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Integrated Dual Disorders

Treatment (IDDT)

Mental Health and

Substance AbuseBy Judith Magnon RN-BC, BS, CAC

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Conflict of interest note:

This presenter has no conflict of interest, commercial support,

or off label use to

disclose.

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Learning Objectives:

Gap: Skill-How to deliver integrated mental health and substance abuse treatment to individuals with serious mental health disorders and substance abuse disorders in the community.

Cite the evidence supporting the integration of mental health and substance abuse services for people with co-occurring disorders in the community

Cite mental health nursing practices/processes that will blend in to IDDT (Integrated Dual Disorder Treatment) model of care

Cite substance abuse skills that need to be incorporated into IDDT nursing practice

Cite examples of nursing practices that can effectively incorporate Stages of Change to support IDDT

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Person comes into ER with a broken leg

Do we assess the other leg to see if it is broken? Why?

Do we ask which one broke first?If both are broken, do we wait for one to

heal before treating the other?Do we send them to another doctor and

hospital to treat the second broken leg.

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Best Practice Interventions:

IDDT (Integrated Dual Disorders Treatment) PACT (Program of Assertive Community

Treatment) Psychopharmacological interventions Supportive Employment Supported Housing

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Best Practice Interventions:

Stage of Change/Motivational Interviewing CBT (Cognitive Behavioral Therapy) DBT (Dialectical Behavioral Therapy) IMR (Illness Management & Recovery) FES (Family Education and Support)

by Lindy Fox Smith & Kim Musser

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Co-Occurring Disorders

Why Focus on C0-Occurring Disorders? SA is most common co-occurring

disorder in people with MI Negative Outcomes:

More relapses Demoralization Repeated Hospitalization Violent behaviors

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Co-Occurring Disorders

MH/Psychiatric Disorders and

Substance Abuse are both Brain Disorders.Both effect Dopamine

And Serotonin

functioning in the nerve cells.

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Prevalence of Substance Abuse Disorders with

SMI

Regular Marijuana use

Other drug use

Binge drinking(4+ drinks

at one sitting)

Tobacco:

Regular use

General Population

18% 12% 8% 33%

Severe Mental Illness

50% 50% 30% 75%

1/3/14 SA News; Washington Un. School of Medicine

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PARALLELS: Psychosis and Addiction By Dr. Ken MinkoffAddiction Disease Major MI Disease

1. A biological illness

1. A biological illness

2. Hereditary (In part)

2. Hereditary (In part)

3. Chronicity 3. Chronicity

4. Incurable 4. Incurable

5. Leads to lack of control of behavior & emotions

5. Leads to lack of control of behavior & emotions

6. Affects the whole family

6. Affects the whole family

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PARALLELS: Psychosis and Addiction By Dr. Ken Minkoff

Addiction Disease Major MI Disease

7. Symptoms can be controlled with proper treatment

7. Symptoms can be controlled with proper treatment

8. Progression of the disease without treatment

8. Progression of the disease without treatment

9. Disease of denial 9. Disease of denial

10. Facing the disease can lead to depression and despair

10. Facing the disease can lead to depression and despair

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Addiction Disease Major MI Disease

11. Disease is often seen as a “Moral” issue, due to personal weakness rather than biological causes

11. Disease is often seen as a “Moral” issue, due to personal weakness rather than biological causes

12. Feelings of guilt and failure

12. Feelings of guilt and failure

13. Feelings of shame and stigma

13. Feelings of shame and stigma

Physical, mental, and spiritual disease

Physical, mental, and spiritual disease

PARALLELS: Psychosis and Addiction By Dr. Ken

Minkoff

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Parallels--Recovery By Dr. Ken Minkoff

1. First phase is acute stabilization with medication

(Detox/antipsychotic) 2. First phase often requires

hospitalization 3. Following acute

stabilization, next phases are prolonged stabilization and rehabilitation.

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Parallels--Recovery By Dr. Ken Minkoff

4. a. A prerequisite for rehabilitation is maintaining stabilization by following a long term program: “Don’t drink”…, Go to meetings, read

literature, etc. Take meds, attend groups, see CM/Dr.,

etc.

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Parallels--Recovery By Dr. Ken Minkoff

4. b. Once stabilization has been maintained long enough (usually 1 year) growth and rehabilitation can occur.

