Integrated Dual Disorders Treatment (IDDT)

Integrated Dual Disorders Treatment (IDDT)
Mental Health and Substance Abuse By Judith Magnon RN-BC, BS, CAC

Conflict of interest note:
This presenter has no conflict of interest, commercial support, or off label use to disclose.

Learning Objectives: Gap: Skill-How to deliver integrated mental health and substance abuse treatment to individuals with serious mental health disorders and substance abuse disorders in the community. Cite the evidence supporting the integration of mental health and substance abuse services for people with co-occurring disorders in the community Cite mental health nursing practices/processes that will blend in to IDDT (Integrated Dual Disorder Treatment) model of care Cite substance abuse skills that need to be incorporated into IDDT nursing practice Cite examples of nursing practices that can effectively incorporate Stages of Change to support IDDT

Person comes into ER with a broken leg
Do we assess the other leg to see if it is broken? Why? Do we ask which one broke first? If both are broken, do we wait for one to heal before treating the other? Do we send them to another doctor and hospital to treat the second broken leg.

Best Practice Interventions:
IDDT (Integrated Dual Disorders Treatment) PACT (Program of Assertive Community Treatment) Psychopharmacological interventions Supportive Employment Supported Housing

Best Practice Interventions:
Stage of Change/Motivational Interviewing CBT (Cognitive Behavioral Therapy) DBT (Dialectical Behavioral Therapy) IMR (Illness Management & Recovery) FES (Family Education and Support) by Lindy Fox Smith & Kim Musser

Co-Occurring Disorders
Why Focus on C0-Occurring Disorders? SA is most common co-occurring disorder in people with MI Negative Outcomes: More relapses Demoralization Repeated Hospitalization Violent behaviors

Co-Occurring Disorders
MH/Psychiatric Disorders and Substance Abuse are both Brain Disorders. Both effect Dopamine And Serotonin functioning in the nerve cells.

Prevalence of Substance Abuse Disorders with SMI
Regular Marijuana use Other drug use Binge drinking (4+ drinks at one sitting) Tobacco: Regular use General Population 18% 12% 8% 33% Severe Mental Illness 50% 30% 75% 1/3/14 SA News; Washington Un. School of Medicine

PARALLELS: Psychosis and Addiction By Dr. Ken Minkoff
Addiction Disease Major MI Disease 1. A biological illness 2. Hereditary (In part) 3. Chronicity 4. Incurable 5. Leads to lack of control of behavior & emotions 6. Affects the whole family

Addiction Disease Major MI Disease 7. Symptoms can be controlled with proper treatment 8. Progression of the disease without treatment 9. Disease of denial 10. Facing the disease can lead to depression and despair

Addiction Disease Major MI Disease 11. Disease is often seen as a “Moral” issue, due to personal weakness rather than biological causes 12. Feelings of guilt and failure 13. Feelings of shame and stigma Physical, mental, and spiritual disease

Parallels--Recovery By Dr. Ken Minkoff
1. First phase is acute stabilization with medication (Detox/antipsychotic) 2. First phase often requires hospitalization 3. Following acute stabilization, next phases are prolonged stabilization and rehabilitation.

4. a A prerequisite for rehabilitation is maintaining stabilization by following a long term program: “Don’t drink”…, Go to meetings, read literature, etc. Take meds, attend groups, see CM/Dr., etc.

4. b Once stabilization has been maintained long enough (usually 1 year) growth and rehabilitation can occur. 5. Person must overcome Denial/Disbelief. 6. Person must acknowledge powerlessness over the disease

Parallels—Recovery By Dr. Ken Minkoff
7. Person must ask for help from a power greater than themselves to control symptoms (Higher Power, AA/NA, Therapist, Meds, etc.) 8. Recovery proceeds one day at a time through increasing acceptance of one’s illness and gradually learns better coping skills to cope with daily reality.

9. Recovery is never “complete”, but slow, gradual progress can be made. 10.Risk of relapse is always present—need help over time. 11.Family must also be involved in a program to get help dealing with the disease.

