Transcript CLINICAL SUPERVSIOR ORIENTATION

National Alliance on Mental
Illness of MetroWest
Forum on Mental Illness and
Substance Abuse
Revision 3
Romas Buivydas, PhD, LMHC
• VP, Clinical Development
Spectrum Health Systems, Inc.
• Twenty years of experience in the behavioral
health field
• Formerly the Director of Evaluation at a hospitalbased psychiatric/addiction department for six
years
• A national presenter/trainer at
conferences/symposia across the country.
•
Spectrum Health Systems, Inc.
• Originally known as “Spectrum House.”
• For 42 years a national leader in Substance
Abuse and Mental Health Services
• Serving 40,000 individuals each year from
Maine to Washington State
• 501 C 3 Nonprofit
Massachusetts Substance Abuse
Services (Dual Diagnosis )
• Detox Westborough
• Residential Treatment Centers
▫ 80 Bed Adult Men & Women Westborough
▫ 30 Bed Adult Men Weymouth
• Outpatient Counseling
▫ Framingham
▫ Milford
▫ Worcester
Massachusetts Mental Health
Services
• Outpatient
▫ Framingham, Milford, Worcester
• Domestic Violence
▫ Fitchburg, Southbridge, Westborough, Worcester
• Anger Management
▫ Fitchburg
Court Ordered Correctional
Recovery Services
• Adults
• Adolescents (D.Y.S. Funded)
Drug Free Housing
• 14 unit rooming house
• Worcester
Assessment and Treatment
of Co-occurring Mental Health
and Substance Abuse
Disorders
Romas Buivydas, PhD, LMHC
VP, Clinical Development
Spectrum Health Systems, Inc.
Introduction
• Historically, individuals with mental illness have seen minimal success in
substance abuse treatment and tend to experience frequent relapses and
inpatient admissions
Introduction
Why?
• Historically, and currently, systems of care do not effectively engage and
treat people with co-occurring disorders
• Diagnosis is difficult because it takes time to unravel the interacting effects
of substance abuse, withdrawal, post acute withdrawal, and mental illness
• The symptoms of their illness may not be understood and their behaviors
may not be tolerated in drug rehabilitation programs.
• Substance abuse treatment providers may have concerns about and/or not
understand psychopharmacology
Prevalence
• In any given year, 5.6 million adults in the nation
have co-occurring mental illness and substance
use disorder (NSDUH, 2006).
• Mueser, et al. (2006) report that, in clinic
samples, as many as 40-60% of individuals
presenting in mental health settings have a cooccurring substance use diagnosis, and 60-80%
of individuals presenting in a substance abuse
facility have co-occurring mental illness.
• 50% of individuals with co-occurring serious
mental illness and substance use disorders
receive no care; 45% receive poor care; and only
five% receive evidence-based care. (Drake,
2006)
POST ACUTE WITHDRAWAL
Post Acute Withdrawal Syndrome is a group of withdrawal
symptoms that generally appear 7 to 14 days into abstinence
and can last 6 to 18 months last use.
As a result of continued drug and alcohol abuse the brain
needs to adjust in order to 'right itself' as neurotransmitters
return to normalcy and acclimate to a life without mood altering
chemicals.
This sometime takes time and that is where post acute
withdrawal symptoms come in, they are like lingering
withdrawal. Even after several weeks without substances,
people may have severe mood swings, insomnia, and anxiety.
POST ACUTE WITHDRAWAL
• Healthy habits such as limiting caffeine, getting
8-10 hours of sleep, eating three balanced
meals and exercising and/or meditating threefour times weekly
• The severity of symptoms decreases as time
progresses. By the end of one year, most
persons have returned to their respective levels
of functioning.
INTEGRATED TREATMENT
Best Practices for Treating Co-occurring Disorders:
(Minkoff, 2000)
• Co-occurring disorders are an expectation, not an exception
• Treatment success involves formation of empathic, hopeful, integrated
treatment relationships
• Integrated co-occurring primary diagnosis-specific treatment interventions
are recommended
INTEGRATED TREATMENT
Best Practices for Treating Co-occurring Disorders:
(Minkoff, 2000)
• Interventions need to be matched not only to diagnosis, but also to phase of
recovery, stage of treatment, and stage of change
• Treatment success is enhanced by maintaining integrated treatment
relationships
• Providing disease management interventions for both disorders
continuously across multiple treatment episodes,
• Balancing case management support with detachment & expectation
Cross-cutting Issues
• Suicidality
• Nicotine Dependence
Suicidality
• What is the relationship between suicide and substance abuse:
• Alcohol abuse is associated with 25 to 50 percent of suicides.
Between 5 and 27 percent of all deaths of people who abuse
alcohol are caused by suicide, with the lifetime risk for suicide
among people who abuse alcohol estimated to be 15 percent.
