Treating the Whole Person: Integrating Care for Persons with Co-Occurring Disorders Thomas E. Freese, Ph.D. Beth A. Rutkowski, M.P.H. UCLA ISAP/Pacific.

Treating the Whole Person: Integrating Care for Persons with Co-Occurring Disorders

Thomas E. Freese, Ph.D. Beth A. Rutkowski, M.P.H.

UCLA ISAP/Pacific Southwest ATTC

www.uclaisap.org www.psattc.org

Ice Breaker

• In pairs, discuss a consumer who has experienced both mental health and substance use disorders.

• How is this consumer unique from other mental health consumers?

• How does the consumer present? What behaviors does he/she exhibit that are different from a consumer with mental illness only?

Introduction:What we will cover

• Overview of the evolving field of Co-Occurring Disorders

• What is happening in the brain?• Using motivational interviewing with this

population—why and how• Importance of conducting effective screening

and assessment for COD• Conducting a brief intervention for

consumers with COD• Ways in which trauma and HIV impact COD

Co-Occurring Disorders

Co-occurring disorders • Refers to co-occurring substance use (abuse or

dependence) and mental disorders

In other words…

consumers with co-occurring disorders have:• one or more disorders relating to the use of alcohol

and/or other drugs of abuse and one or more mental disorders

Co-Occurring Disorders

Diagnosis of COD occurs when:• at least one disorder of each type can be

established independent of the other and • is not simply a cluster of symptoms resulting from

the one disorder

Clinicians knowledge of both mental health and substance abuse

is essential, but challenging to achieve

So, all of that is well and good, but…

…is dealing with drug abuse REALLY important to my job?

Prevalence of COD

• In 2006, 5.6 million adults (2.5% of persons aged 18+) met the criteria for both serious psychological distress (SPD) and substance dependence and abuse (i.e., substance use disorder, SUD)

• In 2006, 15.8 million adults (7.2% of persons aged 18+) had at least one major depressive episode (MDE) in the past year– Adults with MDE in the past year were more

likely than those without MDE to have used an illicit drug in the past year (27.7 vs. 12.9 percent)

SOURCE: 2006 National Survey on Drug Use and Health, SAMHSA.

Past Year Treatment of Adults with Both Serious Psychological

Distress (SPD) and SUD (2006) 39.60

2.8

8.4

49.2

Tx for MH ProblemsTx for SUD OnlyTx for SPD and SUDNo Tx


5.6 Million adults with co-occurring SPD and substance use disorder.

Past Year Treatment of Adults with Both MDE and AUD

48.6

1.98.8

40.7

Tx for MDE onlyTx for Alcohol OnlyTx for MDE and AlcoholNo Tx


Percentage of Adults with Past Year MDE and AUD by Age Group


Substance Use and Depression among Adults


Substance Use and Depression among Adolescents


*Aged 12-17

Adolescents with Substance Use Disorders...

• Are largely undiagnosed

• Are distributed across diverse health and social service systems

• Are more likely to be involved in the juvenile justice system

• Have higher rates of child abuse (neglect, physical and sexual abuse

• Have high co-morbidity with psychiatric conditions

Data from LA County DMH, 2007

• 61,739 new episodes opened in DMH Directly Operated Programs:– 17,647 (29%) dual code field was empty (i.e.,

neither presence nor absence of substance use noted);

– 44,092 episodes where dual field was completed:

• 31,187 (71%) indicated NO substance abuse issues• 12,905 (29%) indicated substance abuse issues.

Prevalence and Other Data

Data now show:• COD are common in general adult population.• Increased prevalence of people with COD and

programs for people with COD• People with COD are more likely to be

hospitalized and the rate may be increasing• Rates of mental disorders increase as the

number of substance use disorders increase• If we treat the SUD, we also address mental

health symptoms

So, the answer is…

We must address SUD in order to increase the

effectiveness of mental health treatment

Yes, this really IS important to your job!

Yes, this really IS important to your job!

One Client’s Perspective

…and to complicate the picture even more…

Substance Use and Trauma

• The co-occurrence of PTSD and substance use among those in treatment is 12-34%; for women it is 30-59%.

• Up to two-thirds of men and women in substance abuse treatment report childhood abuse or neglect.

• People with PTSD and substance abuse are vulnerable to repeated traumas.

