Transcript Co-occurring: Integrated Model

Co-occurring an Integrative
Approach
William J. Udrow Jr. PsyD, LCP, CRADC, MISA I, PCGC
Ecuador: 2012
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Co-occurring
Mental and substance use conditions often cooccur. In other words, individuals with substance
use conditions often have a mental health
condition at the same time and visa versus.
Individuals who have at least one mental disorder
as well as an alcohol or drug use disorder. While
these disorders may interact differently in any
one person (e.g., an episode of depression may
trigger a relapse into alcohol abuse, or cocaine
use may exacerbate schizophrenic symptoms),
at least one disorder of each type can be
diagnosed independently of the other. (SAMSHA, 2012)
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Co-occurring
• The term "co-occurring disorders" typically refers
to an individual having co-existing mental health
and substance use disorders. There are a
number of other terms that have been used to
describe people in this category as well,
including:
• Dually diagnosed
• MICA (mentally ill chemical abusers)
• MISA (mentally ill substance abusers)
• CAMI (chemical abuse and mental illness)
• SAMI (substance abuse and mental illness)
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Co-occurring
Some of the most common psychiatric
disorders seen in patients with co-occurring
addiction issues include.
• schizophrenia
• bipolar disorder
• borderline personality disorder
• major depression
• anxiety and mood disorders
• post traumatic stress disorder
• pathological gambling
• sexual and eating disorders
• conduct disorders
• attention deficit disorder
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Co-occurring
Clients being treated for mental health
disorders also often abuse the following
types of substances.
• alcohol
• nicotine
• opiates
• sedatives
• stimulants
• marijuana
• hallucinogens
• prescription drugs
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Co-occurring: U.S. Statistics
Serious mental illness (SMI) is strongly correlated
with illicit drug use and cigarette use. Adults with
serious mental illness were more than twice as
likely as those without serious mental illness to
use an illicit drug and to smoke cigarettes in the
past year. Among persons with serious mental
illness , 26.5 percent used an illicit drug in the
past year, while among those without serious
mental illness the rate was 10.5 percent.
Similarly, among adults with serious mental
illness , the rate of cigarette use was 44.9
percent, while among adults without serious
mental illness the rate was only 24.9 percent.
See Figure 8.3. (SAMSHA, 2008),
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Co-occurring: U.S. Statistics
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Co-occurring: U.S. Statistics
Approximately 8.9 million adults have co-occurring
disorders; that is they have both a mental and
substance use disorder. (Mental Health Advisory Team Six, 2009).
In 2002, more than half of adults with co-occurring
serious mental illness serious mental illness and
a substance use disorder (a total of 2 million
adults) received neither specialty substance use
treatment nor mental health treatment during the
past year.
(NSDUH, 2004).
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Co-occurring: U.S. Statistics
Among adults with co-occurring serious mental
illness and a substance use disorder, women
were more likely to receive mental health
treatment in the past year than men
The rate of perceived unmet need for mental
health treatment was higher than the rate of
perceived unmet need for substance use
treatment among adults with co-occurring
serious mental illness and a substance use
disorder.
(NSDUH, 2004).
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Co-occurring: U.S. Statistics
Receipt of Mental
Health or
Substance Use
Treatment in the
Past Year
among Adults
Aged 18 or
Older with CoOccurring
serious mental
illness and a
Substance Use
Disorder
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Co-occurring: Integrated Model
• Integrated treatment works
• Integrated treatment or treatment that addresses
mental and substance use conditions at the
same time is associated with lower costs and
better outcomes such as:
• Reduced substance use
• Improved psychiatric symptoms and functioning
• Decreased hospitalization
• Increased housing stability
• Fewer arrests
• Improved quality of life
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Co-occurring: Integrated Model
• Integrated treatment
Integrated treatment produces better outcomes for
individuals with co-occurring mental and
substance use disorders. Without integrated
treatment, one or both disorders may not be
addressed properly. Mental health and
substance abuse authorities across the country
are taking steps to integrate systems and
services, and promote integrated treatment.
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Co-occurring: Integrated Model
• Systems Integrated treatment
Systems integration focuses on reorganizing the