5. Person must overcome Denial/Disbelief.

6. Person must acknowledge powerlessness over the disease

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Parallels—Recovery By Dr. Ken Minkoff

7. Person must ask for help from a power greater than themselves to control symptoms (Higher Power, AA/NA, Therapist, Meds, etc.)

8. Recovery proceeds one day at a time through increasing acceptance of one’s illness and gradually learns better coping skills to cope with daily reality.

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Parallels—Recovery By Dr. Ken Minkoff

9. Recovery is never “complete”, but slow, gradual progress can be

made. 10.Risk of relapse is always present—

need help over time. 11.Family must also be involved in a

program to get help dealing with the disease.

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Parallels—Recovery By Dr.

Ken Minkoff

12.Education about the disease is an important component.

13.Treatment must focus on feelings about the disease, and feeling

good about oneself with a disease.

14.Ultimately, recovery is a physical, mental, and spiritual process.

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BIOLOGICAL COMPONENTS

Impaired brain chemistry effects the metabolism of substances, resulting in loss of control, abuse, and/or dependence.

Dopamine receptors are effected by alcohol/drug use and this is the same area effected by psychotropic medication. (and Caffeine & Nicotine)

HELP

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Often persons with severe mental illness will have a lower tolerance to the effects of substances due to the changes in brain chemistry.

Their pattern of use does lead to the same outcomes as a “heavy” user.

BIOLOGICAL---

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PSYCHOLOGICAL

THE PERSON IS AWARE OF OR HAS BEEN TOLD HOW CONTINUED USE IMPACTS:

PSYCHIATRIC SYMPTOMS

RELATIONSHIPS

SOCIAL ACTIVITIES

PHYSICAL HEALTH

VOCATIONAL ACTIVITIES

QUALITY OF LIFE

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Frequently missing work or drop in productivity rate;

Sudden appearance or increase in psychiatric symptoms;

Isolation, paranoia, delusions, lethargy, incoherent speech,

Hostility, angry outbursts, hallucinations, poor concentration,

Poor judgment, etc. due to not taking meds as prescribed)

Physical symptoms—weight loss (esp. with cocaine use), poor hygiene,

PSYCHOLOGICAL ---

RESULTING BEHAVIORS:

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Withdrawal symptoms

Spending all their time with known S.A. users;

Selling possessions for alcohol or drugs (including food, furniture, TV’s—theirs or others)

Shoplifting items to sell or over the counter meds (benedryl, actifed, sudifed, sleeping pills)

“Pan handling” or intimidating others for money to buy alcohol or drugs;

PSYCHOLOGICAL---

RESULTING BEHAVIORS:

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Prostituting, dealing or “running” drugs to support alcohol/drug use;

Seeking hospitalization or visiting the ER to obtain meds;

Moving to a new “catchment area” as part of drug seeking activity.

Their housing can be very unstable—evictions, moving from one place to another, live with family, live at the shelter.

PSYCHOLOGICAL ---

RESULTING BEHAVIORS:

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He/she is at a higher risk for victimization—rape, assaults, “robbed” by using peers (both money and possessions).

He/she have already been victimized by adults as children—Sexual abuse, physical abuse, emotional abuse.

He/she have adults (case manager, psychiatrist, family members, group members, community members) pointing out their use and the negative consequences.

PSYCHOLOGICAL--

RESULTING BEHAVIORS:

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He/she have a higher suicide rate and death rate.

He/she may have Axis II diagnosis as well as other Axis I diagnosis.

PSYCHOLOGICAL---

RESULTING BEHAVIORS:

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History of IDDT 1980’s Dr Robert Drake looked for model

to address both disorders & picks PACT. Did research for over 10 years using

PACT model as core and added other treatment strategies. Many of the team leaders were MH nurses.

Has now been replicated around the world.

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PACT MODEL Developed in 1972 by Arnold Marx,

Leonard Stein, & Mary Ann Test in WI

For SPMI(Severe and Persistent Mental Illness) population (Schizophrenia, BP, SA)

Community based, multidisciplinary team, 24 hour coverage

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PACT MODEL Mental Health Team = ACT Team

Function interchangeably Community based Provide basic living skills education

& assistance Assimilation of community

resources Assertive approach to decrease

dropout

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Mission of ACT Teams

•Keep the person in the community--Out of the hospital, Crisis Units, Jails, etc.