• Becoming abstinent from substances does not resolve PTSD; some symptoms may become worse with abstinence.

• Treatment outcomes for those with PTSD and substance abuse are worse than for those with substance abuse alone.

Substance Use and HIV

• By 2010, HIV/AIDS will have caused more deaths than any disease outbreak in history.

• “HIV is spread by unsafe behaviors that mental health care providers are often in the best position to identify and address.” **

• Individuals with Severe Mental Illness (SMI) are disproportionately affected by HIV/AIDS.

• Persons with HIV/AIDS and who have a mental illness have special needs.

**McKinnon, K. 1999. Psychiatric Services, 50 (9) 1225-1228.**McKinnon, K. 1999. Psychiatric Services, 50 (9) 1225-1228.

So, How Do We Treat COD?

TIP 42

Guiding Principles and Recommendations

Six Guiding Principles (SAMHSA, TIP 42)

• Employ a recovery perspective

• Develop a phased approach to treatment

• Address specific real-life problems early in treatment

• Plan for cognitive and functional impairments

Delivery of Services (SAMHSA, TIP 42)

• Provide access

• Complete a full assessment

• Provide appropriate level of care

• Achieve integrated treatment

- Treatment Planning and Review

- Psychopharmacology

• Provide comprehensive services

• Ensure continuity of care

Vision of Fully Integrated Treatment

• One program that provides treatment for both disorders

• Mental and substance use disorders are treated by the same clinicians

• The clinicians are trained in psychopathology, assessment, and treatment strategies for both disorders

Vision of Fully Integrated Treatment (continued)

• Treatment is characterized by a slow pace and a long-term perspective

• Providers offer motivational counseling• 12-Step groups are available to those who

choose to participate• Pharmacotherapies are utilized according

to consumers’ psychiatric and other medical needs

• Sensitivity to issues of trauma, culture, gender, and sexual orientation

Consumer Improvement Strategies

• Increase the focus on consumer satisfaction and consumer perception of care

• Increase the use of behavioral enhancement techniques (use of positive reinforcement techniques).

• Increase the use to strategies to increase consumer access to care and appreciation of care (eg. NIATx)

• Increase measurement of service effectiveness and greater provider accountability

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• Differing practice styles

• Differing practice cultures and language

• Difficulty in matching provider skills with patient needs

• Heavy reliance on physician services

• Tension between direct patient care services (reimbursable) and integrative (non-reimbursable) services

Provider/practice barriers

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• Lack of recognition of provider limitations

• Lack of MH knowledge in PC providers and lack of health knowledge in BH providers

• Lack of clinical competence in integrated service models (MH/SU and BH/PC) and selection of proper integration model based on practice context

• Differing coding and billing systems

• Provider resistance

Provider/practice barriers

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Addiction: A Brain Disease

Putting Drug Use into Context with other Mental Disorders

Onset of Mental Health Disorders

• Oppositional Defiance: 5yo

• Attention Deficit Disorder-ADHD: 1.3-2.4 yo

• Anxiety Disorders: 3.8 yo

• Conduct Disorder: 5.6 yo

• Depression: 10.1 yo

• Schizophrenia-affective disorders: mid-teens to mid-thirties

Typical Progression of Use

FAS---Substance use in-uterus

No SocialUse Experimentation Use Use Abuse Dependence-----------------------------------------------------------------------------------------------

0-2 3-5 6-8 9-10 11-12 13-14 15-16 17+Infant Child Pre- Adolescent adol

Mental Health Disorder’s onset----------------------------------

What are we talking about?

Alcoholism/Addiction Major Mental Disorders

Both heredity and environment play a roleCharacterized by chronicity and “denial”

Affects the whole familyProgresses without treatmentFeelings of shame and guilt

Inability to control behavior and emotionsOften seen as a moral issue

Leads to feelings of despair and failureBiological, psychological, social and spiritual components

Collision of Symptomology

• Differential Diagnosis is essential for accurate assessment. Is the presenting problem affected by a medical condition or substance?– Is it depression or alcohol, prescription pain killer,

heroin use?– Is it ADHD or is it methamphetamine,

cocaine use?– Is it bipolar disorder or cocaine use?– Is it schizophrenia or methamphetamine use?– Is it PTSD or polysubstance use?