12.Education about the disease is an important component. 13.Treatment must focus on feelings about the disease, and feeling good about oneself with a disease. 14.Ultimately, recovery is a physical, mental, and spiritual process.

BIOLOGICAL COMPONENTS
Impaired brain chemistry effects the metabolism of substances, resulting in loss of control, abuse, and/or dependence. HELP Dopamine receptors are effected by alcohol/drug use and this is the same area effected by psychotropic medication (and Caffeine & Nicotine)

BIOLOGICAL--- Often persons with severe mental illness will have a lower tolerance to the effects of substances due to the changes in brain chemistry. Their pattern of use does lead to the same outcomes as a “heavy” user.

PSYCHOLOGICAL THE PERSON IS AWARE OF OR HAS BEEN TOLD HOW CONTINUED USE IMPACTS: PSYCHIATRIC SYMPTOMS RELATIONSHIPS SOCIAL ACTIVITIES PHYSICAL HEALTH VOCATIONAL ACTIVITIES QUALITY OF LIFE

PSYCHOLOGICAL --- RESULTING BEHAVIORS:
Frequently missing work or drop in productivity rate; Sudden appearance or increase in psychiatric symptoms; Isolation, paranoia, delusions, lethargy, incoherent speech, Hostility, angry outbursts, hallucinations, poor concentration, Poor judgment, etc. due to not taking meds as prescribed) Physical symptoms—weight loss (esp. with cocaine use), poor hygiene,

PSYCHOLOGICAL--- RESULTING BEHAVIORS:
Withdrawal symptoms Spending all their time with known S.A. users; Selling possessions for alcohol or drugs (including food, furniture, TV’s—theirs or others) Shoplifting items to sell or over the counter meds (benedryl, actifed, sudifed, sleeping pills) “Pan handling” or intimidating others for money to buy alcohol or drugs;

PSYCHOLOGICAL --- RESULTING BEHAVIORS:
Prostituting, dealing or “running” drugs to support alcohol/drug use; Seeking hospitalization or visiting the ER to obtain meds; Moving to a new “catchment area” as part of drug seeking activity. Their housing can be very unstable—evictions, moving from one place to another, live with family, live at the shelter.

PSYCHOLOGICAL-- RESULTING BEHAVIORS:
He/she is at a higher risk for victimization—rape, assaults, “robbed” by using peers (both money and possessions). He/she have already been victimized by adults as children—Sexual abuse, physical abuse, emotional abuse. He/she have adults (case manager, psychiatrist, family members, group members, community members) pointing out their use and the negative consequences.

He/she have a higher suicide rate and death rate.
PSYCHOLOGICAL--- RESULTING BEHAVIORS: He/she have a higher suicide rate and death rate. He/she may have Axis II diagnosis as well as other Axis I diagnosis.

History of IDDT 1980’s Dr Robert Drake looked for model to address both disorders & picks PACT. Did research for over 10 years using PACT model as core and added other treatment strategies. Many of the team leaders were MH nurses. Has now been replicated around the world.

PACT MODEL Developed in 1972 by Arnold Marx, Leonard Stein, & Mary Ann Test in WI For SPMI(Severe and Persistent Mental Illness) population (Schizophrenia, BP, SA) Community based, multidisciplinary team, 24 hour coverage

PACT MODEL Mental Health Team = ACT Team Function interchangeably
Community based Provide basic living skills education & assistance Assimilation of community resources Assertive approach to decrease dropout

Mission of ACT Teams Keep the person in the community--Out of the hospital, Crisis Units, Jails, etc. Get them back to or to WORK-- PAID Employment, or Volunteering and/or to School [Independent]

Mission of ACT Teams Diminish the family’s burden of providing care & increase independence Foster a productive community member Increase wellness Decrease stigma

Nursing Practice: Communication is the core of relationship building
The Mental Health Nurse’s knowledge and ability to communicate is a critical component of the IDDT model of care. Being able to engage, connect and educate patients/clients/participants, families, team members, and community members changes lives and fosters recovery.