framework within which agencies and programs
operate. It includes integrated system planning,
implementation, and continuous quality
improvement including developing mechanisms
for addressing.
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Co-occurring: Integrated Model
• Services integration:
Services Integration refers to the process of merging
separate clinical services to meet the individual's
substance abuse, mental health, and other needs.
• integrated screening for mental and substance use
disorders
• integrated assessment
• integrated treatment planning
• integrated or coordinated treatment
• continuing care
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Co-occurring: Integrated Model
In the State of Connecticut the Department of
Mental Health & Addiction Services applied
the following 7 principles to their integrated
treatment in 2010:
• Integrated: The same clinician (or team of clinicians)
provides treatment for mental illnesses and substance
use disorders at the same time.
• Comprehensiveness: When needed, access to
residential services, case management, supported
employment, family psychoeducation, social skills
training, training in illness management, and
pharmacological treatment is available.
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Co-occurring: Integrated Model
• Assertiveness: Clinicians must make every effort
possible to actively engage reluctant individuals in the
process of treatment and recovery.
• Reduction of negative consequences: Reduce the
negative consequences of substance use, while
developing a good working alliance that can ultimately
help develop the motivation to address their substance
use and mental health challenges.
• Long-term perspective: Recognizing that each individual
recovers at his or her own pace, given sufficient time and
support.
• Motivation-based treatment: Interventions must be
motivation-based – that is, adapted to clients’ motivation
for change.
• Multiple psychotherapeutic modalities: Including
individual, group, and family approaches has been found
to be effective.
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Co-occurring: Evidenced Based
Treatment
Evidence-based practices are at the core of stage-wise
treatment:
From the earliest moments of the treatment process
through sustained periods of remission, integrated
treatment specialists use numerous evidence-based
tools and practices that can help make treatment a
success. Treatment includes:
• Integrated screening and assessment techniques
• Treatment planning strategies
• Motivational interviewing
• Cognitive behavioral therapy
• Peer support
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Co-occurring: Evidenced Based
Treatment
• Stage-wise treatment helps people build
meaningful lives
• Most people with co-occurring disorders want to
recover and pursue meaningful goals. For many
individuals, stage-wise treatment provides a
path to recovery—a process that can drastically
improve the quality of their lives.
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Integrated
Treatment
for Co-Occurring
Disorders
An Evidence-Based Practice
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What Are Evidence-Based
Practices?
•Services that have consistently
demonstrated their effectiveness in helping
people with mental illnesses achieve their
desired goals
•Effectiveness was established by different
people who conducted rigorous studies and
obtained similar outcomes
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Examples of Evidence-Based
Practices
– Integrated Treatment for Co-Occurring
Disorders
– Supported Employment
– Assertive Community Treatment
– Family Psycho-education
– Illness Management and Recovery
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Why Implement Evidence-Based
Practices?
•According to the President’s New Freedom
Commission on Mental Health:
State-of-the-art treatments, based on decades
of research, are not being transferred from
research to community settings
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Why Implement Evidence-Based
Practices?
•According to the President’s New Freedom
Commission on Mental Health:
If effective treatments were more efficiently
delivered through our mental health services
system . . . millions of Americans would be
more successful in school, at work, and in their
communities
—Michael Hogan, Chairman
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What Is Integrated Treatment for
Co-Occurring Disorders?
•Integrated Treatment is a research-proven
model of treatment for people with serious
mental illnesses and co-occurring substance
use disorders
•Consumers receive combined treatment for
mental illnesses and substance use disorders
from the same practitioner or treatment team.
They receive one consistent message about
treatment and recovery
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Practice Principles for Integrated
Treatment for Co-Occurring Disorders
 Mental health and
substance abuse
treatment are
integrated to meet the
needs of people with
co-occurring disorders

