Co-Occurring Disorders

Co-Occurring Disorders

Tim Hicks, PCCCommunity Counseling Center

Alcohol or Other Drug (AOD) Department

Co-Occurring Disorders

• Disclaimer• Today’s presentation is without bias of any

commercial product or medication

Objectives

• Increase understanding of Co-Occurring Disorders• Be able to Identify common mental health disorders

likely to co-occur with substance use disorders in adolescents

• Be able to Identify common mental health disorders likely to co-occur with substance use disorders in adults

• Be able to describe the stages of change and how it applies to individuals with co-occurring disorders

• Have a better understanding of how individuals with co-occurring disorders are likely to be referred.

Definitions

• Co-Occurring Disorders• Substance Related Disorders• Mental Illness

Definitions

• Co-Occurring Disorder• Co-Occurring Disorders refers to having at

least one substance use disorder and at least one mental health disorder.

• Dual Disorders• This term is used to refer to someone who has

an Axis I Diagnosis of Mental Illness and an Axis II Diagnosis of Mental Retardation

Definitions

• Substance Related Disorders• “The Substance-Related Disorders include

disorders related to the taking of a drug of abuse (including alcohol), to the side effects of a medication, and to toxin exposure” (APA, 2000, p. 191)

• There are two categories of Substance Related Disorders: Substance Use and Substance Induced Disorders

Definitions

• Substance Use Disorders– Dependence vs. Abuse vs. Withdrawal vs.

Intoxication vs. Substance Induced Disorders. • The DSM defines Substance Dependence as “a

cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems” (APA, 2000, p. 192).

Substance Dependence

• Symptoms according to DSM (p. 197)– Tolerance– Withdrawal– Greater Amounts and/or Longer Periods– Desire to stop, can’t stop or control– Third of the day– Giving up or reducing important activities– Mental or Physical Health issues caused by or made worse by

substance use– According to the DSM a person must have at least three

symptoms over a 12 month period

Substance Abuse

• The DSM defines a Substance Abuse Disorder as “a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances (APA, 2000, p. 198).

• The DSM states a person must have at least one symptom over a 12 month period– Not meeting expectations at home, school, or work– Using when dangerous– Legal problems– Relationship problems caused or made worse by the use

Mental Disorder

• The DSM (p. xxxi) defines a mental disorder “as a clinically significant behavioral or psychological syndrome or pattern….that is associated with ….distress or functioning.”

Use, Intoxication, Withdrawal

• People with Co-Occurring Disorders often meet criteria for dependence/abuse to multiple substances. Furthermore, many mental health disorders tend to be comorbid (i.e. depression and anxiety, Bipolar and anxiety disorders) The key in diagnosing Co-Occurring Disorders is that each disorder is able to be shown to be a separate problem from the other. People with Substance Use Disorders often present with mental health symptoms, but don’t meet criteria for a psychiatric illness because the symptoms are due to intoxicating, withdrawal, or the consequences of using. For instance people in withdrawal from Stimulants often present with severe depressive symptoms. Feelings of anxiety, depression, and guilt are very common in early recovery.

Substance Induced Disorders

• Is a Duck really a Duck just because it quacks? • Alcohol and Drugs can

– Cause Mental Health Problems (Semi-Independence)– Exacerbate Mental Health Symptoms (Clients I have worked with have reported their

anxiety tended to get worse during the actual use. Usually this is not noticed until they have been abstinent for 3-4 months)

– Mimic Mental Health Symptoms: Individuals who abuse certain substances may report experiences similar to mental health symptoms (i.e. the person using Methamphetamines may talk quicker, have difficulty sitting still, and be hypersexual. Individuals using Hallucinogens may experience scary visual hallucinations similar to those experienced in Schizophrenia. Individuals withdrawing from Stimulants appear very depressed, lose appetite, have low energy, and sleep disturbances. People withdrawing from Opioids or Alcohol may hallucinate.

– Cover Up Mental Health Symptoms- Many individuals with Major Mental Health symptoms may start using to cope with their illness. Initially the substances work for them. (i.e. the person with an anxiety disorder who drinks alcohol to feel more confident around others)

Matrix Model

• The recovery process can lead to symptoms that are similar to mental illness.