Nursing Practice: Collaboration
In community based mental health nursing, one of the major goals is community integration. Working with families, PCP, dentist, ophthalmologist, employers, volunteer programs, landlords, 12 step programs, other treatment providers, lawyers, law enforcement, etc, requires a well skilled MH nurse.

PACT MODEL KEY FACTORS: Supportive relationship between person & Team
Team carries & inspires HOPE for person through its resourcefulness and innovation in service provision Not typical Case-management model that refers & links PACT Team works collaboratively to deliver most of the services required by each person, based on the following principles:

PACT PRINCIPLES 1. Primary provider of services/Fixed point of responsibility Responsible for providing most educational & support services needed to live successfully in the community Person & family receive response from familiar team member, which eliminates gaps & fragmentation [ Nursing skills: education, communication]

PACT PRINCIPLES 2. Services provided out of office (75%)
Key element is mobility Services in the community, home, employment & recreational sites Able to implement individualized recovery plan Person can immediately see what works in their surroundings [ Nursing skills: Assessment & TX Planning]

PACT PRINCIPLES 3. Highly individualized services to the person
Get to know the person & family & others to effectively customize interventions and services that address current needs & preferences Individualized type of services, frequency and amount of support [ Nursing skills: relationship building, communication, providing service/care, goal setting]

PACT PRINCIPLES 4. An Assertive approach
Do “whatever it takes” to help meet needs & Goals Team adapts to person & environment to be more effective in providing services, versus requiring the person to adapt to external treatment program [Nursing skills: implement, revaluate, develop new plan, implement, holistic approach, etc]

PACT PRINCIPLES 5. Continuous Long-term services
Teach person how to deal with the pattern of symptoms and impairments their illness presents in their lives Model provides a continuous system of care with ability to provide services based on needs at any point along the continuum Results in effective rehabilitation [Nursing skills: Educate, communication, variety of knowledge]

THE ACT TEAM MEMBERS Psychiatrist, Social Workers, Nurses, Mental health staff, SA Staff, Support Staff Knowledge of Vocational Rehabilitation, Mental Illness, sexual abuse, Substance Abuse, Trauma informed care, etc Coverage—24 hours/365 days with use of on-call system

IDDT ACT OVERLAP OF THE MODELS Integrated Dual Disorders Treatment
Focus is on developing motivation for treatment using Stage Wise interventions VS on SX Management & everyday problems; Based on: Recovery thinking, individual choice, shared decision making, and the individual drives TX. Assertive Community Treatment ACT & IDDT equals addressing all areas.

IDDT—Evidenced Based Model (Dr. Robert Drake & team at DPRC)
Treating the Mental Health AND Substance Abuse at the same time with in the ACT Team based on PACT model of care. Using Stages of Change & Motivational Interviewing interventions for the purpose of reducing mental health symptoms and a long range goal of abstinence. Supports ACT outcomes. Is a recovery based model of care.

Co-Occurring Disorder (S) IDDT
Schizophrenia, Bipolar Disorder, Schizoaffective Disorder Substance Abuse/Dependence Disorder Anxiety Disorders/OCD Personality Disorder PTSD issues—Physical/Sexual/Emotional abuse trauma issues Medical Conditions Developmental Disorders, Learning disabilities

IDDT GOALS Assisting the individual in developing the motivation for treatment and the establishment of goals that are meaningful to the person. Decrease risk of suicide Stabilize acute psychotic symptoms Reduce likelihood of relapse of MH & SA SX and rehospitalization Ensure appropriate individualized treatment

Overall Treatment Goals continued
Decrease alcohol/substance abuse Increase overall wellness Reduce stress and burden on families Begin rehabilitation

IDDT BASED ON Recovery Thinking
The person’s illness(s) is not all they are. (EXAMPLE— Judy is a person who experiences Schizophrenia instead of Judy is Schizophrenic.) (Just like experiencing Diabetes)

IDDT BASED ON Recovery Thinking
The person is a partner in the treatment process and The provider is a guide with knowledge and experience to share, discuss, educate, explore, coach, advise, assist, encourage, negotiate, role model, validate, etc.

