Transcript Bridging the Gap between 12-Step Recovery and Dual Disorders

Bridging the Gap between 12Step Recovery & Co-Occurring
Disorders Treatment
James Gamache, MSW, MLADC
Gordon Woods, ACT Care Manager
NH Behavioral Health Conference
Oct 27th & Oct 28th, 2016
www.westbridge.org
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ICE BREAKER
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Show of Hands
 Mental
Health Field
 Addiction Field
 Co-Occurring Disorder Field
 Medical Field
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TREATMENT PROVIDER
MYTHS
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Co-Occurring Disorder Treatment Myths
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Myths
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Talking about spirituality makes people
symptomatic
Substance use disorders are caused by lack of
willpower or moral failure
Working with people who struggle with
substance use disorders will never get better
Medications will help those with mental illness
but not with substance use disorders
www.westbridge.org
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Co-Occurring Disorder Treatment Myths
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Myths
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People with Co-Occurring Disorders do not
benefit from 12 step support groups
People who struggle with Co-Occurring disorders
are referred to as the hopeless cases.
Symptoms of substance use disorders are viewed
as choices vs symptoms of mental illness are not
It’s the families fault
www.westbridge.org
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Co-Occurring Disorder Treatment Myths
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Misconceptions
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Primary vs Secondary illness
Sobriety must come first
If you don’t talk about it, it does not exist
Misunderstandings of 12 step recovery
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Medication
Religious or cultish
Attendance is temporary
Need abstinence to attend 12 step meetings
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Quadrant Model for Co-Occurring
Disorders
Substance Abuse
HI
Lo
III
IV
I
II
Lo
HI
Mental Illness
Department of Psychiatry, Dartmouth Medical School, McGovern MP, Clark RE, Samnaliev M.
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Quadrant Model for Co-Occurring
Disorders
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The 4 Quadrants Are:
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Quadrant 1 – Less severe substance use disorder and
less severe mental health disorder
Quadrant 2 – More serious mental health disorder and
less severe substance use disorder
Quadrant 3 – More serious substance use disorder and
less severe mental health disorder
Quadrant 4 – Severe mental health disorder and severe
substance use disorder
Department of Psychiatry, Dartmouth Medical School, McGovern MP, Clark RE, Samnaliev M.
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Quadrant Model for Co-Occurring
Disorders
Substance Abuse and Mental Health Services Administration. Substance Abuse Treatment for Persons With Cooccurring Disorders. Treatment Improvement Protocol (TIP) Series, No. 42. HHS Publication No. (SMA) 133992.
Rockville, MD
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Barriers to Accessing
12-Step Support
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Barriers for Treatment Providers
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Philosophical differences
 Medical model vs. recovery/spiritual model
Stigma
Staff education within colleges and the
profession
Medication bias in some self help groups
Parallel Treatment
 Medications vs. Abstinence
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Barriers for Individuals
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Social anxiety which increases symptoms
Too many people in a small room
Lack of transportation
Support can be annoying
Many 12 step meetings happen in churches
Fear that meetings are a cult
Sponsor sponsee relationship
Many meetings occur in the evening
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TREATMENT THAT IS NOT
EFFECTIVE FOR
CO-OCCURRING DISORDERS
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Traditional Treatment Models
Addiction Treatment
Mental Health Treatment
Peer Counselor Model
Medical/professional model
Spiritual Recovery
Scientific treatment
Self-help
Medication
Confrontation & Expectation
Support & flexibility
Detachment/Empowerment
Case management/care
Episodic treatment
Continuous treatment
Recovery ideology
Deinstitutionalization ideology
View of psychopathology as
secondary to addiction
View of addiction as secondary to
psychopathology
Muser, Kim; Noordsy, Doug; Drake, Robert; Fox, Lindy. Integrated Treatment for Dual Disorders, A Guide
to Effective Practice. The Guilford Press. New York. 2003.
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Treatment Approaches
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Sequential
The untreated disorder worsens the treated disorder,
making it impossible to stabilize one without
attending to the other.
There is a lack of agreement as to which disorder
should be treated first.
It is unclear when one disorder has been successfully
treated” so that treatment of the other disorder can
commence.
The client is not referred for further treatment.
Muser, Kim; Noordsy, Doug; Drake, Robert; Fox, Lindy. Integrated Treatment for Dual Disorders, A Guide to Effective Practice. The
Guilford Press. New York. 2003.
