1. Co-Occurring Disorders
Quadrants and Stages of Change

2. Objectives
Gain knowledge and understand quadrants’ terminology, stages of change, addiction severity, and seriousness of mental disorder
Identify and determine appropriate treatment placement based on co-occurring profile
Identify and determine appropriate treatment recommendations and referrals

3. DEFINITIONS

4. Co-Occurring Disorder (1)
Presence of two or more independent disorders/diseases that exist in the life of a person
Each disorder/disease has a life of its own and is NOT dependent on the other for its cause or continuation
Diagnoses interact with each other, either exacerbating or inhibiting the specific symptoms or behaviors

5. Substance Abuse(2)
Substance Abuse: Maladaptive patterns of substance use, including clinical impairment or distress as manifested by one or more of the following within a 12 month period:
Failure to fulfill major role obligations
Use in hazardous situations
Use despite negative consequences

6. Substance Use Dependence(3)
Addiction is a primary, chronic disease with biological, psycho-social, and environmental factors influencing its development and manifestation
Progressive and fatal
Maladaptive patterns of substance use, including impairment or distress

7. Substance Use Dependence (3 continued)
Manifested by (three or more):
Increased tolerance
Withdrawal
Inability to control use, even with negative consequences
Preoccupation with substance use
Important social, occupational, or recreational activities given up or reduced

8. Psychiatric Disorder (4)
Includes numerous diagnoses of though and mood disorders
Health conditions of the brain characterized by alterations of perception, mood, or behavior (or some combination)
Associated with distress and/or impaired functioning

9. Psychiatric Disorder (4 continued)
Alterations in thinking, mood, or behavior that give rise to a host of symptoms and problems that can lead to
Heightened risk of pain
Loss of freedom
Disability and even death

10. Mild Psychopathology (5)
Few, if any, symptoms in excess of those required to make diagnosis
Symptoms result in no more than minor impairment in social or occupational functioning

11. Severe Psychopathology (6)
Many symptoms in excess of those
required for diagnosis OR
Several symptoms are severe OR
Symptoms result in marked impairment in social or occupational functioning

12. Four Quadrant Model (7)
The Four Quadrant Model is a viable mechanism for categorizing individuals with co-occurring disorders for purposes of:
Service planning and
System responsibility

13. PART 2 CO-OCCURRING DISORDERS SUB-GROUPS

14. Co-occurring Disorder Sub-groups
Quadrant 3:
High substance and low psychiatric
Mild to moderate psychopathology complicated with substance dependence
Quadrant 4:
High substance and high psychiatric
Serious and persistent mental illness with substance dependence
Quadrant 1:
Low substance and low psychiatric
Mild psychopathology with substance abuse (not dependence)
Quadrant 2:
Low substance and high psychiatric
Substance abuse with serious and persistent mental illness

15. Examples of Sub-groups and Specific Treatment Interventions

16. May abuse substances but not develop substance dependence
Quadrant 1 Low and Low (low substance abuse and mild-to-moderate psychopathology)
Clients not usually in public mental health system, can maintain employment and usually have health insurance
Have periodic combinations of psychiatric symptoms (e.g. anxiety, depression, family conflict) and
May abuse substances but not develop substance dependence

17. Low & Low treatment interventions
Addiction education
Outpatient – individual and/or family sessions
Psychiatric assessment and medication evaluation, if appropriate

18. Individuals usually appear in the mental health system
Quadrant 2 Low and High (low substance abuse and serious and persistent psychopathology)
Schizophrenia, major affective disorders, serious post-traumatic stress disorder (PTSD), and severe personality disorders
Individuals usually appear in the mental health system
Clients do not usually view substance abuse as a problem

19. Low and High treatment interventions
Addiction education – harm reduction and relapse prevention
Empathic confrontation contracting approach
Inpatient psychiatric stabilization
Ongoing psychiatric treatment, including medication, if appropriate

