1. Treating Addiction and Other Mental Disorders: Clinical Issues Cutting Edge 2004 Palmerston North, New Zealand September 3, 2004 Joan E. Zweben, Ph.D. Executive Director: EBCRP and 14 th Street Clinic Clinical Professor of Psychiatry; University of California, San Francisco Joan E. Zweben, Ph.D. Executive Director: EBCRP and 14 th Street Clinic Clinical Professor of Psychiatry; University of California, San Francisco

2. General Treatment Considerations Need for realistic expectations Need for realistic expectations Offer appropriate forms of hope to counteract despair Offer appropriate forms of hope to counteract despair Accept chronicity of the disorder without viewing self as a failure or using this as an excuse Accept chronicity of the disorder without viewing self as a failure or using this as an excuse Educate about other mental disorders as well as AOD use Educate about other mental disorders as well as AOD use

3. Prioritizing Treatment Tasks Safety Safety Stabilization Stabilization Development/growth Development/growth Maintenance of gains; relapse prevention Maintenance of gains; relapse prevention

4. Psychosocial Treatment Issues client attitudes/feelings about medication client attitudes/feelings about medication client attitude about having an illness client attitude about having an illness other clients’ reactions: misinformation, negative attitudes other clients’ reactions: misinformation, negative attitudes staff attitudes staff attitudes medication compliance medication compliance control issues: whose client? control issues: whose client?

5. History & Current Context patients referred from other services with insufficient attention to motivation patients referred from other services with insufficient attention to motivation no specific arena to address ambivalence no specific arena to address ambivalence “Wait until they are ready” “Wait until they are ready” AOD programs: discharge for non- compliance with high expectations AOD programs: discharge for non- compliance with high expectations discovery that untreated substance abuse is expensive discovery that untreated substance abuse is expensive

6. Reasons to Resist an Abstinence Commitment fear of failure fear of failure addiction pattern in family of origin addiction pattern in family of origin self medication self medication trauma history trauma history survivor guilt survivor guilt

7. Negotiating an Abstinence Commitment Connect AOD use with presenting complaints Connect AOD use with presenting complaints facilitate progress through initial decision making phases of change facilitate progress through initial decision making phases of change blend careful inquiry, giving information, gentle confrontation blend careful inquiry, giving information, gentle confrontation experiment with abstinence; sobriety sampling experiment with abstinence; sobriety sampling enhance motivation, vs punish ambivalence enhance motivation, vs punish ambivalence

8. Motivational Enhancement Your relationship is a great asset, in addition to your leverage Your relationship is a great asset, in addition to your leverage Identify where people are on the continuum of readiness to change and move them forward Identify where people are on the continuum of readiness to change and move them forward Connect the pain in their life with AOD use Connect the pain in their life with AOD use Explore benefits and problems of AOD use Explore benefits and problems of AOD use Use forthright feedback that is not harsh or punitive Use forthright feedback that is not harsh or punitive Offer options for change Offer options for change

9. Confrontation Many practices are believed helpful because we don’t follow our dropouts Many practices are believed helpful because we don’t follow our dropouts Firm feedback needed in supportive atmosphere Firm feedback needed in supportive atmosphere More disturbed clients are highly vulnerable to aggressive exchanges and become disorganized; they do better with low levels of expressed emotion More disturbed clients are highly vulnerable to aggressive exchanges and become disorganized; they do better with low levels of expressed emotion

10. Educate Clients about Psychiatric Conditions The nature of common disorders; usual course; prognosis The nature of common disorders; usual course; prognosis Important factors: genetics, traumatic and other stressors, environment Important factors: genetics, traumatic and other stressors, environment Recognizing warning signs Recognizing warning signs Maximizing recovery potential Maximizing recovery potential Misunderstandings about medication Misunderstandings about medication Teamwork with your physician Teamwork with your physician

11. Barriers to Accessing Offsite Psychiatric Services Distance, travel limitations Distance, travel limitations Obstacle of enrolling in another agency Obstacle of enrolling in another agency Stigma of mental illness Stigma of mental illness Cost Cost Fragmentation of clinical services Fragmentation of clinical services Becoming accustomed to new staff Becoming accustomed to new staff (COD TIP, in press) (COD TIP, in press)

12. Prescribing Psychiatrist Onsite Brings diagnostic, behavioral and medication services to the clients Brings diagnostic, behavioral and medication services to the clients Psychiatrist learns about substance abuse Psychiatrist learns about substance abuse Case conferences, supervision allow counselors to learn more about dx and tx Case conferences, supervision allow counselors to learn more about dx and tx Better retention and outcomes Better retention and outcomes (COD TIP, in press)

13. Attitudes and Feelings about Medication shame shame feeling damaged feeling damaged needing a crutch; not strong enough needing a crutch; not strong enough “I’m not clean” “I’m not clean” anxiety about taking a pill to feel better anxiety about taking a pill to feel better “I must be crazy” “I must be crazy” medication is poison medication is poison expecting instant results expecting instant results