•Get them back to or to WORK--

PAID Employment, or Volunteering and/or to School [Independent]

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Mission of ACT Teams

Diminish the family’s burden of providing care & increase independence

Foster a productive community memberIncrease wellnessDecrease stigma

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• Communication is the core of relationship building

• The Mental Health Nurse’s knowledge and ability to communicate is a critical component of the IDDT model of care.

• Being able to engage, connect and educate patients/clients/participants, families, team members, and community members changes lives and fosters recovery.

Nursing Practice:

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Nursing Practice: Collaboration

In community based mental health nursing, one of the major goals is community integration.

Working with families, PCP, dentist, ophthalmologist, employers, volunteer programs, landlords, 12 step programs, other treatment providers, lawyers, law enforcement, etc, requires a well skilled MH nurse.

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PACT MODEL KEY FACTORS:

Supportive relationship between person & Team

Team carries & inspires HOPE for person through its resourcefulness and innovation in service provision

Not typical Case-management model that refers & links

PACT Team works collaboratively to deliver most of the services required by each person, based on the following principles:

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PACT PRINCIPLES 1. Primary provider of

services/Fixed point of responsibility Responsible for providing most

educational & support services needed to live successfully in the community

Person & family receive response from familiar team member, which eliminates gaps & fragmentation

[ Nursing skills: education, communication]

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PACT PRINCIPLES 2. Services provided out of office

(75%) Key element is mobility Services in the community, home,

employment & recreational sites Able to implement individualized

recovery plan Person can immediately see what works

in their surroundings[ Nursing skills: Assessment & TX Planning]

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PACT PRINCIPLES 3. Highly individualized services to the

person Get to know the person & family & others

to effectively customize interventions and services that address current needs & preferences

Individualized type of services, frequency and amount of support

[ Nursing skills: relationship building, communication, providing service/care, goal setting]

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PACT PRINCIPLES 4. An Assertive approach

Do “whatever it takes” to help meet needs & Goals

Team adapts to person & environment to be more effective in providing services, versus requiring the person to adapt to external treatment program

[Nursing skills: implement, revaluate, develop new plan, implement, holistic approach, etc]

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PACT PRINCIPLES 5. Continuous Long-term services

Teach person how to deal with the pattern of symptoms and impairments their illness presents in their lives

Model provides a continuous system of care with ability to provide services based on needs at any point along the continuum

Results in effective rehabilitation[Nursing skills: Educate, communication,

variety of knowledge]

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THE ACT TEAM MEMBERS

Psychiatrist, Social Workers, Nurses, Mental health staff, SA Staff, Support Staff

Knowledge of Vocational Rehabilitation, Mental Illness, sexual abuse, Substance Abuse, Trauma informed care, etc

Coverage—24 hours/365 days with use of on-call system

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IDDT

ACT Integrated Dual Disorders Treatment

Assertive Community Treatment

OVERLAP OF THE MODELS

Focus is on developing motivation for treatment using Stage Wise interventions VS on SX Management & everyday problems;

Based on: Recovery thinking, individual choice, shared decision making, and the individual drives TX. ACT & IDDT equals addressing all

areas.

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IDDT—Evidenced Based Model (Dr. Robert Drake & team at DPRC)

Treating the Mental Health AND Substance Abuse at the same time with in the ACT Team based on PACT model of care.

Using Stages of Change & Motivational Interviewing interventions for the purpose of reducing mental health symptoms and a long range goal of abstinence. Supports ACT outcomes. Is a recovery based model of care.

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Co-Occurring Disorder (S) IDDT

Schizophrenia, Bipolar Disorder, Schizoaffective Disorder

Substance Abuse/Dependence Disorder

Anxiety Disorders/OCD Personality Disorder

Medical Conditions

Developmental Disorders, Learning disabilities

PTSD issues—Physical/Sexual/Emotional abuse trauma issues

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IDDT GOALS • Assisting the individual in developing the motivation for treatment and the establishment of goals that are meaningful to the person.

• Decrease risk of suicide• Stabilize acute psychotic symptoms• Reduce likelihood of relapse of MH & SA SX and

rehospitalization• Ensure appropriate individualized treatment

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•Decrease alcohol/substance abuse

•Increase overall wellness

•Reduce stress and burden on families

•Begin rehabilitation

Overall Treatment Goals

continued

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IDDTBASED ON Recovery

Thinking

The person’s illness(s) is not all they are.