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Treatment Approaches
Parallel
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Mental health and substance abuse treatment are not
integrated into a cohesive treatment package.
Treatment providers fail to communicate with each other.
Burden of integration falls on the client and family.
Funding and eligibility barriers to accessing both
treatments still exist.
Different providers have incompatible treatment
philosophies.
A client “slips between the cracks” and receives no
services due to failure of either treatment provider to
accept final responsibility for the client.
Providers lack a common language and treatment
methodology
Muser, Kim; Noordsy, Doug; Drake, Robert; Fox, Lindy. Integrated Treatment for Dual Disorders, A Guide to Effective Practice. The Guilford Press. New York. 17
2003.
Treatment That Has Been Proven
to Work
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Integrated Co-Occurring Disorders
Treatment
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Mental health and substance abuse services are
provided by the same team.
Collaborates with Participants
Both disorders are considered primary.
Conflict is minimized when MI & SA professionals
work together on a team.
The integration of smoking cessation
Diet, exercise, sleep and other wellness activities are
incorporated
Maximize funding.
Improved outcomes.
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Muser, Kim; Noordsy, Doug; Drake, Robert; Fox, Lindy. Integrated Treatment for Dual Disorders, A Guide to Effective Practice. The Guilford Press. New York. 2003.
Evidenced Based Practices
for Co-occurring Disorders
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Assertive Case Management (ACT/CTT/PACT)
Integrated Dual Disordered Treatment
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Motivational Interviewing
Cognitive Behavioral Therapy
Contingency Management
Stages of Change
Family Education & Support
Individual Placement & Support “Vocational Support”
Illness Management & Recovery
Medication Management
Wellness Management
WestBridge Community Services
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Evidence Based Practice
Assertive Community Treatment
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Assertive Community Treatment is
Characterized by:
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Team approach
In vivo services
Time unlimited services
Flexible service delivery
24/7 crisis availability
Small caseload
Shared caseload
Fixed point of responsibility
Muser, Kim; Noordsy, Doug; Drake, Robert; Fox, Lindy. Integrated Treatment for Dual Disorders, A Guide to Effective Practice. The Guilford
Press. New York. 2003.
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Mutual Help in the Community
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Peer Support
Recovery Groups
Family and Friends
Faith based support groups
12 – Step Groups
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Peer Support
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In general, a peer specialist is an individual
who has made a personal commitment to his
or her own recovery, has maintained that
recovery over a period of time, has taken
special training to work with others, and is
willing to share what he or she has learned
about recovery in an inspirational way.
National Association of Peer Specialists
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Recovery Groups
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Bipolar Support Groups
Schizophrenia Support Groups
Depression Support Groups
DDA
NAMI
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In Our Own Voice
Family to Family
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Family and Friends
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There are higher rates of
recovery and wellness when
family and friends are part of the
solution not part of the problem.
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Faith Based Groups
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Alcoholics for Christ
Alcoholics Victorious
Celebrate Recovery
Christians United Against Addiction
Free in One
Jewish Alcoholics, Chemically Dependent
Persons and Significant Others (JACS)
The Spiritual River
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12 Step Support Groups
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Alcoholics Anonymous
Cocaine Anonymous
Narcotics Anonymous
Gamblers Anonymous
Dual Recovery Anonymous
Emotional Health Anonymous
Debtors Anonymous
Nicotine Anonymous
All Addictions Anonymous
Chemically Dependent Anonymous
Crystal Meth Anonymous
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Dual Diagnosis Anonymous
Heroin Anonymous
Marijuana Anonymous
Methadone Anonymous
Pills Anonymous
Prescription Anonymous
Recoveries Anonymous
Bettors Anonymous
Bloggers Anonymous
Clutterers Anonymous
Emotions Anonymous
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The Gap Between Co-Occurring Disorders
Treatment and 12 Step Recovery Groups
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AA is not therapy/therapy is not AA
“A body badly burned by alcohol does not often recover
overnight nor do twisted thinking and depression vanish in a
twinkling…… But this does not mean that we disregard
human health measures. God has abundantly supplied this
world with fine doctors, psychologists and practitioners of
various kind. Do not hesitate to take your health problems to
such persons. ….. We should never belittle a good doctor or
psychiatrist. Their services are indispensable in treating a
newcomer and in following his case afterwards”.
The AA Member – Medications and Other Drugs
Alcoholics Anonymous Big Book, Alcoholics Anonymous World Services, Inc. New York City 1976.chapter 9 page 133.