IDDT BASED ON Recovery Thinking, Nursing practice should incorporate the following:
EXPECT THEY WILL IMPROVE/RECOVER!!!!!!!!!!! Celebrate the successes, no matter how small, Use positive language in meetings and in day to day job tasks to practice the recovery way of thinking, EMPOWERMENT: Offer choices, clarify they have the power to make choices/decisions, You are offering tools, and they can choose to use them or not. You hope they will, but you respect their choice to not be ready yet.

No matter what level of illness—Expect that they can participate at some point in “Meaningful Day time Activity” WORK is Therapy!!!!!! They do not have to be sober to work. (Clinical evidence shows that some people will stop using to keep a job!)

Ask about their hopes, dreams, wishes. Encourage and value their input and feedback. Explore and help resolve barriers to treatment (Childcare, transportation, etc.) Explore what natural support network is available and self help groups are being used or may be used.

Explore about connections to the faith community and consider the importance of faith to the persons recovery. Explore what signs the individual would look for that are indicative that they no longer need your assistance. Consider the role culture may play in this person’s life and its influence on language, faith, family and the person.

Differences in the models
ACT: More concrete & itemized with lists of tasks “Doing for” (I.e. To Dr’s, med drops. Etc) IDDT: More theoretical, harder to put into place, harder to conceptualize, more recovery-oriented, may take more skill (MI, IDDT counseling, CBT, etc)

WHY integrate these two models??
The Stage wise interventions reduce staff frustration as using the right intervention at the right time enhances the therapeutic relationship and decreases resistance Outcomes improve Hope increases and active participation/partnering in treatment occurs Recovery gives the gift of a new life to people served

INTEGRATED MODEL Focus of service delivery changes from treating the disorder to Treating the whole person Development of the person’s strengths becomes the road to overcoming the limitations of the illness and to recovery

NUSING PROCESS that blend into IDDT
Providing an environment conductive to communication Involve family/significant other(s) Obtain a multidimensional history with current & past problems Complete multiple assessments Assessments lead to nursing diagnosis

NURSING PROCESS that blend into IDDT
Assessments & Diagnosis results in: Structured Care Planning Identifying contributing factors and behavioral symptoms leads to development of short and long term goals Carrying out selected interventions Evaluating the outcome or effectiveness of those interventions Adjusting the care plans

FIRST INTERVENTIONS: ENGAGEMENT RELATIONSHIP BUILDING Without a relationship, no treatment will happen and no positive outcomes!

INTERVENTIONS: Individual Supportive Treatment Reality Based
Here and Now Discussion of negative consequences of Mental Illness, Substance Abuse, Medical issues, etc. in non-confrontational way

INTERVENTIONS: Crisis Interventions Substance Abuse Treatment-- IDDT
Individual/Group Treatment AA/Smart Recovery/Co-Occurring Disorders meetings S. A. Education Stages of Change Model

INTERVENTIONS Psychopharmacologic Treatment Medications Med Education
Setting up Med Planners Medication Monitoring Coordinating Meds from PCP Working with local Pharmacy(s) CLOZARIL coordination

INTERVENTIONS Rehabilitation: Behavioral/Functional Skill Building
Education VOC Skills (Budget skills, Communication skills, Leisure skills, Social skills, Vocational skills, ADL skills, Community Integration skills, etc.) Communication Skills Social Skills Budgeting Skills ADL Skills

INTERVENTIONS Supportive Employment Assistance with Résumé
Assistance with job interviews Assistance with job skills (staying on task, keeping a schedule, accepting constructive criticism, communicating with peers & supervisor, etc.) [ Nursing skills: Education, Assessment, TX planning, Collaboration, skill building, commitment]

INTERVENTIONS Supported Housing Team works with landlord & family
Payment made by others when necessary, such as family, payeeship In home assistance with ADL’s—cooking, shopping, cleaning, budgeting Assessment of social contacts [ Nursing skills: Education, Assessment, TX planning, Collaboration, skill building, commitment]

INTERVENTIONS Collaboration with Families/Significant others
Collaboration with Guardian, PCP, dentist, lawyers, probation or parole officer, landlords, employers, etc. Collaboration with other providers (Hospitals, Crisis units, SA providers) [ Requires good Communication Skills!]