(EXAMPLE—Judy is a person who experiences Schizophrenia instead of Judy is Schizophrenic.) (Just like experiencing Diabetes)

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IDDTBASED ON Recovery

ThinkingThe person is a partner in the treatment process and

The provider is a guide with knowledge and experience to share, discuss, educate, explore, coach, advise, assist, encourage, negotiate, role model, validate, etc.

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IDDTBASED ON Recovery Thinking, Nursing

practice should incorporate the following:

EXPECT THEY WILL IMPROVE/RECOVER!!!!!!!!!!!

Celebrate the successes, no matter how small,

Use positive language in meetings and in day to day job tasks to practice the recovery way of thinking,

EMPOWERMENT: Offer choices, clarify they have the power to make choices/decisions,

You are offering tools, and they can choose to use them or not. You hope they will, but you respect their choice to not be ready yet.

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IDDTBASED ON Recovery Thinking,

Nursing practice should incorporate the following:

No matter what level of illness—Expect that they can participate at some point in “Meaningful Day time Activity”

WORK is Therapy!!!!!!

They do not have to be sober to work. (Clinical evidence shows that some people will stop using to keep a job!)

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IDDTBASED ON Recovery Thinking, Nursing

practice should incorporate the following:

Ask about their hopes, dreams, wishes.

Encourage and value their input and feedback.

Explore and help resolve barriers to treatment (Childcare, transportation, etc.)

Explore what natural support network is available and self help groups are being used or may be used.

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IDDTBASED ON Recovery Thinking, Nursing

practice should incorporate the following:

Explore about connections to the faith community and consider the importance of faith to the persons recovery.

Explore what signs the individual would look for that are indicative that they no longer need your assistance.

Consider the role culture may play in this person’s life and its influence on language, faith, family and the person.

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Differences in the models ACT: More concrete & itemized with lists

of tasks “Doing for” (I.e. To Dr’s, med

drops. Etc)

IDDT: More theoretical, harder to put into

place, harder to conceptualize, more recovery-oriented, may take more skill (MI, IDDT counseling, CBT, etc)

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WHY integrate these two models??

The Stage wise interventions reduce staff frustration as using the right intervention at the right time enhances the therapeutic relationship and decreases resistance

Outcomes improve Hope increases and active

participation/partnering in treatment occurs

Recovery gives the gift of a new life to people served

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INTEGRATED MODEL Focus of service delivery changes

from treating the disorderto

Treating the whole person Development of the person’s strengths becomes the road to overcoming the limitations of the illness and to recovery

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NUSING PROCESS that blend into IDDT

Providing an environment conductive to communication

Involve family/significant other(s) Obtain a multidimensional history with

current & past problems Complete multiple assessments Assessments lead to nursing diagnosis

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NURSING PROCESS that blend into IDDT

Assessments & Diagnosis results in: Structured Care Planning

Identifying contributing factors and behavioral symptoms leads to development of short and long term goals

Carrying out selected interventions Evaluating the outcome or effectiveness of those

interventions Adjusting the care plans

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FIRST INTERVENTIONS:

ENGAGEMENT RELATIONSHIP BUILDING

Without a relationship,

no treatment will happen and no positive outcomes!

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INTERVENTIONS: Individual Supportive

Treatment Reality Based Here and Now Discussion of negative consequences of Mental Illness, Substance Abuse, Medical issues, etc. in non-confrontational way

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INTERVENTIONS: Crisis Interventions Substance Abuse Treatment--

IDDT Individual/Group Treatment AA/Smart Recovery/Co-Occurring

Disorders meetings S. A. Education Stages of Change Model

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INTERVENTIONS Psychopharmacologic Treatment

Medications

Med EducationSetting up Med PlannersMedication MonitoringCoordinating Meds from PCPWorking with local Pharmacy(s)CLOZARIL coordination

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INTERVENTIONS Rehabilitation:

Behavioral/Functional Skill Building Education

(Budget skills, Communication skills, Leisure skills, Social skills, Vocational skills, ADL skills,Community Integration skills, etc.)

