Sue Fortune and Karen Poffenroth

Reasons for High Co-morbidity Rates of Severe Mental Illness and Substance Abuse Biological sensitivity, genetic and early environmental events, interact with environmental stress to precipitate the onset of psychiatric disorder or to trigger relapses Substances can increase vulnerability Smaller amounts of substances result in problems “Normal” substance use is problematic for clients with severe mental illness but not in general population

Outcomes IDDT Model increases likelihood of abstinence Fidelity to IDDT Model improves abstinence outcomes Abstinence correlates to other positive outcomes

IDDT: Basic Principles Integration of treatment Assertive engagement Comprehensiveness of services Stage wise treatment Stage wise treatment Time unlimited services

Substance-Related Disorders Refers to maladaptive behavior associated with regular use of substances Challenge is to distinguish use, abuse, dependence Two categories of Substance-Related Disorders Substance Use Disorders: (Substance Dependence & Substance Abuse) Substance –Induced Disorders

DSM-IV Definitions of Substance Use Disorders Use--use without causing problems Abuse--use for 12 months despite causing problems Failure to fulfill major role obligations Use in hazardous situations Legal problems Social – Interpersonal problems Has control – poor decision making

Dependence Substance Use Disorders Dependence--use for 12 months resulting in 3 or more of the following: Tolerance Withdrawal More amount or time than intended Desire to cut down Other activities reduced Use despite problems Psychological dependence Physical dependence – development of tolerance to effects of substance, withdrawal symptoms following cessation of substance use, use of substance to decrease withdrawal symptoms.

Clinician Rating Scales Clinician 5 point rating scale to determine severity of use based on worst use within last six months Consistent with diagnostic classification (DSM IV) Based on team consensus Be data driven/avoid assumptions Use multiple sources of assessment

Clinician Rating Scales M ethod of Discrimination 1. Abstinence 2. Use without impairment 3. Abuse (severity of problems lasting at least one month) 4. Dependence (3 types of evidence) 5. Severe dependence (use contributed to more than one institutionalization or three of six months institutionalized)

Role Play Get into pairs (clinician, client – use an actual client) Using the Alcohol or Drug Use Scale, rate the clients drug or alcohol use (ie, use, abuse, dependence)? What are the indicators for that diagnosis?

SUBSTANCE ABUSE, MENTAL ILLNESS, OR DUAL DISORDERS? It is often difficult to figure out whether alcohol abuse causes depression and anxiety or whether these symptoms are due to a separate and distinct co-occurring disorder. If the symptoms are caused by drinking, they should go away within one month of becoming abstinent (no alcohol or other substances at all). Clinicians should look for periods of abstinence in the client’s life and ask the client whether depressive or anxiety symptoms were present during that time. Including family or supports in the assessment can help you get an accurate history. They may be able to remember a client’s symptoms and level of function during periods of sobriety better than the client can. Tanya’s year-long period of abstinence is incredibly valuable information. It was during this period that she experienced a post- partum depression, strongly suggesting that her depressive illness is distinct from her alcohol dependence.

ETOH, Anxiety and hypnotic sedatives People with alcohol and anxiety problems are often prescribed sedative-hypnotic medications (such as the benzodiazepine, clonazepam) for their anxiety. Use of these kinds of medications may make the alcohol problem worse and lead to abuse, however, because they have a similar effect on the brain as alcohol (they are “cross reactive”). Benzodiazepines, in particular, tend to be overused and abused in the same way as alcohol. Once a person is taking a sedative-hypnotic medication regularly, he or she may have a hard time stopping it because they experience increased anxiety and withdrawal symptoms when they do. For some individuals with severe anxiety, the use of benzodiazepines might be necessary, but experts believe that antidepressant medications, which are very effective for treating anxiety, and behavioral treatments should be tried first.

