to be an effective approach and more
programs now are being developed to treat both
disorders together. - Ideally, both problems should be treated
simultaneously.
60How is a Co-Occurring Disorder Treated?
- A person with a Co-Occurring Disorder may or may
not fit into traditional 12-Step groups. - Opportunities to socialize and access to
recreational activities to develop peer
relationships - Attendance in groups that deal with education and
awareness of dual diagnosis issues, medication
support and management, life skills, and wellness - Family support and education
61How is a Co-Occurring Disorder Treated?
- The first step in treatment for any substance
abuse must be detoxification - For safety, detoxification should take place
under medical supervision. - Treatment programs for this population should
take a gradual approach. Those with dual
diagnosis have to proceed at their own pace in
the treatment process. - Abstinence may be a goal of the program but
should not be a pre-condition to enter treatment
\
62General Rules
- Meet the recipients where theyre at
- Acknowledge and allow them to have emotional,
cognitive, behavioral and intellectual
limitations - Develop action plans according to where they are
and not where you think they should be - Set the client up to succeed not fail
www.rolandwilliamsconsulting.com
63Responsible and Careful Assessment
- To begin treatment based solely on the appearance
of psychiatric symptoms denies the person
accurate diagnosis - Need to distinguish between substance use
disorder, substance-induced problems, self
medication of a primary mental disorder, or true
dual diagnosis. - careful assessment rather than reactive treatment
of presenting symptoms - pharmacological and psychosocial aspects of
addiction can mimic psychiatric disorders. - What can appear to be a significant major
depression can dissipate decisively with
abstinence and recovery It is equally important
to avoid persistent admonition to not drink and
go to meetings if there is a primary depressive
disorder, which the client attempts to self
medicate with alcohol. David Mee-Lee
64The Four Quadrant Model
- The Four Quadrant Model is a viable mechanism
for categorizing individuals with co-occurring
disorders for the purpose of service planning and
system responsibility.
65Sub-Groups of Dual Diagnosis Client Types
www.rolandwilliamsconsulting.com
www.rolandwilliamsconsulting.com
66Choosing the Right Program
- There are several different levels of care,
including full hospitalizations, partial
hospitalizations, and out patient treatment. The
need for hospitalization depends on the nature
and severity of illness, the associated risk or
complication, and personal treatment history.
Because both illnesses are treated at the same
time, a person needs to be able to take
psychiatric medications while treating the
substance abuse. So choosing the right program is
crucial for successful outcomes.
67AOS Programs
- Programs that offer Addiction-Only Services (AOS)
- Some addiction treatment programs cannot
accommodate patients with psychiatric illnesses
that require ongoing treatment, however stable
the illness and however well functioning the
individual. Such programs are said to provide
Addiction-Only Services (AOS).
68DDC Programs
- Dual Diagnosis Capable (DDC) Programs
- Dual Diagnosis Capable (DDC) programs routinely
accept individuals who have co-occurring mental
and substance-related disorders. DDC programs can
meet such patients needs so long as their
psychiatric disorders are sufficiently stabilized
and the individuals are capable of independent
functioning to such a degree that their mental
disorders do not interfere with participation in
addiction treatment.
69DDE Programs
- Dual Diagnosis Enhanced (DDE) Programs
- DDE programs can accommodate individuals with
dual diagnoses who may be unstable or disabled to
such an extent that specific psychiatric and
mental health support. monitoring and
accommodation are necessary in order for the
individual to participate in addiction treatment.
Such patients are not so acute or impaired as to
present a severe danger to self or others, nor do
they require 24-hour, intensive psychiatric
supervision.
70Treatment Providers Should
- Take good history A definitive psychiatric
diagnosis by history requires the psychiatric
symptoms to have occurred during drug-free
periods of time and/or to have preceded the
beginning of addiction problems. - Observe the client for a sufficient time
drug-free Shorter time for objective, psychotic
symptoms longer for subjective, affective
symptoms. Clients are encouraged to try non-drug
ways of coping such as active involvement in a
recovery program that incorporates self/mutual
help meetings, tools, techniques, and a wide
variety of non-drug coping responses to help
clients deal with the stresses of everyday
living. - If there is evidence of a documented co-occurring
mental disorder, then no drug-free period is
necessary.
71Typical Response to Treatment
- Dual diagnosis clients were more often discharged
due to determinations that the individuals were
inappropriate for the treatment program or for
program decisions related to patient
non-compliance with rules. - Substance abuse clients were more likely to be
transferred to another level of service or
referred out of the system for alternative
services. - In one study the two groups were equivalent in
the percentage of clients who completed
treatment, when placed in the appropriate
clinical setting.
www.rolandwilliamsconsulting.com
72Co-Occurring Recovery and Relapse Calendar
www.rolandwilliamsconsulting.com
www.rolandwilliamsconsulting.com
73Negative Outcomes among Dually Diagnosed
More relapses, re-hospitalization, depression,
suicides, violence, housing instability and
homelessness, treatment noncompliance , HIV,
family burden, increased service utilization and
certainly difficulty and/or inability to acquire
and maintain gainful employment, and for Calworks
caseload, the inability to meet the work
requirements and possible loss of benefits.