• Four Stages of Recovery– Withdrawal– Early Abstinence– Protracted Abstinence– Readjustment

• “The chemistry of the brain is altered by habitual substance use; clients can think of this adjustment period as a “healing” of the brain.” (CSAT, 2006, p. 48)

Matrix Model• Four Stages of Recovery

– Withdrawal• Lasts 7-14 days• Duration and Intensity of the withdrawal stage depends on the type of substance(s) used,

frequency and amount used, length of abuse history. • Symptoms can include increased heart rate, vomiting, diarrhea, seizures, increased blood

pressure, increased sweating, chills, muscle aches, cramping, visual hallucinations, depression, anxiety, loss of appetite, decreased energy, weight loss, and paranoia. Suicidal ideation and/ or attempts, while not symptoms of withdrawal needs to be assessed for during this stage due to the possible severity of withdrawal.

– Early Abstinence• Lasts approximately 4 weeks• Nicknamed the “Honeymoon Stage” or “The Pink cloud”• People in this stage are feeling better as cravings are likely to have decreased, they are

experiencing increased energy, their appetites and sleep patterns are starting to stabalize, their mood has improved, and they are able to think more clearly.

• People in this stage of recovery are at a greater risk for relapse because they begin to think they are cured.

Matrix Model (continued)• Protracted Abstinence

– Lasts approximately 3.5 months– Starts around week six of recovery lasting to the 5th or 6th month

of recovery– This stage of recovery is called the “Wall”– People in this stage of recovery experience symptom similar to

mental illness, but do not meet full diagnostic criteria.– Symptoms include depressed or irritable mood, mild paranoia,

loss of energy, loss of interest leading to feelings of boredom, distractibility.

– People in this stage of recovery are at a greater risk for relapse due to what recovering people call “The Fuck Its.”

Matrix Model

• Readjustment– Lasts approximately 2 months– Starts around the 5th or 6th month of recovery– People in this stage can begin to develop personally

meaningful goals and take action towards those goals. – Because people in this stage are more stable due to

decreased cravings and less emotionality, other important issues can be addressed in treatment such as marital counseling, employment counseling, etc.

– People in this stage need to be vigilant to relapse warning signs.

Adult Characteristics

• Based upon information reported by states to SAMHSA a DASIS reported called Admissions of Persons with Co-Occurring Disorders, 2000 was released in 2003.

• Based upon this information the following characteristics were reported– 40% of individuals with Co-Occurring Disorders

were female while only 28% of admissions for substance use only were female

Adult Characteristics– 68% of individuals with Co-Occurring disorders were white,

while 54% of those who were admitted for substance use only treatment were white

– Individuals with co-occurring disorders were less likely to be working compared to those admitted for substance use only treatment.

– Individuals admitted for substance use services who met criteria for a mental health disorder were more likely to be divorced or separated than those presenting for treatment with just a substance use issue. When examined by gender women with co-occurring disorder were more likely to be separated or divorced than their male counterparts.

Prevalence

• National Epidemiological Survey on Alcohol and Related Conditions (NESARC) (Grant, B.F. et. al., 2004)

• Sponsored by the National Institute on Alcohol Abuse and Alcoholism

• 43093 surveys conducted between 2001 and 2002

• Focused on Adults 18 and older

NESARC Findings

• Prevalence of Mental Disorders• First looked at Mood Disorders and Anxiety Disorders

as two groupings. • Any Mood Disorders (Major Depression, Dysthymia,

Bipolar, Types I and II)– 9.21%

• Any Anxiety Disorders (Panic Disorder with and without Agoraphobia, Social Phobia, Specific Phobia, GAD)– 11.08%

NESARC Findings Continued

• Prevalence of Substance Use Disorders• Reported prevalence for three categories– Any Substance Use Disorder: 9.35%– Any Alcohol Use Disorder: 8.46%– Any Drug Use Disorder: 2.00%

NESCAR Co-occurrence

• Examined people who had Substance Use Disorder to assess prevalence of Mood and Anxiety Disorders during the same 12 month period

• Findings• 19.6% had at least one mood or anxiety disorder• 17.71% had an anxiety disorder• Top two Mental Health Disorders identified as co-

occurring with substance use disorders were Major Depression and Specific Phobia

NESCAR Co-occurrence• Examined people identified as having mood or anxiety disorder to

assess prevalence of substance use disorders amongst this group• Found that people who had been identified with mood or anxiety

disorder 19.97% also had a substance use disorder in the same 12 month period.