INTERVENTIONS Provide transportation:
Rides to work until comfortable with public transportation system Dr. appointments (until clinically appropriate, individuals have to have staff with them) Grocery shopping trips (Assist with healthy choices) Trips to community resources and leisure activities (Exercise, building new pathways) [ Nursing skills: Education, Assessment, TX planning, Collaboration, skill building, commitment]

What ACT Team can not do:
Violate the client’s right to make poor decisions, even when we disagree (I.e.— Not taking medications as ordered, drinking alcohol or using drugs, being with people who use drugs, living where they want, refusing services that would help) Provide information to non-guardians without consent to release information by the person. Place the person in a hospital or CSU against their will, unless they meet the law’s definition of danger to self or others. Prevent them from leaving the team, unless they have a guardian.

Skills MH nurses need: Have a clear vision of the mission of the team
Be committed to the model Have a support system Have a strong voice on the team Organizational skills

Nurses-- NEEDED ABILITIES
Ability to be a team player To be flexible and organized Able to communicate effectively to all team members, especially with the person served To understand Stages of Change/Motivational Interviewing To develop a long term relationship Able to carry the hope for the person, until they are ready to take it back.

To be able to NOT take individual’s anger personally Able to partner with the person in treatment, instead of as the “expert” To not join/align with the illness(s) and enable the person to use To advocate with them to take the medications (Or they are unable to participate in TX offered)

To use legal means during crisis for involuntary admissions, Payeeship, guardianship and any other tools as needed to ensure proper care Work with families, S/O, Partners, police, guardians, lawyers, physicians, etc. To understand the consequences of person’s use of any substances—alcohol, drugs, tobacco, caffeine, etc

To understand: Recovery is a slow process with ups and downs Recovery is not an event, it’s a marathon Treatment is like Insulin—without it, the illness returns and progression is faster with worse physical and mental damage The Family is not to blame and neither is the person. We do not blame for Cancer.

To have compassion for the illness Have a commitment to the SPMI Population Have knowledge of: MI & SA, Sexual Abuse issues, medical issues, PTSD, Personality Disorders, medications, documentation, etc.

ASAM (American Society of Addiction Medicine) Criteria
Substance Abuse knowledge needed to effectively deliver care that incorporates IDDT evidence based practices DSM definitions of Abuse and Dependence for drug classifications ASAM (American Society of Addiction Medicine) Criteria Understand addictions, including consequences How to and what assessments to use Treatment of different drugs classification Prevention strategies Impaired professionals issues (Use of EAP) Resources available

Understand the need to address wellness every day: Nutrition Exercise Sleep hygiene Tobacco use

Reasons to look at wellness:
They die 12 to 25 years earlier than general population They die most often from heart disease, cancer, and problems associated with smoking and alcohol use Washington Un. School of Medicine 1/3/14

Precontemplation, Contemplation, Preparation
Prochaska, James O.; Norcross, John C.; DiClemente Carlo C.: Changing for Good New York: Avon Books S of C presentation 10% of Programs Address The 80% Who are in: Precontemplation, Contemplation, Preparation STAGES OF CHANGE What techniques are helpful in what stage? What is the focus of each stage? What are the Tasks of each stage?