A Major Reason People Take a Drug is They Like

What It Does to Their Brains

A Major Reason People Take a Drug is They Like

What It Does to Their Brains

Initially, A Person Takes A Drug Hoping to Change their Mood, Perception, or Emotional State

Initially, A Person Takes A Drug Hoping to Change their Mood, Perception, or Emotional State

Translation---Translation---

…Hoping to Change their Brain…Hoping to Change their Brain

The Brain Undergoes Tremendous Changes During

Development

Increase of brain activity that accompanies the growth of the brain, in the same patient,

from the age of 1 to 12 months.

Information taken from NIDA’s Science of Addiction http://www.drugabuse.gov/ScienceofAddiction/43

Continuing Brain Development During Adolescence

Strengthening the CircuitrySynaptic connections are strengthened

Pruning Unused Connections- Adolescent brain is in a unique state of flux- Neurons are eliminated, pruned and shaped- This process is influenced by interactions with the outside

world (Seeman, 1999)- Pruning occurs from back to front so frontal lobes mature

the last. Other brain areas are also growing during adolescence

(e.g., sub-cortical areas, receptors)

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Continuing Brain Development

Early in development, synapses are rapidly created and then pruned back. Children’s brains have twice as many synapses as the brains of adults. (Shore, 1997)

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Information taken from NIDA’s Science of Addictionhttp://www.drugabuse.gov/ScienceofAddiction/

Gagtay, N., et al. PNAS, 101, 8174-8179

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Brain Development Ages 5-20 years

MRI scans of healthy children and teens compressing 15 years of brain development (ages 5–20).

Red indicates more gray matter, blue less gray matter. Neural connections are pruned back-to-front. The prefrontal cortex ("executive" functions), is last to mature.

The interaction between the developing nervous system and drugs

of abuse leads to: Difficulty in decision making Difficulty understanding the consequences of behavior Increased vulnerability to memory and attention

problems

This can lead to: Increased experimentation Substance addiction

(Fiellin, 2008)

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Young Brains Are Different from Older Brains

Alcohol and drugs affect the brains of adolescents and young adults differently than they do adult brains – Adolescent rats are more sensitive to the

memory and learning problems than adults*– Conversely, they are less susceptible to

intoxication (motor impairment and sedation) from alcohol*

These factors may lead to higher rates of dependence in these groups

(Hiller-Sturmhöfel and Swartzwelder, 2004) 48

Triggers and Cravings

Human Brain


Ivan Petrovich Pavlov


Pavlov’s Dog

Classical Conditioning: Addiction

• Over time, drug or alcohol use is paired with cues such as money, paraphernalia, particular places, people, time of day, emotions

• Through classical conditioning these cues are paired with pleasurable effects of the drug (“high”).

• Eventually, exposure to cues alone produces drug or alcohol cravings or urges that are often followed by substance abuse

Development of Craving Response

Entering Using Site

Use of AODs AOD Effects

Heart

Blood Pressure

Energy


Entering Using Site


Heart

Blood Pressure

Energy

Mild Physiological Response

Heart Rate

Breathing Rate

Energy

Adrenaline Effects


Entering Using Site


Heart

Blood Pressure

Energy

Powerful Physiological Response

Heart Rate

Breathing Rate

Energy

Adrenaline


Entering Using Site


Heart

Blood Pressure

Energy

Powerful Physiological Response

Heart Rate

Breathing Rate

Energy

Adrenaline

Thinking of Using


AOD Effects

Heart

Blood Pressure

Energy

Thinking of Using

Cognitive Process During Addiction

Relief FromDepressionManiaAnxietyInsomnia“Voices” EuphoriaIncreased EnergyIncreased Social ConfidenceIncreased School/Work OutputIncreased Thinking Ability

AOD

May Be IllegalMay Be Expensive

Hangover/Feeling IllMay Miss Work/School

Relief From Fatigue

Relief From Stress

Relief From Depression

Weight Loss/Gain

Paranoia

Loss of Family

Seizures

Severe Depression

Psychosis

Unemployment

Bankruptcy

Effecting Change through the Use of

Motivational Interviewing

How can MI be helpful for us in working with our consumers/patients?