Meds for ETOH abuse and dependence Other medications can be helpful when they are used in combination with integrated dual disorders treatment. Disulfiram (Antabuse), causes a very uncomfortable physical reaction if a person drinks while taking it. Disulfiram is intended to help clients avoid taking a drink because they want to avoid the toxic reaction they will get to alcohol when they have disulfiram in their system. The medication provides a psychological barrier to drinking. Many clients will drink soon after starting disulfiram. Experiencing a disulfiram-alcohol reaction may help them avoid drinking in the future. Disulfiram is most effective if it is monitored: someone should watch the client take the medication to be sure they actually take it. Practitioners or staff can observe clients take disulfiram on some days or family members can provide even more frequent supervision. Naltrexone (Revia) is an opiate antagonist that blocks the effects of certain natural chemicals in the brain and thereby reduces craving for alcohol. Like disulfiram, naltrexone does not have abuse potential. Naltrexone helps to reduce craving for alcohol as clients are trying to reduce their alcohol use. There are no symptoms and no danger to clients if they use alcohol while taking naltrexone, so this medication is appropriate for clients who are still drinking and have not yet developed a strong commitment to sobriety. Naltrexone also blocks the effects of opiate drugs like heroin and morphine. It can be used to treat people with opiate abuse or dependence.

Stages of Change Stages of Treatment Pre-contemplation Contemplation Preparation Action Maintenance Pre-Engagement Engagement Early Persuasion Persuasion Early Active Treatment Late Active Treatment Relapse Prevention Remission/Recovery

Pre-Engagement/Engagement Engagement is the stage when the client has no relationship with a treatment provider. The client typically does not consider substance use or mental illness symptoms a problem. The clinician's job is to help the client get engaged in treatment. They engage the client by providing helpful outreach and practical assistance to help the client face immediate challenges, such as health problems, financial problems, and so on. Clinicians develop a working-together relationship with the client during this phase by providing help and by using good listening skills and motivational interviewing techniques Clinicians do not confront clients about their substance use during this stage, though they do try to complete a basic assessment of the substance use. As regular contact with the clinician occurs, the client may progress to the persuasion stage. Which clients are in this Treatment Stage?

Early Persuasion/Persuasion As the working relationship develops, if the client does not perceive, acknowledge, or understand his or her substance use or mental illness symptoms, the client is in the persuasion stage. The clinical task is to help the client think about the role of substance use in his or her life. Active listening, exploratory questions about experiences and goals, and education are common techniques. These techniques (motivational interviewing), are designed to help the client think about life goals, substance use, mental illness symptoms, and whether substance use or symptoms get in the way of achieving life goals. During this stage, a detailed functional assessment of substance use can be completed During this and later stages, it is often helpful to meet with family members to provide education, get input and include the family in treatment. What other techniques are used in this Stage of Treatment? Which clients are in this stage?

Early/Late Active Treatment Once the client recognizes that substance use is a problem and decides to reduce or stop his use altogether, the client is in the active treatment stage and the goal is to acquire additional skills and supports. For example, the client may need skills to avoid substances (such as assertiveness skills), to socialize without substances (social skills), and to manage feelings without substances (stress management techniques). He or she may need new friends, a better relationship with family, and a support group like Alcoholics Anonymous or SMART Recovery. Helping the client to learn skills and find supports is called active treatment. Which clients are in this Stage of Treatment?

Relapse Prevention/Remission When the client is in stable remission (at least six months without substance abuse), the task is to avoid relapsing back into problematic substance use. The clinician can help with a relapse prevention plan, which examines triggers to use substances, such as feelings, people, or situations, and specifies new ways to avoid or handle these cues. Another common task during relapse prevention is to facilitate further recovery by developing other healthful behaviors and pleasurable activities. Which clients are in this Stage of Treatment?

Progress through the Stages of Tx. Most people move through each stage while making progress towards recovery. Some people move steadily, others move in fits and starts, some move very slowly. People often relapse and move backwards and then forwards again. The important point for you to understand is that when people receive integrated dual diagnosis treatment, the treatment needs to correspond to the stage of treatment. In other words, it does little good to work on active treatment skills if the client is not acknowledging a problem with substance abuse. It makes much more sense at that stage to engage the client in a helping relationship and to use motivational counseling to explore the client’s experience with substance use.

Group work Group according to Stage of Treatment and Stage of Change Identify client who is currently in this stage Identify strategies that you would when working with this client.

IDDT Plan List psychiatric disorder(s) Stage of Treatment/Change Problem Goal Intervention Tx modality Responsible Clincian

Chose a client and complete an IDDT Plan