READINESS TO CHANGE Individual STAFF Not interested Very interested
in change in change (Action) (Precontemplation)

SUMMARY OF SOME CHANGE PROCESS TECHNIQUES
GOALS TECHNIQUES Consciousness Raising Social Liberation Emotional Arousal Self-Reevaluation Commitment Countering Environment Control Reward Helping Relationships Observations, confrontations, interpretations bibliotherapy Advocating for rights of repressed, empowering, policy interventions Psychodrama, grieving losses, role-playing Value clarification imagery, corrective emotional experience Decision making therapy, New Year’s resolutions, logotherapy Relaxation desensitization, assertion, positive self-statements Environmental restructuring (e.g., removing alcohol or fattening foods), avoiding high-risk cures Contingency contracts, overt and cover reinforcement Therapeutic alliance social support, self-help groups Increasing information about self and problem Increasing Social alternatives for behaviors that are not problematic Experiencing and expressing feelings about one’s problems and solutions Assessing feelings and thoughts about self with respect to a problem Choosing and committing to act, or belief in ability to change Substituting alternatives for problem behaviors Avoiding stimuli that elicit problem behaviors Rewarding self, or being rewarded by others, for making changes Enlisting the help of someone who cares

When You Change Action Preparation Precontemplation
[SPIRAL vs. Linear] Action Preparation Maintenance Contemplation Precontemplation

Stages of Change in which particular CHANGE PROCESSESS are most useful
Precontemplation Contemplation Preparation Action Maintenance Consciousness-Raising Social Liberation Emotional Arousal Self-Reevaluation Commitment Reward Countering ACTION Environment Control Prochaska, James O.; Norcross, John C.; DiClemente Carlo C.: Changing for Good New York: Avon Books 1994 Helping Relationships

Self-Confidence: The belief I am able to complete a task.
Focusing on awareness without self-confidence can lead to hopelessness! Self-Esteem Self-Confidence Optimism Awareness, Discrepancies Hopelessness Helplessness Low Self-Esteem Lack of Awareness Direction of Change Self-Confidence + Awareness = Positive Behavior Change Self-Confidence: The belief I am able to complete a task.

Precontemplation Thinking Stage Characteristics: Unaware of Problem
I don’t drink that much! Precontemplation Characteristics: Unaware of Problem Problem is external Resistant, Hopeless Demoralized, Defenses: Denial, minimize, Thinking Stage

Precontemplation Characteristics cont’d.:
Internalize, Projection, Rationalization Displacement Present as Depressed, Anxious, Afraid to risk, Believe they are in control

Shift the focus to THINKING and INSIGHT
Precontemplation GOAL: Shift the focus to THINKING and INSIGHT Techniques Consciousness Raising Social Liberation

Precontemplation Tasks: Develop insight, increase education
Find hope, explore barriers, Gain confidence Become aware of defenses

Precontemplation Comments: Shift in focus, Change way of thinking,
Need to develop a support system

How How to help Precontemplators
Make therapy a safe and supportive place, encourage them to ask someone they trust to share with them their defenses. Use education to show them how defeating defenses can be. Give them permission to be human, encourage participant to be open about their defenses. Help them get control over their defenses.

How to help Precontemplators
Remind them that they are not ready for action, that they need to talk, get feedback, and feel cared for. They need to communicate with others what their goals are to change. Remind them that this is a process and that each step builds toward the next and that it will not happen overnight.

How to help Precontemplators
DO Recognize that participants need assistance to change Provide feedback on participant defenses Assess for shame, guilt, embarrassment DON’T Push someone into action, Nag, Give up, Enable

DATA COLLECTION: Psych/Social Evaluation:
Comprehensive Eval includes biological Mental Status Legal History—SA & MH Substance Abuse Profile: Identifies Risk Factors Identifies Stage of Change Identifies Triggers Identifies Strengths Collateral Resources: Family Law Enforcement Employers Healthcare Workers Friends Lawyers

SGOT (AST) & SGPT (ALT) these enzymes reflect the health of the liver.
Medical History: Hypertension Enlarged Liver GI Problems Sleep Disturbances Anemia Impotence Bone Fractures Anxiety Tremulousness Memory Impairment Blood work* SGOT (AST) & SGPT (ALT) these enzymes reflect the health of the liver. GGTP-This enzyme is found in the liver, brain and blood and appears to be sensitive to the effects of alcohol. This is usually the first enzyme to show an elevation and it has been shown to be a predictor of serious medical problems. *Elevations of these enzymes are also the result of other medical problems it is important to have a physician validate that the elevations are due to alcohol use.