• The successful MI therapist is able to inspire people to want to change

• Use of MI can help engage and retain consumers in treatment

• Using MI can help increase participation and involvement in treatment (thereby improving outcomes)

What Causes a Person to be Judged “Motivated”

• The person agrees with us

• Is willing to comply with our recommendations and treatment prescriptions

• States desire for help

• Shows distress, acknowledges helplessness

• Has a successful outcome

Definition of Motivation

The probability that a person will enter into, continue,

and comply with change-directed behavior

A patient-centered directive method for enhancing intrinsic motivation to change by

exploring and resolving ambivalence.

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwww.samhsa.gov

Where do I start?

• What you do depends on where the consumer is in the process of changing

• The first step is to be able to identify where the consumer is coming from

Stages of ChangeProchaska & DiClemente

Helping People Change

• Motivational Interviewing is the process of helping people move through the stages of change

Stages of Change:Primary Tasks

1. PrecontemplationDefinition:

Not yet considering change or is unwilling or unable to change.

Primary Task:Raising Awareness 2. Contemplation

Definition: Sees the possibility of change but

is ambivalent and uncertain.

Primary Task:Resolving ambivalence/

Helping to choose change

3. DeterminationDefinition:

Committed to changing.Still considering what to do.

Primary Task:Help identify appropriate

change strategies4. ActionDefinition:

Taking steps toward change but hasn’t stabilized in the process.

Primary Task:Help implement change strategies

and learn to eliminate potential relapses

5. MaintenanceDefinition:

Has achieved the goals and is working to maintain change.

Primary Task:Develop new skills for maintaining recovery

6. RecurrenceDefinition:

Experienced a recurrence of the symptoms.

Primary Task:Cope with consequences and

determine what to do next

• Open-ended questioning

• Affirming

• Reflective listening

• Summarizing

Building Motivation OARS(the microskills)

The goal is to elicit and reinforce

self-motivational statements (Change Talk)

The goal is to elicit and reinforce

self-motivational statements (Change Talk)

Use the Microskills of MI to:

Express Empathy

• Acceptance facilitates change

• Skillful reflective listening is fundamental

• Ambivalence is normal


Develop Discrepancy• Discrepancy between present behaviors

and important goals or values motivates change

• Awareness of consequences is important

• Goal is to have the PERSON present reasons for change

Decisional Balance


Avoid Argumentation• Resistance is signal to change strategies• Labeling is unnecessary• Shift perceptions • Peoples’ attitudes are shaped by their

words, not yours

Support Self-Efficacy• Belief that change is possible is an

important motivator

• Person is responsible for choosing and carrying out actions to change

• There is hope in the range of alternative approaches available


Providing Feedback

• Elicit (ask for permission)

• Give feedback or advice

• Elicit again (the person’s view of how the advice will work for him/her)

Screening and Assessing for COD

What can be determined through the screening and assessment process?

• The interplay between the substance use and the mental health problem

• The degree to which each disorder interferes with functioning and is situational or social

• The frequency, intensity and duration of use and associated diagnosis (i.e., substance abuse or dependence)

THESE DETERMINATIONS TAKE TIME

‘The Secret in the Pocket’

• Please write down one personal experience, that you have determined to keep to yourself. This can be an experience or character flaw that you are NOT proud of. YOUR SECRET.

• A word or phrase that will help identify this experience to you and you alone.

YOU WILL NOT BE ASKED TO SHARE THIS OR SHOW THIS TO ANYONE.

Appreciating the ‘difficult to tell….’

Before we begin to ask questions, we need to:• understand and appreciate the DIFFICULT process

of sharing what is considered personal and private• understand the processes whereby individuals communicate

‘family secrets’ and information to strangers

We need to review what we see ashealthy, intrapersonal non-disclosure versus

unhealthy, self destructive secret-keeping

Tasks of Addiction Counselor and/or Mental Health Clinician:

• Our responsibility is to provide the best, most comprehensive assessment and treatment for clients

• This requires a complete and thorough assessment

• Balance timeframes between completing necessary forms and paperwork and providing Best Practice

• Those who struggle with COD need an ally who has a complete understanding of the problem

• Services must move at the pace set by the client

When do I bring up ‘the topic’

• Ensure that sufficient rapport has been established with the client

• Embed questions about substance use and mental health into the overall assessment

• Completing paperwork and broaching specific topics may be two different events

“Tips for Communicating”

“Talking with clients about their medication”

What for?