Communication

Skills

Social Skills

Budgeting Skills

VOC Skills

ADL Skills

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INTERVENTIONS Supportive Employment

Assistance with Résumé Assistance with job interviews Assistance with job skills (staying on

task, keeping a schedule, accepting constructive criticism, communicating with peers & supervisor, etc.)

[ Nursing skills: Education, Assessment, TX planning, Collaboration, skill building, commitment]

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INTERVENTIONS Supported Housing

Team works with landlord & family Payment made by others when

necessary, such as family, payeeship

In home assistance with ADL’s—cooking, shopping, cleaning, budgeting

Assessment of social contacts[ Nursing skills: Education, Assessment, TX

planning, Collaboration, skill building, commitment]

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INTERVENTIONS Collaboration with

Families/Significant others Collaboration with Guardian, PCP,

dentist, lawyers, probation or parole officer, landlords, employers, etc.

Collaboration with other providers (Hospitals, Crisis units, SA providers)

[ Requires good Communication Skills!]

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INTERVENTIONS Provide transportation:

Rides to work until comfortable with public transportation system

Dr. appointments (until clinically appropriate, individuals have to have staff with them)

Grocery shopping trips (Assist with healthy choices) Trips to community resources and leisure

activities (Exercise, building new pathways)[ Nursing skills: Education, Assessment, TX planning,

Collaboration, skill building, commitment]

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What ACT Team can not do:

Violate the client’s right to make poor decisions, even when we disagree (I.e.— Not taking medications as ordered, drinking alcohol or using drugs, being with people who use drugs, living where they want, refusing services that would help)

Provide information to non-guardians without consent to release information by the person.

Place the person in a hospital or CSU against their will, unless they meet the law’s definition of danger to self or others.

Prevent them from leaving the team, unless they have a guardian.

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Skills MH nurses need: Have a clear vision of the

mission of the team Be committed to the model Have a support system Have a strong voice on the

team Organizational skills

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Nurses-- NEEDED ABILITIES

Ability to be a team player To be flexible and organized Able to communicate effectively to all

team members, especially with the person served

To understand Stages of Change/Motivational Interviewing

To develop a long term relationship Able to carry the hope for the person,

until they are ready to take it back.

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Nurses-- NEEDED ABILITIES

To be able to NOT take individual’s anger personally

Able to partner with the person in treatment, instead of as the “expert”

To not join/align with the illness(s) and enable the person to use

To advocate with them to take the medications (Or they are unable to participate in TX offered)

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Nurses-- NEEDED ABILITIES

To use legal means during crisis for involuntary admissions, Payeeship, guardianship and any other tools as needed to ensure proper care

Work with families, S/O, Partners, police, guardians, lawyers, physicians, etc.

To understand the consequences of person’s use of any substances—alcohol, drugs, tobacco, caffeine, etc

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Nurses-- NEEDED ABILITIES To understand:

Recovery is a slow process with ups and downs

Recovery is not an event, it’s a marathon

Treatment is like Insulin—without it, the illness returns and progression is faster with worse physical and mental damage

The Family is not to blame and neither is the person. We do not blame for Cancer.

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Nurses-- NEEDED ABILITIES To have compassion for the illness Have a commitment to the SPMI

Population Have knowledge of:

MI & SA, Sexual Abuse issues, medical issues, PTSD, Personality Disorders, medications, documentation, etc.

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Substance Abuse knowledge needed to effectively deliver care that incorporates IDDT evidence based practices

DSM definitions of Abuse and Dependence for drug classifications

ASAM (American Society of Addiction Medicine) Criteria Understand addictions, including consequences How to and what assessments to use Treatment of different drugs classification Prevention strategies Impaired professionals issues (Use of EAP) Resources available

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Nurses-- NEEDED ABILITIES

Understand the need to address wellness every day: Nutrition Exercise Sleep hygiene Tobacco use

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Reasons to look at wellness:

They die 12 to 25 years earlier than general population

They die most often from heart disease, cancer, and problems associated with smoking and alcohol use

Washington Un. School of Medicine 1/3/14

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10% of Programs Address The 80% Who are in:

Precontemplation, Contemplation, Preparation

STAGES OF CHANGEWhat techniques are helpful in what stage?

What is the focus of each stage?

What are the Tasks of each stage?

