Presentation on theme: "The Art and Science of Treating Clients with Addictions and Dual Diagnosis Problems in Community Counseling Setting. Cathy Moonshine, Ph.D., MAC, CADC."— Presentation transcript:
1The Art and Science of Treating Clients with Addictions and Dual Diagnosis Problems in Community Counseling Setting.Cathy Moonshine, Ph.D., MAC, CADC IIISchool of Professional PsychologyPacific University
2AbstractThis paper will focus on how to treat mild to moderate addictions in a community counseling setting that primarily provides mental health services. The paper will discuss the process of diagnosing and initial level of care placement. When to refer for medical evaluation, detox services and formal addictions treatment program will be reviewed. When and how to chose an abstinence or harm reduction treatment approach. Recommendations will be made for the use of the evidence based practices of ASAM PPC-II-R, Motivational Interviewing, Matrix Model, Dialectical Behavior Therapy and 12-Step Facilitation. Coordinating and collaborating care when client is enrolled in treatment program.
3Treatment TeamStudents received a brief overview of diagnosing and treating addictions in the first year course work.Self select to be placed on substance use disorder treatment team at community counseling setting.Student clinicians receive individual and group supervision focused on treating addictions and dual diagnosis clients.Students can also take a semester long course on addictions treatment as an elective.
4PrevalenceAccording to the Center for Substance Abuse Treatment (2005) anywhere from 20%-50% of individuals seeking mental health treatment also meet criteria for a co-occurring disorder (COD). “The term co-occurring disorders (COD) refers to co-occurring substance-related and mental disorders. Clients said to have COD have one or more substance-related disorders as well as one or more mental disorders” (Center for Substance Abuse Treatment, 2006).
5UseUse can be defined as the ingestion of alcohol or other drugs for encouragement, relaxation, etc that does not negatively impact the individual’s life. This impact can be in terms of:Physical HealthEmotional Well-beingSocial SkillsRelationshipsAdequate Work PerformanceLegalFinancial
6AddictionComplex progressive behavior patterns having biological, psychological and behavioral component’s with an individual’s pathological involvement in or attachment to it, subjective compulsion to continue it and reduced ability to exert personal control over it.
7Substance Intoxication The results from the recent ingestion of a substance such as alcohol, marijuana, heroin or even caffeine (APA, 2000).
8Substance WithdrawalThis occurs when an individual stops using a substance in which he or she has become physiologically, cognitively and behaviorally dependent. It is most important to intervene if there are medical concerns. Alcohol and benzodiazepines are the most medically compromising (APA, 2000).
9Substance AbuseA maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following within the last 12 months:Failure to fulfill major life obligationUse when physically hazardousLegal problems related to useContinued use despite having persistent or recurrent social or interpersonal problems(APA, 2000)
10Substance DependenceA maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by at least 3 of the following in the same 12 months:ToleranceWithdrawalSubstances taken in larger amounts than plannedPersistent desire or inability to cut downGreat deal of time spent in activities related to useImportant social, occupational or recreational activities given upContinued use despite knowledge of having a persistent or recurrent physical or psychological problem(APA, 2000)
11Substances that qualify AlcoholAmphetamineCaffeineCannabisCocaineHallucinogensInhalantNicotineOpioidsPhencyclidineSedatives, hypnotics or anxiolytics(APA, 2000)
12Polysubstance Dependence This diagnosis is reserved for behavior during a consecutive 12-month period in which the person has repeatedly used at least three groups of substances, not including caffeine and nicotine, but no single substance predominated. (APA, 2000)
13Initial Screening Tools CAGECut downAnnoyed by useGuilty about useUse as an eye openerCRAFFTCarRelaxAloneFamily & FriendsForgetTrouble
14Initial Screening Tools Alcohol Use Disorder Identification Test (AUDIT)Drug Use Disorder Identification Test (DUDIT)Michigan Screening Alcohol Test (MASTDrug Abuse Screening Test (DAST)
15Initial Level of Care Placement Is the client appropriate for outpatient therapy in a student clinic?What substances are being use?How often is the use?Use may be physical risk?When did use begin?Any previous treatment?Willingness to attend community support?
16Medical EvaluationIn most cases it is recommended that the client be evaluated by a primary care physician to rule out any medical problems and support treatment.