14. Medication Adherence important relationship to positive treatment outcome important relationship to positive treatment outcome reasons for non-compliance: denial of illness, attitudes and feelings, side effects, lack of support, other factors reasons for non-compliance: denial of illness, attitudes and feelings, side effects, lack of support, other factors role of the counselor: periodic inquiry, exploring charged issues, keeping physician informed role of the counselor: periodic inquiry, exploring charged issues, keeping physician informed Work out teamwork, procedures with docs Work out teamwork, procedures with docs

15. Treating Co-Occurring Mental Disorders: Depression & PTSD Joan E. Zweben, Ph.D. Executive Director: EBCRP and 14 th Street Clinic Clinical Professor of Psychiatry; University of California, San Francisco Joan E. Zweben, Ph.D. Executive Director: EBCRP and 14 th Street Clinic Clinical Professor of Psychiatry; University of California, San Francisco

16. Mood & Anxiety Disorders: Counselor Recommendations Distinguish anxiety and mood disorders from: Distinguish anxiety and mood disorders from:  Normal feelings in recovery  Symptoms of severe mental illness  Medical conditions  Medication side effects  Substance-induced changes (COD TIP, in press)

17. Mood & Anxiety Disorders: Counselor Recommendations (2) Maintain calm demeanor, reassuring presence Maintain calm demeanor, reassuring presence Teach deep breathing, relaxation Teach deep breathing, relaxation Start low, go slow Start low, go slow Respond immediately to any intensification of symptoms Respond immediately to any intensification of symptoms Understand special sensitivities to social situations Understand special sensitivities to social situations Gradually introduce and teach skills for participation in self-help groups Gradually introduce and teach skills for participation in self-help groups (COD TIP, in press) (COD TIP, in press)

18. Suicidality AOD use is a major risk factor, especially for young people AOD use is a major risk factor, especially for young people Alcohol: associated with 25%-50% Alcohol: associated with 25%-50% Alcohol & depression = increased risk Alcohol & depression = increased risk Intoxication is associated with increased violence, towards self and others Intoxication is associated with increased violence, towards self and others High risk when relapse occurs after substantial period of sobriety, especially if it leads to financial or psychosocial loss High risk when relapse occurs after substantial period of sobriety, especially if it leads to financial or psychosocial loss (COD TIP, in press) (COD TIP, in press)

19. Suicidality: Counselor Recommendations Treat all threats with seriousness Treat all threats with seriousness Assess risk of self harm: Why now? Past attempts, present plans, serious mental illness, protective factors Assess risk of self harm: Why now? Past attempts, present plans, serious mental illness, protective factors Develop safety and risk management process Develop safety and risk management process Avoid heavy reliance on “no suicide” contracts Avoid heavy reliance on “no suicide” contracts 24 hour contact available until psychiatric help can be obtained 24 hour contact available until psychiatric help can be obtained Note: must have agency protocols in place (COD TIP, in press) (COD TIP, in press)

20. Elements of PTSD  Acting or feeling as if the traumatic event were recurring  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  Intrusion symptoms and/or numbing symptoms

21. Complex PTSD Alterations in: Affect regulation Affect regulation Consciousness Consciousness Self perception Self perception Perception of perpetrator Perception of perpetrator Relations with others Relations with others Systems of meaning Systems of meaning

22. Treatment Issues

23. Relationships between Trauma and Substance Abuse Traumatic experiences increase likelihood of substance abuse, especially if PTSD develops Traumatic experiences increase likelihood of substance abuse, especially if PTSD develops Childhood trauma increases risk of PTSD, especially if it is multiple trauma Childhood trauma increases risk of PTSD, especially if it is multiple trauma Substance abuse increases the risk of victimization Substance abuse increases the risk of victimization Need for linkages between systems: medical, shelters, social services, mental health, criminal justice, addiction treatment (Zweben et al 1994) Need for linkages between systems: medical, shelters, social services, mental health, criminal justice, addiction treatment (Zweben et al 1994)

24. PTSD Counselor Recommendations Identify clients who are high risk Identify clients who are high risk Develop a plan for increased safety Develop a plan for increased safety Listen to behavior more than words Listen to behavior more than words Limit questioning about details of the trauma Limit questioning about details of the trauma Help client de-escalate intense emotions Help client de-escalate intense emotions Teach coping skills Teach coping skills Prepare client for long term treatment Prepare client for long term treatment (COD TIP, in press)

25. How PTSD Complicates Recovery More difficulty: establishing trusting therapeutic alliance establishing trusting therapeutic alliance obtaining abstinence commitment; resistance to the idea that AOD use is itself a problem obtaining abstinence commitment; resistance to the idea that AOD use is itself a problem establishing abstinence; flooding with feelings and memories establishing abstinence; flooding with feelings and memories maintaining abstinence; greater relapse vulnerability maintaining abstinence; greater relapse vulnerability

26. Impact of Physical/Sexual Abuse on Treatment Outcome N=330; 26 outpatient programs; 61% women and 13% men experienced sexual abuse abuse associated with more psychopathology for both; sexual abuse has greater impact on women, physical abuse has more impact on men abuse associated with more psychopathology for both; sexual abuse has greater impact on women, physical abuse has more impact on men psychopathology is typically associated with less favorable tx outcomes, however: psychopathology is typically associated with less favorable tx outcomes, however: abused clients just as likely to participate in counseling, complete tx and remain drug-free for 6 months post tx abused clients just as likely to participate in counseling, complete tx and remain drug-free for 6 months post tx (Gil Rivas et al 1997) (Gil Rivas et al 1997)