Alcohol Expectancy Questionnaire
Total Bilirubin- A severely damaged liver cannot metabolize bilirubin. This is one of the causes of jaundice, a late stage of liver disease. Uric Acid- Byproduct of the kidneys, an alcohol damaged liver can not excrete uric acid and thus it builds up in the bloodstream. This may result in Gout, a painful inflammation of the joints. QUESTIONNAIRES: Alcohol Expectancy Questionnaire Alcohol Effects Questionnaire CAGE Questionnaire Comprehensive Drinker Profile The Drinker Inventory of Consequences Addiction Severity Index Substance Abuse Subtle Screening Inventory

Consciousness-Raising
The first step to fostering intentional change is to become conscious of the self-defeating defenses that get in the participant’s way. KNOWLEDGE IS POWER. Becoming aware of defenses Checking the participant’s defenses Increased awareness and practice can help a participant turn a maladaptive defense into a positive behavior.

Social liberation involves utilizing community resources, social norms to create more alternative and choices for problem behavior. Examples include: No Smoking sections Fat free foods Designated drivers Public service messages Employee wellness programs Reimbursement for exercise equipment Lower insurance rates for non-smokers. Self-help groups Precontemplators can perceive these forces as positive and helpful, in which case they will progress to contemplation. They may also perceive these forces as coercive, believing that their rights are being infringed upon by society.

Providing Feedback Journals Family Input Friend’s input
Target the person’s present situation and its risks or consequences. Journals Family Input Friend’s input Objective tests Blood Work/Medical tests Probation Input Work Performance

Treatment Planning Precontemplation
Goal: Shift in Focus Target participant’s perception Educate to develop insight Increase Hope Consciousness Raising Objectives: Conciseness raising Assessment Review Assessments Education Stress Management Coping/Wellness Assess for Depression Assess Lifestyle Interventions: Assessment Tools Medical Evaluation Education Groups Social Alternatives Typical Day Journal Timeline Lifestyle Awareness Wellness Exercise

Contemplation Thinking Stage
Characteristics: Increase awareness causes ambivalence (Normal) There is a resistance to change, The desire to change exists simultaneously with an unwitting resistance to it. Open to information about problem, May feel stuck, Action may be avoided,

Contemplation Await some type of external intervention,
Characteristics Continued: Await some type of external intervention, Analysis causes paralysis, Fear of failure, Fear of new self, Threatened identity or security, Wait for the magic moment. CHRONIC CONTEMPLATOR

Contemplation GOAL: Shift the focus to awareness of the problem and the solutions Techniques: Consciousness Raising & Social Liberation Emotional Arousal Self-Reevaluation

Contemplation TASKS Increase awareness of problem and solution,
Self-appraisal, Resolve fear and ambivalence, Make an informed decision to change problem behavior, Pros and cons of changing, Skill building, exercise, functional analysis

Contemplation COMMENTS: Shift in perception,
Learn to make an informed decision, Positive attitude, hope, self-esteem, Need a support system, Dual disorders--TX both!, Environmental control

Contemplators may present as:
Contemplation Comments Contemplation is essential prior to preparation. Ambivalence is a natural part of the change process. Contemplators may present as: Depressed Passive Serious about solving their problem Eager to talk about themselves and their problem Open to any information about their problem

Emotional Arousal Emotions can be harnessed to provide the energy to move from contemplation to preparation. Not the same as fear arousal Serves as a cleansing function Do not confuse emotions with change

Self-Reevaluation The goal of self-reevaluation is to emotionally and cognitively appraise the problem and self. This reevaluation should leave the participant thinking, feeling and believing that life would be much better if his behavior was changed. Develop techniques that focus on: Abandoning the hope of finding an easy route to change Confronting difficult questions regarding the outcome of change Looking at how change will effect self-image

Chronic Contemplators
Substitute thinking for acting Will make statements about taking action in the future or “someday” Conflicts and problems are suspended Decisions are never completed Action is avoided Await some type of type of external intervention Prochaska, James O.; Norcross, John C.; DiClemente Carlo C.: Changing for Good New York: Avon Books 1994

Preparation GOAL: Using the decisions made in Contemplation Stage
to develop specific steps to solve the problem for implementation during Action Stage

Preparation Techniques: Social Liberation Emotional Arousal: Experiencing & expressing feelings about the problem & solution Self-Reevaluation: Assessing feelings & thoughts about self with respect to a problem Commitment: Choosing and committing to act coupled with a belief in the ability to change, which reinforces the will to act.