17DetoxificationIf the client requests detox or use indicates a need for detox, then a referral should be made. In particular, if the client is using alcohol and/or benzodiazepines then detox is recommended. While detox from heroin, methadone or opioid pain pills may not be medically compromising, social detox may be very useful in establishing initial abstinence.
18Formal Addictions Treatment Program Referral When using in a dangerous waysIf drug screens are recommendedMeets criteria for dependence of two or more substancesNeeds significant case management servicesWill benefit from Intensive Outpatient or Residential ServicesRefuses to attend community supportsIndications of dishonesty and delinquency
19Psychiatric Medications Based on the prevalence of co-occurring disorders, psychiatric evaluation is likely appropriateInform psychiatric prescriber of addictions issuesMedications that are contraindicated for addictions areRitalin and AdderallValium, Xanax, Klonopin or other benzodiazepinesVicodin, Oxycodone or other opiod pain killers
20Abstinence or Harm Reduction Evidence of biological/genetic componentDemonstrated inability to cut downUsing when physically/psychological dangerousExacerbates mental health issues
21Abstinence or Harm Reduction Young adults & college studentsUse creates mild to moderate problemsLevel of functioning not impacted by useOther negative impacts of use are non-existentHarm Reduction as a means to Abstinence
22ASAM PPC-II-RAmerican Society of Addiction Medicine publishes the Patient Placement Criteria 2nd Edition Revised.This publication is used for initial evaluation, placement, continued stay, transfer and discharge planning.
23ASAM PPC-II-R Life Dimensions Intoxication and Withdrawal Potential BiomedicalEmotional, Behavioral and CognitiveReadiness for ChangeRelapse, Continued Use and Continued ProblemRecovery Environment
24ASAM PPC-II-R Levels of Care 0.5 Prevention & Early Intervention Outpatient ServicesIntensive Outpatient ServicesResidential TreatmentInpatient Hospitalization
25Stages of Change Pre-contemplation Contemplation Preparation Action MaintenanceRelapse or return to old behavior/patterns(Prochaski and DiClemente, 1996).
26Motivational Interviewing Extrinsic & intrinsic motivationEnlightened self-interestDeveloping discrepancyRolling with resistanceSupportive & strategic interventionsDecisional balanceChange plan worksheet(Miller and Rollnick, 2002).
27Matrix ModelThe model integrates treatment elements from a number of strategies, including relapse prevention, motivational interviewing, psycho-education, family therapy, and 12-Step program involvement.Combines Evidence Based Practices:Motivational InterviewingCBT & Classic ConditioningDrug & Alcohol EducationBrain ChemistryStages of RecoveryThe basic elements are group sessions, individual sessions, along with encouragement to participate in 12-Step activities, delivered over a 16-week intensive treatment period (Obert, Rawson, McCann, & Ling, 2006).
28Dialectical Behavior Therapy Learn and practice skills in the areas of:MindfulnessEmotional RegulationDistress ToleranceInterpersonal EffectivenessDiary CardsChain AnalysisUltimate goal to build a life worth living(Moonshine, 2008).
2912-Step Facilitation12-Step Facilitation encourages acceptance of the addiction, commitment to abstinence and willingness to participate actively in 12-step fellowships as a means of establishing recovery.Evaluate the substance use problems and advocate abstinence.Explain basic 12-step structure and concepts.Encourage client to engage in 12-Step meetingsFacilitate ongoing participationDiscuss and support client working each of the 12-StepsInclude support system in the therapeutic processUtilizing 12-Step network when in crisisAssist the client making a moral inventory and engaging in amendsEncourage involvement in 12-Step beyond formal therapy
30Coordinating and Collaborating Care Regular conversations with treatment programCollaborative treatment planningInclude ancillary providers such as PCP & dentistOn the same pages with community support meetings
31ReferencesAmerican Psychiatric Association, (2000). Diagnostic and statistical manual of mental disorders (4th ed.) (DSM-IV-TR). Washington, D.C.Center for Substance Abuse Treatment (2006). Definitions and terms relating to co-occurring disorders. COE Overview Paper 1. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services.Center for Substance Abuse Treatment (2005). Substance Abuse Treatment for Persons with Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration.Obert, J.L., Rawson, R.A., McCann, M.J., & Ling W. (2006). Counselor’s treatment manual: Matrix Intensive outpatient treatment for people with stimulant use disorders. Rockville, MD: Substance Abuse and Mental Health Services Administration