Prochaska, James O.; Norcross, John C.; DiClemente Carlo C.: Changing for Good New York: Avon Books 1994 S of C presentation

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READINESS TO CHANGEIndividual STAFF

Not interested Very interested

in change in change

1 2 3 4 5

(Precontemplation) (Action)

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Consciousness Raising 

  

Social Liberation   

Emotional Arousal   

Self-Reevaluation

 

 

Commitment   

 Countering    

Environment Control

    

 

Reward 

 

Helping Relationships

Increasing information about self and problem   Increasing Social alternatives for behaviors that are not problematic

 Experiencing and expressing feelings about one’s problems and solutions

 Assessing feelings and thoughts about self with respect to a problem

 

Choosing and committing to act, or belief in ability to change  

Substituting alternatives for problem behaviors  

 Avoiding stimuli that elicit problem behaviors     Rewarding self, or being rewarded by others, for making changes 

Enlisting the help of someone who cares

TECHNIQUESObservations, confrontations, interpretations bibliotherapy Advocating for rights of repressed, empowering, policy interventions 

Psychodrama, grieving losses, role-playing 

Value clarification imagery, corrective emotional experience

Decision making therapy, New Year’s resolutions, logotherapy

 Relaxation desensitization, assertion, positive self-statements Environmental restructuring (e.g., removing alcohol or fattening foods), avoiding high-risk cures 

Contingency contracts, overt and cover reinforcement

 Therapeutic alliance social support, self-help groups

PROCESS GOALS

SUMMARY OF SOME CHANGE PROCESS TECHNIQUES

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When You Change

Precontemplation

Contemplation

Preparation

Action

Maintenance

[SPIRAL vs. Linear]

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Precontemplation Contemplation Preparation Action Maintenance

Stages of Change in which particular

CHANGE PROCESSESS are most useful

Consciousness-RaisingSocial Liberation

Emotional Arousal Self-Reevaluation

Commitment

Reward

Countering

Environment Control

Helping Relationships

ACTION

Prochaska, James O.; Norcross, John C.; DiClemente Carlo C.: Changing for Good New York: Avon Books 1994

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Self-Esteem

Self-Confidence

Optimism

Awareness, Discrepancies

Hopelessness

Helplessness

Low Self-Esteem

Lack of Awareness

Direction of Change

Self-Confidence + Awareness = Positive Behavior Change

Self-Confidence: The belief I am able to complete a task.

Focusing on awareness without self-confidence can lead to

hopelessness!

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PrecontemplationCharacteristics:

Unaware of Problem

Problem is external

Resistant,

Hopeless

Demoralized,

Defenses:

Denial, minimize,

I don’t drink that

much!

Thinking

Stage

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PrecontemplationCharacteristics cont’d.:

Internalize, Projection, Rationalization

Displacement

Present as Depressed,

Anxious,

Afraid to risk,

Believe they are in control

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PrecontemplationGOAL:

Shift the focus to THINKING and INSIGHT

Techniques

Consciousness Raising

Social Liberation

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Precontemplation

Develop insight, increase education

Find hope, explore barriers,

Gain confidence Become aware of defenses

Tasks: 

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Precontemplation

Shift in focus, Change way of

thinking, Need to develop a

support system

Comments:

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How Make therapy a safe and supportive place, encourage them to ask someone they trust to share with them their defenses. Use education to show them how defeating defenses can be.

Give them permission to be human, encourage participant to be open about their defenses. Help them get control over their defenses.

How to help Precontemplators

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Remind them that they are not ready for action, that they need to talk, get feedback, and feel cared for. They need to communicate with others what their goals are to change.

Remind them that this is a process and that each step builds toward the next and that it will not happen overnight.

How to help Precontemplators

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DO Recognize that participants need

assistance to change Provide feedback on participant defenses Assess for shame, guilt, embarrassment

DON’TPush someone into action, Nag, Give up,Enable

How to help Precontemplators

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Psych/Social Evaluation:Comprehensive Eval includes

biologicalMental StatusLegal History—SA & MH

Substance Abuse Profile:Identifies Risk FactorsIdentifies Stage of ChangeIdentifies TriggersIdentifies Strengths

Collateral Resources:

Family Law Enforcement

Employers Healthcare WorkersFriends Lawyers

DATA COLLECTION:

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Medical History:Hypertension Enlarged LiverGI Problems Sleep DisturbancesAnemia ImpotenceBone Fractures AnxietyTremulousness Memory Impairment

Blood work*SGOT (AST) & SGPT (ALT) these enzymes reflect the health of the liver.