• There is a particularly strong relationship between substance
abuse and suicide among young people.
Suicidality
• Co-occurring alcoholism and depression increases suicide risk.
• The association between alcohol use and suicide also may
relate to the capacity of alcohol to remove inhibitions, leading to
poor judgment, mood instability, and impulsiveness.
• Substance intoxication is associated with increased violence,
both toward others and self.
Nicotine Dependence
• Evidence suggests that people with mental disorders and/or
dependency on other drugs are more likely to have a tobacco
addiction - about 50 to 95 percent, depending on the subgroup
(CDC, 2001)
• Smokers with mental disorders consume nearly half of all the
cigarettes sold in the United States (Lasser et al. 2000).
• A study of individuals doing well in recovery from alcohol
dependence found that those who smoked lived 12 fewer years
because of their tobacco dependence and the quality of their
lives was affected by other tobacco-caused medical illnesses
(Hurt et al. 1996).
Nicotine Dependence
• All current tobacco dependence clinical practice
guidelines strongly recommend addressing tobacco
during any clinical contact with smokers and suggest
the use of one or more of the six Food and Drug
Administration (FDA)-approved medications as first-line
treatments (e.g., bupropion SR/zyban and the nicotine
patch, gum, nasal spray, inhaler, and lozenges)
• When clients with serious mental illnesses attempt to
quit smoking, watch for changes in mental status,
medication side effects, and the need to lower some
psychiatric medication dosages due to tobacco smoke
interaction.
Mood and Anxiety Disorders and
Substance Abuse
• Approximately one quarter of United States residents are likely to have
some anxiety disorder during their lifetime, and the prevalence is higher
among women than men.
• About one half of individuals with a substance use disorder have an
affective or anxiety disorder at some time in their lives.
• Among women with a substance use disorder, mood disorders may be
prevalent. Women are more likely than men to be clinically depressed
and/or to have posttraumatic stress disorder.
Mood and Anxiety Disorders and
Substance Abuse
• Older adults may be the group at highest risk for combined mood disorder
and substance problems. Episodes of mood disturbance generally
increase in frequency with age. Older adults with concurrent mood and
substance use disorders tend to have more mood episodes as they get
older, even when their substance use is controlled.
• Both substance use and discontinuance may be associated with
depressive symptoms.
Mood and Anxiety Disorders and
Substance Abuse
• Acute manic symptoms may be induced or mimicked by intoxication with
stimulants, steroids, hallucinogens, or polydrug combinations.
• Withdrawal from depressants, opioids, and stimulants invariably includes
potent anxiety symptoms. During the first months of sobriety, many people
with substance use disorders may exhibit symptoms of depression that fade
over time and that are related to post-acute withdrawal.
• Though there may be some preference for those with depression to favor
stimulation and those with anxieties to favor sedation, there appears to be
considerable overlap. The use of alcohol, perhaps because of its availability
and legality, is ubiquitous.
Mood and Anxiety Disorders and
Substance Abuse
• It is now believed that substance use is more often a cause of anxiety
symptoms rather than an effort to cure these symptoms.
• Since mood and anxiety symptoms may result from substance use
disorders, not an underlying mental disorder, careful and continuous
assessment is essential.
Substance Abuse and PTSD
• Among clients in substance abuse treatment, PTSD is two to three
times more common in women than in men.
• 55-99% of women with substance abuse problems report a lifetime
history of physical and/or sexual abuse. (Najavits et al. 1997)
• The rate of PTSD among people with substance use disorders is 12
to 34%; for women with substance use disorders, it is 30-59%. (Brown
and Wolfe 1994).
• Clinicians are advised not to overlook the possibility of PTSD in men.
• People with PTSD and substance abuse are more likely to
experience further trauma than people with substance abuse alone.
Substance Abuse and PTSD
• Repeated trauma is common in domestic violence, child abuse, and
substance-using lifestyles, helping the client protect against future trauma
may be an important part of work in treatment.
• People with PTSD tend to abuse the most serious substances (cocaine and
opioids); abuse of other drugs is common.
• From the client's perspective, PTSD symptoms are a common trigger for
substance use.
• While under the influence of substances, a person may be more vulnerable
to trauma
• Becoming abstinent from substances does not resolve PTSD; both disorders
must be addressed in treatment.
Substance Abuse and Psychotic Disorders
• There is no clear pattern of drug choice among clients with schizophrenia.
Instead, it is likely that whatever substances happen to be available or in
vogue will be the substances used most typically.
• What looks like resistance or denial may in reality be a manifestation of
negative symptoms of schizophrenia.
• Clients with a co-occurring mental disorder involving psychosis are
particularly vulnerable to homelessness, housing instability, victimization,
poor nutrition, and inadequate financial resources.