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Comparing AA and Treatment
Chapter 7 Working With Others
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“Don’t start out as an evangelist or reformer”
Start with person’s perception
“…find out all you can about him”
Do a thorough assessment
“…never force yourself upon him”
Respect, empathy
“Be careful not to brand him as an alcoholic. Let him draw his own conclusions.”
Don’t label and Stages of Change
Talk about the conditions of body and mind which accompany alcoholism.
Educate about the disease model
Make clear that he is under no pressure, that he needn’t see you again if he doesn’t
want to.
Give Choices
Your candidate may give reason why he need not follow all of the program…Do
not contradict such views.
Roll with Resistance, avoid one size fits all
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Alcoholics Anonymous, Alcoholics Anonymous World Services, Inc. New York City 1976. pages 89-94
WestBridge’s Model
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Outreach to recovery community
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Outreach to individuals
Outreach to district meetings
Outreach to local meetings
Orientation to Alcoholics Anonymous
meetings and principles
Provide Support to attend meetings
Encourage participants to contribute to the
meetings
WestBridge
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Outreach to Recovery Community
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Attend local business and district meetings to
advocate for people with Co-Occurring Disorders
Get speakers to come in to share at the residential or
outpatient programs
Invite people active in the 12 Step community for
meals and social events
Hire staff who are qualified and also in recovery to
assist in making connections/developing sober
relationships within the 12 step community
Recovery Dinner acknowledges peoples length of
sobriety and invite others in recovery to attend
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Alcoholics Anonymous Orientation
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Expose people to Big Book meetings, speaker discussion
meetings & speaker meetings
Provide 12 step materials
Educate people about the 12 steps & focus on Steps 1,2,3
Attend functions such as sober dances, music festivals
anniversaries, boat cruises, camping trips and conventions
that are sponsored by 12 step groups
Attend meetings prior to supporting participants in
attending
Open conversations that parallel recovery while engaging
in community activities (example soccer, cooking group
and connections)
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WestBridge’s Model
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We have staff who guide in the sponsor
selection “explore characteristics”
We provide education on sponsorship, 12
steps and 12 traditions, types of 12 step
meetings.
We provide support in attending all types of
self-help meetings
Staff modeling active participation
Hire staff who are qualified but are also in
recovery
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WestBridge’s Model
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Monthly mentor and participant meetings to
discuss what going on in the 12 step
community
Inviting members of the recovery community
to attend dinners
Support AA field trips
Alumni supported recovery events
Support fellowship after meetings
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Use of 12 Step Groups with Stages of Change
Model
Stage Appropriate
Pre-contemplation: Attend some open 12 step meetings, 12 step functions and literature are used
provide education and develop awareness
Contemplation: Attend open 12 step meetings, 12 step functions and literature are used to educate,
build identification and ambivalence and to making a decision to be sober/manage symptoms
Preparation: A decision to change has been made and the person demonstrates his/her commitment by
going to open and closed 12 step meetings, obtaining sponsorship, going to 12 step functions verbalizes a
commitment to take action, learning new skills, obtaining a temporary sponsor, discussion of Steps 1–3
with the sponsor and hearing statements of struggling with alcoholism in a meeting
Action: The person is sober, stable and continues to go to meetings, has sponsor, joined a 12 step
group and has made significant lifestyle changes, working the steps under guidance of sponsor,
obtaining 12 step home group, helping set up, clean up, and chair home group meeting and going
out on commitments
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Connors, G., DiClemente, C. C., Velasquez, M., & Donovan, D. (2012). Substance Abuse Treatment and the Stages of Change (Second Edition). Guilford Press.
Support for Mutual Help
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Stages of Change Model
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Pre-contemplation: Increase Awareness
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Size and Type of meeting is important
Staff support
Debrief after the meeting
Contemplation: Increase Ambivalence/Decision Making
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Size and Type of meeting is important
Staff support
Debrief the meeting with the focus on what the person
could identify with and feelings that were evoked.