GGTP-This enzyme is found in the liver, brain and blood and appears to be sensitive to the effects of alcohol. This is usually the first enzyme to show an elevation and it has been shown to be a predictor of serious medical problems.*Elevations of these enzymes are also the result of other medical problems it is important to have a physician validate that the elevations are due to alcohol use.

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Total Bilirubin- A severely damaged liver cannot metabolize bilirubin. This is one of the causes of jaundice, a late stage of liver disease.

Uric Acid- Byproduct of the kidneys, an alcohol damaged liver can not excrete uric acid and thus it builds up in the bloodstream. This may result in Gout, a painful inflammation of the joints.

QUESTIONNAIRES: Alcohol Expectancy Questionnaire Alcohol Effects QuestionnaireCAGE QuestionnaireComprehensive Drinker ProfileThe Drinker Inventory of ConsequencesAddiction Severity IndexSubstance Abuse Subtle Screening Inventory

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The first step to fostering intentional change is to become conscious of the self-defeating defenses that get in the participant’s way.

KNOWLEDGE IS POWER.

Becoming aware of defenses

Checking the participant’s defenses

Increased awareness and practice can help a participant turn a maladaptive defense into a positive behavior.

Consciousness-Raising

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Social liberation involves utilizing community resources, social norms to create more alternative and choices for problem behavior.

Examples include:No Smoking sectionsFat free foodsDesignated driversPublic service messagesEmployee wellness programsReimbursement for exercise equipmentLower insurance rates for non-smokers.Self-help groups

Precontemplators can perceive these forces as positive and helpful, in which case they will progress to contemplation.

They may also perceive these forces as coercive, believing that their rights are being infringed upon by society.

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Target the person’s present situation and its risks or consequences.• Journals• Family Input• Friend’s input• Objective tests• Blood Work/Medical tests• Probation Input• Work Performance

Providing Feedback

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Goal: Shift in FocusTarget participant’s perceptionEducate to develop insightIncrease HopeConsciousness RaisingObjectives:Conciseness raising AssessmentReview Assessments EducationStress Management Coping/WellnessAssess for Depression Assess Lifestyle

Interventions:Assessment Tools Medical EvaluationEducation Groups Social AlternativesTypical Day JournalTimeline Lifestyle AwarenessWellness Exercise

Treatment PlanningPrecontemplation

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Contemplation

Increase awareness causes ambivalence

(Normal) There is a resistance to change, The desire

to change exists simultaneously with an unwitting resistance to it.

Open to information about problem, May feel stuck, Action may be avoided,

Characteristics:

Thinking Stage

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Contemplation

Await some type of external intervention,

Analysis causes paralysis, Fear of failure, Fear of new self, Threatened identity or

security, Wait for the magic moment.

Characteristics Continued:

CHRONIC CONTEMPLATOR

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Contemplation GOAL:

Shift the focus to awareness of the problem and the solutions

Techniques: Consciousness Raising & Social

Liberation

Emotional Arousal Self-Reevaluation

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ContemplationTASKS Increase awareness of problem and

solution, Self-appraisal, Resolve fear and ambivalence, Make an informed decision to change

problem behavior, Pros and cons of changing, Skill building, exercise, functional

analysis

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Contemplation

COMMENTS: Shift in perception, Learn to make an informed

decision, Positive attitude, hope, self-

esteem, Need a support system, Dual disorders--TX both!, Environmental control

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Contemplation is essential prior to preparation.Ambivalence is a natural part of the change process.Contemplators may present as:

Depressed PassiveSerious about solving their problemEager to talk about themselves and their problemOpen to any information about their problem

Contemplation Comments

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Emotional Arousal

Emotions can be harnessed to provide the energy to move from contemplation to preparation.

Not the same as fear arousal

Serves as a cleansing function

Do not confuse emotions with change

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Self-Reevaluation

The goal of self-reevaluation is to emotionally and cognitively appraise the problem and self.

This reevaluation should leave the participant thinking, feeling and believing that life would be much better if his behavior was changed.