Co-occurring disorders
are treated in a stagewise fashion with
different services
provided at different
stages
 Integrated treatment
specialists are trained
to treat both
substance use and
serious mental
illnesses

Motivational
interventions are used to
treat consumers in all
stages,
but especially in the
persuasion stage
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Practice Principles for Integrated
Treatment for Co-Occurring
Disorders
 Substance abuse
counseling, using a
cognitive-behavioral
approach, is used to
treat consumers in the
active treatment and
relapse prevention
stages

Multiple formats for
services are available,
including individual,
group, self-help, and
family

Medication services
are integrated and
coordinated with
psychosocial services
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Treatment is Integrated
•Mental health and substance abuse treatment
are evaluated and addressed
– Same team
– Same location
– Same time
•Treatment targets the individual needs of
people with co-occurring disorders and is
integrated on organizational and clinical levels
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Treatment is in a Stage-Wise Fashion
•Precontemplation —
Engagement
•Assertive outreach,
practical help (housing,
entitlements, other), and an
introduction to individual,
family, group, and self-help
treatment formats
Action — Active treatment
Counseling and treatment
based on cognitive-behavioral
techniques, skills training,
and support from families
and self-help groups
Maintenance — Relapse
prevention continued
•Contemplation and
counseling and treatment
Preparation — Persuasion
based on relapse prevention
•Education, goal setting,
techniques, skill building, and
and building awareness of
ongoing support
problem through
to promote recovery
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motivational counseling
Integrated Treatment Recovery
Model
Hope is critical
Services and treatment goals are consumerdriven
Unconditional respect and compassion for
consumers is essential
Integrated treatment specialists are
responsible
for engaging consumers and supporting their
recovery
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Integrated Treatment Recovery
Model
•Focus on consumers’ goals and functioning, not on
adhering to treatment
•Consumer choice, shared decision making, and
consumer/family education are important
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Integrated Treatment Recovery Model
•Integrated treatment is associated with the following
positive outcomes:
– Reduced substance use
– Improvement in psychiatric symptoms and functioning;
– Decreased hospitalization
– Increased housing stability
– Fewer arrests and
– Improved quality of life
-(Drake et al.,2001)
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Summary
•Integrated Treatment for Co-Occurring Disorders is
effective in the recovery process for consumers with
co-occurring disorders
•The goal of this evidence-based practice is to
support consumers in their recovery process
•In Integrated Treatment programs, the same
practitioners, working in one setting, provide mental
health and substance abuse interventions in a
coordinated fashion
•Consumers receive one consistent message about
treatment and recovery
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Integrative Approach: Therapy
A comprehensive integrative approach when
providing therapy should including the
following at a minimum:
• Pharmacotherapy Interventions
• Cognitive behavioral interventions
• Constant reassessing symptoms and behaviors
related to both mental illness and substance
using.
• Networking within the milieu (medical staff)
• Networking outside of the milieu (community
resources/family involvements/12-step model
(MISA groups).
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Integrative Approach: Therapy
• Pharmacotherapy Interventions
Psychiatric medications can be used to rebalance
the neurochemistry of mental illness:
psychopharmacology is the primary form of
clinical treatment. Common medication therapy
will include: antidepressants/mood
stabilizers/antipsychotics and anti-anxiety
medications. (Inaba & Cohen, 2000).
Beware of addictive medication (some anti-anxiety
and pain medications) and keep psychiatrist and
other medical professions aware. Possible
“drug seeking behaviors).
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Integrative Approach: Therapy
• Cognitive behavioral interventions
Research has generally confirmed that a
combination of cognitive-behavior therapy and
pharmacotherapy is somewhat better than either
modality alone (especially for patients with
severe or chronic depression) and that
cognitive-behavior therapy is associated with a
lower risk for relapse than is pharmacotherapy.
(Gloaguen,1998).
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Integrative Approach: Therapy
• Constant reassessing symptoms and
behaviors related to both mental illness and
substance using.
Each session the therapist/clinician needs to
assess symptoms related to both psychiatric and
substance using behaviors: “how are the
medications working? How are the voices?
Difficulty with sleep? Have you used any
substance since our last session?” Once
symptoms and behaviors are reported as stable
therapy can be progress.
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Integrative Approach: Therapy
• Networking within the milieu (medical staff).
Psychiatrist and nurses are trained to manage
symptoms. Also the training of a psychiatrist
usually involves a minimum of chemical
dependence knowledge.
When a consumer presents with symptoms that
may resemble a diagnostic disorder the
consumer may be detoxing, experiencing PAWS
and/or just drug seeking. Therefore, staffing
with psychiatrist, nurses and other healthcare
professional is demonstrating a integrative
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approach.
Integrative Approach: Therapy
• Networking outside of the milieu (community
resources/family involvements/12-step model
(MISA groups).
Evidence based supportive employment can
enhance an consumers self-esteem.
Family involvement in therapy with pschoeducation is valuable and evidenced based.
12-Step groups use cognitive behavior approaches
to remaining substance free.
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Reference
DMHAS Co-Occurring Enhanced Program Guidelines(2009).
http://www.ct.gov/dmhas/lib/dmhas/cosig/CODenhancedguidelines.pdf
Gloaguen, V., Cottraux. J., Cucherate, M., & Blackburn, I. M. (1998). A meta-analysis of
the effects of
cognitive therapy in depressed patients. Journal of Affective Disorders, 49, 59-72.
Inaba, S. D. & Cohen, E. W. (2000). Uppers, Downers, All Arounders:
Physical and Mental Effects of Psychoactive Drugs. Oregon: CNS
Publications, Inc.
Mental Health Advisory Team Six. (2009). Operation Iraqi Freedom 07-09. Washington,
DC: Office of the Surgeon, Multi-National Corps-Iraq & Office of the Surgeon
General, United States Army Medical Command.
National Survey on Drug Use and Health (NSDUH, 2004). Adults with Co-Occurring
Serious Mental Illness and a Substance Use Disorder.
SAMSHA, (2008), Chapter 8: Prevalence and Treatment of Mental Health Problems
http://www.samhsa.gov/data/nhsda/2k1nhsda/vol1/Chapter8.htm
Substance Abuse and Mental Health Services Administration (SAMHSA, 2012). About
Co-Occurring: http://www.samhsa.gov/co-occurring/
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