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Support for Mutual Help
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Preparation: Made a decision, doing the leg work
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Size and type of meeting
Role of sponsor, service work, fellowship
Begin Step Work
May need support: staff or sober supports
Action: lifestyle changes, abstinent
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Encouragement and celebrate milestones
May need support: staff or sober supports
Working the steps with sponsor or counselor
Reinforce service work
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Community Resources
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Support Groups
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Google for what is available near you
There are also apps available for download
Provide support in attending the meetings
12 Step Groups
Faith Based support groups
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NH Community Resources
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Alcoholics Anonymous
Narcotics Anonymous
Double Trouble in Recovery
Dual Diagnosis Anonymous
Dual Recovery Anonymous
Smart Recovery
Dharma Punx’s
Celebrate Recovery
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Alcoholics Anonymous
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12 step self help model that has been around
since 1935
There are over 760 meetings that occur in NH
on a weekly basis
www.aa.org
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Narcotics Anonymous
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12 step concepts derived from Alcoholics
Anonymous and has been around since 1953
There are over 80 meetings that occur in NH
on a weekly basis
www.narcoticsanonymous.org
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Double Trouble in Recovery
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Provides 12 Steps that are similar to AA’s 12
Steps.
Membership
The organization provides a format for
meetings that are chaired by members
www.doubletroubleinrecovery.org
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Dual Diagnosis Anonymous
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Since 1996, the DDA peer support group offers
sessions in most of the western states, including
Hawaii, and in other countries such as Great Britain
and Canada.
The program is based on the 12 steps of Alcoholics
Anonymous with an additional five steps that focus
on Dual Diagnosis (mental illness and substance
abuse).
www.ddaws.com
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Dual Recovery Anonymous
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Dual Recovery Anonymous™ is a 12 Step self-help program that is based
on the principals of the Twelve Steps and the experiences of men and
women in recovery with a dual diagnosis. The DRA program helps us
recover from both our chemical dependency and our emotional or
psychiatric illness by focusing on relapse prevention and actively
improving the quality of our lives. In a community of mutual support, we
learn to avoid the risks that lead back to alcohol and drug use as well as
reducing the symptoms of our emotional or psychiatric illness.
There are only two requirements for membership:
A desire to stop using alcohol or other intoxicating drugs.
A desire to manage our emotional or psychiatric illness in a healthy and
constructive way.
www.dualrecovery.org
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SMART Recovery
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Advocates the appropriate use of prescribed
medications and psychological treatments.
Works on substance abuse, alcohol abuse, addiction
and drug abuse as complex maladaptive behaviors with
possible physiological factors.
Evolves as scientific knowledge in addiction recovery
evolves.
Differs from Alcoholics Anonymous, Narcotics
Anonymous and other 12-step programs
www.smartrecovery.org
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Dharma Punks
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Is a Buddhist path of addiction recovery that uses a
mindfulness-based approach. Levine says it is about
"creating a reliable internal wisdom and compassion
refuge" through personal efforts.
According to Levine, there are about 200 meetings
across the country where participants "meditate, tell
some dopey war stories" and "focus on the solution,
through your own efforts, training your mind and
supporting each other, and making amends."
www.hopefornhrecovery.org
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Celebrate Recovery
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Celebrate Recovery is a biblically balanced
12-Step program that helps people to deal
with their hurts, habits and hang-ups and
move towards healing while seeking God’s
best for their lives.
www.manchesterchristian.com
www.centerpointnh.org
www.celebraterecovery.com
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National Alliance of the Mentally
Ill
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Education
Support
Advocacy
Research
www.nami.org
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What We Have Learned
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Marathon not a Sprint
 People often experience episodes of illness with
lengthening periods of recovery.
Relapses in either substance abuse or mental illness
are opportunities to develop insight and learn new
skills.
Patience
Understanding of illness
 Brain Disease
 Negative Symptoms
 Trauma
 Role of substances
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What We Have Learned
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Developmental stage
 Emotional maturity
Pain management
 Providing alternative treatment methods
Wellness initiatives
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Living independently
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Sleep, exercise, nutrition, meditation and medication
management, smoking cessation
ADL support
Vocational support
 Work, school and volunteer opportunities
Hire staff who are qualified but also in recovery
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What We Have Learned
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12 Step/Mutual Help Community
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We need to educate clients about the various types of
12 step and mutual help meetings “what their options
are”
We need to invest time to support clients in getting
connected
We need to educate the 12 step communities because
they don’t know what they don’t know
We need to incorporate conversations about the
recovery community in all the work that we do
Conversations are the key to success
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Julian
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What is Julian’s perspective?
What is Julian’s message?
What’s your take away ?
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Theo
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What is Theo’s perspective?
What is Theo’s message?
What’s your take away ?
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Thank You!
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