www.rolandwilliamsconsulting.com
www.rolandwilliamsconsulting.com
74Individuals with Co-occurring DisordersTreatment
Rules
- All good treatment proceeds from empathic,
hopeful, clinical relationship. - Consequently, promote opportunities to initiate
and maintain integrated, continuing, empathic,
hopeful relationships whenever possible. - Specifically, remove arbitrary barriers to
initial mental health assessment and evaluation,
including psychopharmacology evaluation. - Similarly, never deny access to substance
disorder evaluation and/or treatment because a
patient is on a prescribed non-addictive
psychotropic medication. - Moreover, never discontinue medication for a
known serious mental illness because a patient
uses substances.
75Individuals with Co-occurring DisordersTreatment
Rules Continued
- In fact, when mental illness and substance
disorder co-exist, both disorders require
specific and appropriately intensive primary
treatment. - There are no rules! The specific content of dual
primary treatment for each person must be
individualized according to diagnosis, phase of
treatment, level of functioning and/or
disability, and assessment of level of care based
on acuity, severity, medical safety, motivation,
and availability of recovery support. Kenneth
Minkoff, M.D
76The Self-Medication Theory
- People with serious mental illness use
substances - To alleviate general feelings of isolation,
loneliness, boredom, and despair, - To facilitate peer interaction/socialization
- To create a sense of well-being, and escape from
bleak life experience. Sound familiar?
77FOUR STEP PROCESS
- Empathize with reality of despair.
- Establish legitimacy of their need to ASK for
extensive help. - 3. Identify meaningful, attainable measures of
successful progress. - 4. Emphasize a hopeful vision of pride and
dignity to counter self-stigmatization.
78Individuals with Co-occurring DisordersPrinciples
of Successful Treatment
- Co morbidity is an expectation, NOT an exception.
- Use the Four Quadrant Model.
- Treatment success derives from the implementation
of an empathic, hopeful, continuous treatment
relationship, which provides integrated treatment
and coordination of care through the course of
multiple treatment episodes. - Within the context of the empathic, hopeful,
continuous, integrated relationship, case
management/care and empathic detachment/
observation are appropriately balanced at each
point in time. - When substance disorder and psychiatric disorder
co-exist, each disorder should be considered
primary, with integrated treatment. Each disorder
receives appropriately intensive
diagnosis-specific treatment.
79Individuals with Co-occurring DisordersPrinciples
of Successful Treatment
- Both major mental illness and substance
dependence are examples of primary mental
illnesses which can be understood using a disease
and recovery model, with parallel phases of
recovery, each requiring phase-specific
treatment. - There is no one type of dual diagnosis program or
intervention. For each person, the correct
treatment intervention must be individualized
according to diagnosis, phase of
recovery/treatment, level of functioning and/or
disability associated with each disorder, and
level of acuity, dangerousness, motivation,
capacity for treatment adherence, and
availability of continuing empathic treatment
relationships and other recovery supports.
80Strategies that Support Success
- Medication for addiction is presented as
ancillary to a full recovery program that
requires work independent of medication.
Individuals on proper medication must work as
hard as those with addiction only. - Distinguish normal feelings from disorders with
similar names (anxiety, depression) - Psychiatric medications are directed to known or
probable disorders, not to medicate feelings - Proper medication for mental illness does not
take away normal feelings, but permits patients
to feel their feelings more accurately. - Use fixed dosage regimes, not prn, (as needed)
meds.
81More Strategies for Success
- Pain Management should occur in collaboration
with a prescribing physician who is fully
informed about the status of substance use
disorder - Individuals addicted to opiates for non-specific
neck, back, etc. conditions can be informed that
continued use of opiates worsens perceived pain.
Full withdrawal plus alternative pain management
strategies can actually improve pain in the long
run.
82Resources
- ASAM
- NAMI
- NIDA
- SAMHSA
- DRA
- AA, NA, CA
- SMART RECOVERY, LIFERING
83Opportunities for Interventions
- Building Self-Efficacy and engagement strategies
- Screening
- Opportunity for Interventions (services,
referrals, funding) - Co-locating services
- Funded integrated quality treatment
- Recovery/employment retention support services
- Employment and Family/Survival Resources
- Accountability
- Outreach for Sanctioned Families
83
84Working Together
- Evaluate current status of planning, policies and
programs to address substance abuse and mental
health employment barriers - Assess new opportunities and challenges related
to reauthorization use this opportunity to plan
for system improvements - Prevent or eliminate policies designed for
individual or program failure - Compassion and respect
84
85In Summary
- A significant proportion of clients may suffer
from mental health and/or substance abuse
problems that impede their ability to participate
in required program activities and move
successfully into the workplace. Others may have
caretaking responsibilities for a family member
who suffers from mental illness or substance
abuse. These employment barriers pose unique
challenges to agencies, which must meet the
treatment needs of these individuals as well as
work participation requirements. We are further
challenged by ongoing budget constraints that
limit agency resources and the availability of
treatment options.