Develop techniques that focus on: Abandoning the hope of finding an easy route to

change Confronting difficult questions regarding the

outcome of change Looking at how change will effect self-image

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Prochaska, James O.; Norcross, John C.; DiClemente Carlo C.: Changing for Good New York: Avon Books 1994

Chronic Contemplators

Substitute thinking for acting Will make statements about taking action in the future

or “someday”

Conflicts and problems are suspended

Decisions are never completed

Action is avoided

Await some type of type of external intervention

106

Preparation

GOAL:Using the decisions made in Contemplation Stage

to develop specific steps to solve the problem

for implementation during Action Stage

107

Preparation

Techniques: Social Liberation

Emotional Arousal: Experiencing & expressing feelings about the problem & solution

Self-Reevaluation: Assessing feelings & thoughts about self with respect to a problem

Commitment: Choosing and committing to act coupled with a belief in the ability to change, which reinforces the will to act.

108

PreparationCharacteristics Ambivalence is resolved, Self-reevaluation, anticipate

roadblocks, Make a decision to take

action By end of stage: Make a

commitment to change

Practice behavior change Stage

109

Preparation

Characteristics continued:

Have self-confidence, Hopeful about future, careful

planning, rehearsing for action, Self pride, Become responsible for

behavior.

110

PreparationTASKS:

List benefits of changing,

Focus on positive outcomes,

Increased energy, Let go of past,

111

PreparationTASKS cont’d New self-image, Belief in ability to change, Anxiety is a normal reaction to

change, Skill building (anger management, assertiveness

training, 12 step groups)

112

Preparation

COMMENTS: Recovery is a process not an

event, [A marathon not a sprint]

Identify strengths, Learn new skill to succeed, Need to have a support system, Relapse may occur.

113

Action GOAL:

Purposefully modify lifestyle in order to alter behavior based on commitment.

114

Action

Techniques:

Countering Substituting healthy

responses for problem behaviors

Active diversion: keeping busy Exercise Relaxation 10 to 20 Min. per

day

115

Action

Countering (Cont’d.)

Counter thinking: substituting positive thoughts for negative/B&W thoughts

(I would like rather than I need to) Assertiveness: exercising right to communicate your thoughts, feeling, wishes, and intentions clearly, thereby countering feelings of helplessness.

116

Technique:

Environmental Control:Restructuring the environment so

that the likely occurrence of a problematic stimulus is significantly reduced.

Avoidance (i.e. bars); Deal with cues & develop a plan;

Reminders: To do list, including use of relaxation & exercise, appointments, etc.

Action

117

Technique: REWARD: Environmental control modifies the

cues that precede & trigger problem behavior, Reward modifies the consequences that follow and reinforce it.

Positive thoughts: “Nice job relaxing” A way of re-parenting self!

Action

118

Action

Modified lifestyle to alter behavior,

Need to be committed to change,

Understand-- No guarantees that action will be successful,

Characteristics:

Guarantee

119

Action

Characteristics continued:

Prepared, Aware of pitfalls, May be active in 12 step program

120

Action

Tasks Be aware of time, effort

and energy needed to change,

Relapse prevention skills

No simple solutions to complex problems

121

ActionCOMMENTS:

Relapse may occur, Need to have support system

in place already, Change in lifestyle, Treat core issues.

122

Maintenance

Goal Maintain new behavior

FOCUS

On Behavior and Lifestyle

123

Maintenance

Relapse Prevention:Task Continue integration and utilization

of new coping skills,Goal

Abstinence

124

Maintenance

Techniques/Interventions:

Rewards Support Relapse Prevention tools

125

Maintenance

Hobbies Skill development Social Alternatives Exercise

Techniques/Interventions

126

x

Nursing practices that can effectively incorporate Stages of

ChangeKnowledge: Knowing the right Stage of Change means Providing the

right stage based interventionsAbility to partner, collaborate, educate, assist, coach, assess,

plan, implement, evaluate and documentProvide appropriate skill building to enhance quality of life

as addressing both illnesses in the correct Stage of ChangeEnhances your skills: as a team player, to have compassion

for both illnesses, to be willing to be on the journey over a long period of time, share your medial knowledge, etc

Equals improved outcomes and job satisfaction

127

Presenter Information

Judy Magnon, RN-BC, BS, CAC

WestBridge

7300 Grove Road

Brooksville, FL 34613

jmagnon@westbridge.org

Office (352) 678-5553 Cell(727) 277-6094