27. How Substance Abuse Complicates Resolution of PTSD early treatment goal: establish safety (address AOD use) early treatment goal: establish safety (address AOD use) early recovery: how to contain or express feelings and memories without drinking/using early recovery: how to contain or express feelings and memories without drinking/using firm foundation of abstinence needed to work on resolving PTSD issues firm foundation of abstinence needed to work on resolving PTSD issues full awareness desirable, vs emotions altered by AOD use full awareness desirable, vs emotions altered by AOD use relapse risk: AOD use possible when anxiety- laden issues arise; must be immediately addressed relapse risk: AOD use possible when anxiety- laden issues arise; must be immediately addressed

28. Building a Foundation BEWARE OF DOGMA May need to work with client who continues to drink or use for a long time avoid setting patient up for failure avoid setting patient up for failure reduce safety hazards; contract about dangerous behavior reduce safety hazards; contract about dangerous behavior carefully assess skills for coping with feelings and memories; work to develop them carefully assess skills for coping with feelings and memories; work to develop them

29. Possible Meanings of Drug Use in the Context of PTSD Access feelings and memories Access feelings and memories Shut off feelings and memories Shut off feelings and memories Revenge against the abuser Revenge against the abuser Re-abuse of self Re-abuse of self Slow suicide Slow suicide Learned behavior Learned behavior (Najavits, 2001)

30. Trauma & Recovery: Stages of Healing “Recovery is based on the empowerment of the survivor and the creation of new connections.” Safety Safety Mourning Mourning Reconnection Reconnection (Herman, 1992)

31. Seeking Safety: Early Treatment Stabilization 25 sessions, group or individual format 25 sessions, group or individual format Safety is the priority of this first stage tx Safety is the priority of this first stage tx Treatment of PTSD and substance abuse are integrated, not separate Treatment of PTSD and substance abuse are integrated, not separate Restore ideals that have been lost Restore ideals that have been lost  Denial, lying, false self – to honesty  Irresponsibility, impulsivity – to commitment

32. Seeking Safety: (2) Four areas of focus: Four areas of focus:  Cognitive  Behavioral  Interpersonal  Case management Grounding exercise to detach from emotional pain Grounding exercise to detach from emotional pain Attention to therapist processes: balance praise and accountability; notice therapists’ reactions Attention to therapist processes: balance praise and accountability; notice therapists’ reactions

33. Seeking Safety (3): Goals Achieve abstinence from substances Achieve abstinence from substances Eliminate self-harm Eliminate self-harm Acquire trustworthy relationships Acquire trustworthy relationships Gain control over overwhelming symptoms Gain control over overwhelming symptoms Attain healthy self-care Attain healthy self-care Remove self from dangerous situations (e.g., domestic abuse, unsafe sex) Remove self from dangerous situations (e.g., domestic abuse, unsafe sex) (Najavits, 2002)

34. Safe Coping Skills Ask for help Ask for help Honesty Honesty Leave a bad scene Leave a bad scene Set a boundary Set a boundary When in doubt, do what is hardest When in doubt, do what is hardest Notice the choice point Notice the choice point Pace yourself Pace yourself Seek understanding, not blame Seek understanding, not blame Create a new story for yourself Create a new story for yourself ( from Handout in Najavits, 2002) ( from Handout in Najavits, 2002)

35. Detaching From Emotional Pain: Grounding Focusing out on external world - keep eyes open, scan the room, name objects you see Focusing out on external world - keep eyes open, scan the room, name objects you see Describe an everyday activity in detail Describe an everyday activity in detail Run cool or warm water over your hands Run cool or warm water over your hands Plan a safe treat for yourself Plan a safe treat for yourself Carry a grounding object in your pocket to touch when you feel triggered Carry a grounding object in your pocket to touch when you feel triggered Use positive imagery Use positive imagery (Najavits, 2002)

36. EMDR Eye Movement Desensitization and Reprocessing information processing model information processing model trauma “freezes” the system, preventing healthy processing; intrusion & numbing symptoms result trauma “freezes” the system, preventing healthy processing; intrusion & numbing symptoms result AOD use as numbing agent; chemical dissociation AOD use as numbing agent; chemical dissociation eye movements facilitate an altered state in which traumatic experiences can be integrated in a new way eye movements facilitate an altered state in which traumatic experiences can be integrated in a new way support from controlled research support from controlled research

37. EMDR: Basic Components the image the image the negative cognition the negative cognition the positive cognition the positive cognition the emotions and their level of disturbance the emotions and their level of disturbance the physical sensations the physical sensations Integrates cognitive, affective and physical

38. EMDR: Phases of Treatment Client history and treatment planning Client history and treatment planning Preparation Preparation Assessment Assessment Desensitization Desensitization Installation Installation Body Scan Body Scan Closure Closure Reevaluation (Shapiro 1995) Reevaluation (Shapiro 1995)