Practice behavior change Stage
Preparation Characteristics Ambivalence is resolved, Self-reevaluation, anticipate roadblocks, Make a decision to take action By end of stage: Make a commitment to change

Preparation Characteristics continued: Have self-confidence,
Hopeful about future, careful planning, rehearsing for action, Self pride, Become responsible for behavior.

Preparation List benefits of changing, Focus on positive outcomes,
TASKS: List benefits of changing, Focus on positive outcomes, Increased energy, Let go of past,

Preparation TASKS cont’d New self-image, Belief in ability to change,
Anxiety is a normal reaction to change, Skill building (anger management, assertiveness training, 12 step groups)

Preparation COMMENTS:
Recovery is a process not an event, [A marathon not a sprint] Identify strengths, Learn new skill to succeed, Need to have a support system, Relapse may occur.

Action GOAL: Purposefully modify lifestyle in order to alter behavior based on commitment.

Action Countering Substituting healthy responses for problem behaviors
Techniques: Countering Substituting healthy responses for problem behaviors Active diversion: keeping busy Exercise Relaxation 10 to 20 Min. per day

Action Countering (Cont’d.)
Counter thinking: substituting positive thoughts for negative/B&W thoughts (I would like rather than I need to) Assertiveness: exercising right to communicate your thoughts, feeling, wishes, and intentions clearly, thereby countering feelings of helplessness.

Environmental Control:
Action Technique: Environmental Control: Restructuring the environment so that the likely occurrence of a problematic stimulus is significantly reduced. Avoidance (i.e. bars); Deal with cues & develop a plan; Reminders: To do list, including use of relaxation & exercise, appointments, etc.

REWARD: Action Technique:
Environmental control modifies the cues that precede & trigger problem behavior, Reward modifies the consequences that follow and reinforce it. Positive thoughts: “Nice job relaxing” A way of re-parenting self!

Action Characteristics: Modified lifestyle to alter behavior,
Need to be committed to change, Understand-- No guarantees that action will be successful, Guarantee

Action Prepared, Aware of pitfalls, May be active in 12 step program
Characteristics continued: Prepared, Aware of pitfalls, May be active in step program

Action Be aware of time, effort and energy needed to change,
Tasks Be aware of time, effort and energy needed to change, Relapse prevention skills No simple solutions to complex problems

Action COMMENTS: Relapse may occur,
Need to have support system in place already, Change in lifestyle, Treat core issues.

Maintenance Goal Maintain new behavior FOCUS On Behavior and Lifestyle

Abstinence Maintenance Task
Relapse Prevention: Task Continue integration and utilization of new coping skills, Goal Abstinence

Maintenance Techniques/Interventions: Rewards Support
Relapse Prevention tools

Maintenance Techniques/Interventions Hobbies Skill development
Social Alternatives Exercise

Nursing practices that can effectively incorporate Stages of Change
Knowledge: Knowing the right Stage of Change means Providing the right stage based interventions Ability to partner, collaborate, educate, assist, coach, assess, plan, implement, evaluate and document Provide appropriate skill building to enhance quality of life as addressing both illnesses in the correct Stage of Change Enhances your skills: as a team player, to have compassion for both illnesses, to be willing to be on the journey over a long period of time, share your medial knowledge, etc Equals improved outcomes and job satisfaction x

Presenter Information
Judy Magnon, RN-BC, BS, CAC WestBridge 7300 Grove Road Brooksville, FL 34613 Office (352) Cell(727)

Integrated Dual Disorders Treatment (IDDT)

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