• Both psychotic and substance use disorders are chronic, involve relapses
and remissions, supporting the need for long-term treatment.
Substance Abuse and Psychotic Disorders
• Obtain knowledge of the signs and symptoms of the disorder.
• Work closely with a mental health professional.
• Expect crises and have available resources for stabilization.
• Assist the client to obtain entitlements and social services.
• Provide psychoeducation on the illness and use of medication.
• Monitor medication and promote medication adherence
• Provide frequent breaks and shorter sessions or meetings
Substance Abuse and ADHD
• About 1/3 of adults with ADHD have histories of alcohol abuse or
dependence; about 1 in 5 has other drug abuse/dependence histories.
• Adults with ADHD primarily use alcohol, and/or marijuana.
• The client may use self-medication for ADHD as an excuse for drug use.
• The most common attention problems are secondary to short-term toxic
effects of substances, and should decrease with each month of sobriety.
• The presence of ADHD complicates substance abuse treatment, as clients
may have difficulty engaging in treatment and learning abstinence skills, be
at greater risk for relapse, and have poorer substance use outcomes.
Six Guiding Principles in Treating
Clients with COD
1. Employ a recovery perspective.
2. Adopt a multi-problem viewpoint.
3. Develop a phased approach to treatment.
4. Address specific real-life problems early in treatment.
5. Plan for cognitive and functional impairments.
6. Use support systems to maintain and extend treatment effectiveness.
Employ a recovery perspective
• This acknowledges that recovery is a long-term
process of internal change, and it recognizes that
these internal changes proceed through various
stages.
(De Leon, 1996 and Prochaska et al., 1992)
Employ a recovery perspective
The recovery perspective generates two main
principles for practice:
• Develop a treatment plan that provides for
continuity of care over time. In preparing this
plan, the clinician should recognize that treatment
may occur in different settings over time and that
much of the recovery process typically occurs
outside of or following treatment. It is important to
reinforce long-term participation in these continuous
care settings.
• Devise treatment interventions that are specific
to the tasks and challenges faced at each stage
of the co-occurring disorder recovery process.
Readiness to Change
(Prochaska and DiClemente, 1992)
• Precontemplation – raise doubt, increase client’s
perceptions of current behavior
• Contemplation – tip the balance, evoke reasons to
change and risk of not changing
• Preparation – help client to determine best action to
take in seeking change
• Action – help client take steps toward change
• Maintenance – help client to identify and use strategies
to prevent relapse
Adopt a multi-problem viewpoint
•
People with COD generally have an array of
mental health, medical, substance abuse, family, and
social problems and need re/habilitation.
•
Treatment should address immediate and
continuing care needs for housing, work, health care,
and a supportive network.
Address specific real-life problems early in
treatment.
• Requires intensive case management to help clients resolve
personal and social issues such as housing, legal problems
and family matters, as well as individual areas of need like
money management and housing-related support services.
• Psychosocial rehabilitation, which helps the client develop the
specific skills to perform chosen roles (e.g., student,
employee, community member) also is a useful strategy
(Anthony 1996)
• Engagement is a critical part of substance abuse treatment
generally and of treatment for COD specifically.
Plan for cognitive and functional
impairments.
Services must be tailored to individual needs and functioning.
Interventions relatively short, highly structured treatment
sessions focused on practical life problems.
Gradual pacing, visual aids, and repetition often are helpful.
Even more subtle problems like learning disabilities may still
impact treatment
Use support systems to enhance
recovery
The mutual self-help movement, the family, the faith
community, and other resources that exist within the
client's community can play an invaluable role in
continuing care and recovery.
Mutual Self-Help
In the past clients with COD felt that either their mental health or their
substance use issues could not be addressed in a single-themed mutual
self-help group; that has changed.
Mutual self-help principles, highly valued in the substance abuse treatment
field, are now widely recognized as important components in the treatment
of COD. Mutual self-help groups may be used as an adjunct to primary
treatment, as a continuing feature of treatment in the community, or both.
Support during outpatient treatment, but also are used commonly in
residential programs such as therapeutic communities.
As clients gain employment, travel, or relocate, mutual self-help meetings
will be the most easily accessible means for continuing care.
Reintegration with family and
community
• The client with COD who successfully completes treatment
must face the fragility of recovery, the toxicity of the past
environment, and the negative impact of old friends who may
encourage substance use and illicit or maladaptive behaviors.
• There is a need for groups and activities that support change.
In this context it is important that these clients receive support
from family and significant others where that support is
available or can be developed.
• There is also the need to help the client reintegrate into the
community through such resources as religious, recreation,
and social organizations.
“No Wrong Door to Recovery”
WRAP UP
• Questions