20. Most likely client in public mental health system
Quadrant 3 High and Low (high/significant substance use disorder and mild-to-moderate psychopathology
Most likely client in public mental health system
Due to substance use disorder, often lacks ability to sustain employment, often involved in legal system, and may have lost housing
Depression, bipolar disorder (stabilized), PTSD symptoms, personality disorders, and mild anxiety and panic disorders

21. High and Low treatment interventions
Detoxification followed by residential or intensive outpatient treatment
Addiction education – abstinence-oriented and relapse prevention approach
Empathic confrontation contracting approach

22. High and Low treatment interventions continued
Encourage recovery (12 step) support network
Family education (Al-Anon)
Ongoing psychiatric treatment, including medication, if appropriate

23. Quadrant 4 High and High (significant substance use disorder and serious and persistent psychiatric disorders)
This client benefits from high structure
Structure must be consistent
This may include:
Inpatient care
Residential program
Partial hospitalization program

24. High and High treatment interventions
Substance-enhanced psychiatric inpatient setting
Addiction education-harm reduction and relapse prevention approach
Empathic confrontational contracting approach

25. High and High treatment interventions continued
Ongoing motivational interviewing and engagement
0ngoing psychiatric treatment, including medication, if appropriate

26. STAGES OF CHANGE DEFINITIONS AND TASKS* * DiClimente and Prochaska
PART 2
STAGES OF CHANGE
DEFINITIONS AND TASKS*
* DiClimente and Prochaska

27. Stages of Change
Pre-contemplation   Contemplation  Preparation   Maintenance  Action     

28. 1. Pre-contemplation This stage is one in which individuals are:
Unconvinced they have a problem OR
Are unwilling to consider they have a problem OR
Need to change
TASK: Increase awareness of need to change

29. 1. Pre-contemplation example
Jane gets tired of everyone nagging her to stop smoking. It is bad enough that she can’t smoke in restaurants any more, that the cost of cigarettes went up, and now she has to go outside to smoke. Jane wonders, “How do they expect me to finish my projects on time if I keep getting up to go outside to smoke?”

30. 2. Contemplation In this stage, a person is:
Actively considering the possibility of change
Most persons are evaluating options, but are not ready to take action yet
TASK: Increase the positive benefits of change and decrease the negative consequences

31. 2. Contemplation example
John has lost 2 jobs in the past year and both have been due to lateness, absences, and missed project deadlines. John is wondering if his drinking with the boys on the weekend is beginning to affect his ability to focus. He realizes that he misses mostly Mondays and deadlines due to his continual headaches. John thinks, “Maybe I’ll consider cutting down on my drinking.”

32. 3. Preparation This stage is when a person:
Makes a commitment to change AND
Starts initial plans actually to change his or her behavior
TASK: Begin planning and make a commitment to start the change

33. 3. Preparation example
Joseph has been thinking about losing weight, but he just hasn’t been able to start exercising as he used to. He has done some sit-ups for a few mornings the last 2 weeks and has gone to the gym twice. Joe called a couple of his friends to see if they would be interested in starting cycling at least once a week on weekends.

34. 4. Action TASK: Implementing and revising the plan as necessary
Once a person takes effective action to make change, he or she is considered to be in the action stage. At this stage:
Actual behavior change begins to occur
New ways of dealing with situations are learned
Avoiding relapse is attempted
TASK: Implementing and revising the plan as necessary

35. 4. Action example
Mary is so proud of herself! She contacted AA and has gone to 3 meetings. She has not had any alcohol in the past 10 days. She no longer goes to “happy hour” with her friends at work and her boss commented that her work has improved.

36. 5. Maintenance In this stage, a person:
Begins to consolidate the behavior into her or his regular lifestyle
Integrates his or her thinking and actions into a new way of living
TASK: Integrate the changes into a daily lifestyle

37. 5. Maintenance example
Paul can hardly believe he hasn’t been admitted to the hospital in the last 2 years. He is working with a case manager, seeing his therapist, and taking his medication. Since his last suicide attempt and diagnosis of bipolar disorder, he has been involved with support groups to address his mental illness. He is very proud that his relationship with his family has continued to improve.