• Prevent/warn Pt about interactions W/ foods, alcohol and other drugs, medications, pregnancy, etc.

• Inform about the need for lab tests for some medications

• What to expect: positive outcomes & potential side effects

What for?

• Stress reducer (control, knows what to expect, understands the importance of:

– Taking medication

– Avoid interactions

– Schedules

– Combinations of medication

– etc.

Why?

• Untreated psychiatric problems are a common cause for treatment failure in substance abuse and mental health treatment programs

• Supporting clients with mental illness in continuing to take their psychiatric medications can significantly improve substance abuse treatment outcomes

Talking with Clients about their Medication

• 5-10 minutes every few sessions:

– Taking care of their mental health will help prevent relapse



– How their psychiatric medication is helpful?


• “How many doses have you missed?”

• Have you felt or acted different on days when you missed your medication?

• Was missing the medication related to any substance use relapse?

• “Why did you miss the medication? Did you forget, or did you choose not to take it at that time?” Without judgment

Medication Adherence: Common Reasons for Missing Doses


– Taking a pill every day is a hassle



– Everybody on medication misses taking it sometimes


• For clients who forgot:

– Keep medication where it cannot be missed



– Alarm Clock



– Mediset


• For clients who admit to choosing NOT to take their medication: – Acknowledge they have a right to choose NOT to use

any medication – They owe it to themselves to make sure their decision

is well thought out – They need to discuss it with their prescribing

physician– What is the reason for choosing not to take the

medication?– Don’t accept “I just don’t like pills”. Tell them you are

sure they wouldn’t make such an important decision without having a reason


• Don’t believe they ever needed it; never were mentally ill


• Don’t believe they need it anymore; cured


• Don’t like the side effects


• Fear the medication will harm them


• Struggle with objections or ridicule of friends and family members


• Feel taking medication means they’re not personally in control


• Explore the triggers or cues that led to the undesired behavior


• Why the undesired behavior seemed like a good idea at the time?


• Review the actual outcome resulting from their choice

• Did their choice get them what they were seeking?


Strategize with clients about what they could do differently in the future

Activity

Review the “Talking with Clients about their Medication” slides. Choose one of the common reasons why clients do not take their medications. In groups of 3 (counselor, client, observer), role play a client who is non-adherent and a counselor working with the patient to explore reasons and strategize solutions. The observer should watch the dynamics and the client’s responses to the counselors use of the guidelines, and provide the counselor with feedback.

Assessing Risk FactorsFactors affecting risk for

involvement with substance use

Assessing Individual Risk Factors

• Favorable attitudes towards the use of substances

• Early age of onset of substance use

• Gender: Males more likely to abuse substances than females

• Genetics: Family history of substance abuse

• History of sexual/physical abuse

• Trauma/displacement

Assessing Psychological Risk Factors

• Impulsivity

• Novelty-seeking

• Childhood ADHD or conduct disorder

• Antisocial Personality Disorder

• Failure to complete high school

• Poor occupational achievement

• Low frustration tolerance

• Internalized racism/sexism/heterosexism

Assessing Sociocultural Risk Factors

• Social network

• Friends/coworkers that use

• Alcohol/drug use integrated into family culture

• Socioeconomic Status (SES)

• High crime rate/ “culture of violence”

• Degree of acculturation

Assessing HIV Risk Behaviors

• Two broad categories:– Sexual risk behaviors

• How comfortable are you asking questions about explicit sexual behaviors that are high risk for transmission/infection with HIV and other STI’s?

– Injection drug use• Much higher risk of HIV & hepatitis among injection

users – highlights the importance of assessing route of administration of drug use

Understanding the impact of age…

• It is often difficult for us to approach people who are different in age (much younger or much older)

• Not all young people act out and not all old people are depressed.

• Age often brings out our assumptions and biases– “She looks like my grandma, she couldn’t be

using drugs.”– “He’s only 10, substance abuse cannot be an

issue.”

Contact Your Trainerswww.uclaisap.org and www.psattc.org

Thomas E. Freese, Ph.D.

[email protected]

Beth A. Rutkowski, M.P.H.

[email protected]

Thank you for your time!

Treating the Whole Person: Integrating Care for Persons with Co-Occurring Disorders Thomas E. Freese, Ph.D. Beth A. Rutkowski, M.P.H. UCLA ISAP/Pacific.

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