• Found greater co-occurrence between mood and anxiety disorders and substance dependence than abuse.

• Panic Disorder with Agoraphobia and Generalized Anxiety Disorder had highest prevalence of co-occurrence with substance use disorders.

• Of the mood disorders Bipolar, Type I had greatest co-occurrence with substance use disorders

NESCAR Findings• Assessed for respondents who sought treatment.• Separated this group for further analysis• Alcohol Use Disorders

– 40.7% had mood– 33% anxiety disorder

• Drug Use Disorder– 60% mood disorder– 43% anxiety disorder

• Mood Disorders– 20% Substance Use Disorder

• Anxiety Disorders– 16% Substance Use Disorder

• Individuals who reported seeking treatment for mood or anxiety disorders were more likely to have a co-occurrence of alcohol use disorders than drug use disorders.

Prevalence of Co-Occurring Personality Disorders and Substance Use Disorders

• Part of the National Epidemiologic Survey on Alcohol and Related Conditions (NESCAR) Study

• Examined individuals with diagnosed alcohol or drug use disorder to determine rate of personality disorders. – Alcohol Use Disorder: 28.6% had a personality

disorder– Drug Use Disorder: 47.7% had personality disorder


• Examined rates of alcohol use and drug use disorders amongst those with diagnosed personality disorder.– Personality Disorders and Alcohol Use Disorders: 16.4%– Personality Disorders and Drug Use Disorder: 6.5%

• Specific Personality Disorders and Substance Use Disorders:– Individuals with Alcohol Use Disorders or Drug Use Disorders

were most likely to have the following Personality Disorders:• Antisocial Personality Disorder• Histrionic Personality Disorder• Dependent Personality Disorder


• Gender Differences– Women had a stronger relationship between alcohol

and drug use disorders with the following personality disorders compared to men:• Obsessive Compulsive Personality Disorder• Histrionic Personality Disorder• Schizoid Personality Disorder• Antisocial Personality Disorder

– The only significant difference favoring men was between Drug Dependence and Dependent Personality Disorder

Adolescents-Characteristics

• Based upon the Drug and Alcohol Service Information System (DASIS) Report entitled “Adolescents with Co-Occurring Psychiatric Disorders: 2003”

• Compared overall adolescent admissions licensed substance use treatment facilities for substance use problems with adolescents admitted to licensed substance use treatment facilities who had Co-Occurring Disorders


• Adolescents with co-occurring disorders were more likely to be female.

• Adolescents with co-occurring disorders were likely to be Caucasian.

• African American and Hispanic Adolescent admissions were more likely to be substance use only admissions.

• Both adolescents with co-occurring disorders and those with substance use only, the majority identified Cannabis as their drug of choice.


• Adolescents with co-occurring disorders were more likely to report age of first use younger than the age of 12.

• Both groups were likely to be referred by the criminal justice system.

• Adolescents with co-occurring disorders were more likely to be at least 1 and a half years behind expected grade level for age compared to substance use only adolescents.

Adolescent Prevalence Rates

• In 2002 SAMSHA made a report to congress on Co-Occurring Disorders.

• Key finds in the report based upon peer reviewed research include – 43% of youth receiving mental health treatment had a

diagnosed substance use disorder– 62% of males and 83% of female admitted for substance

use treatment met criteria for emotional and/or behavior disorders. These disorders include Conduct Disorder, Attention Deficit/Hyperactivity Disorder, Major Depression, and Post Traumatic Stress Disorder.

Adolescents Prevalence Rates

• Report to Congress (2002) continued• Citing Costello et. al. SAMSHA reported the

following– Behavioral Disorders increased the likelihood of

developing a substance use disorder– Adolescents with Major Depression were four

times as likely to develop a substance use disorder– Adolescents with an anxiety disorder were twice

as likely to develop a substance use disorder

How do people with Co-Occurring disorders get into treatment

• “No Wrong Door”– In their second Over View Paper on Co-Occurring Disorders, CSAT

emphasizes that because assessment is an ongoing processes individuals who have Co-Occurring Disorders can come into the appropriate system of care through multiple avenues.

– For instance individuals may show at CCC for a mental health assessment and then be referred to the Alcohol or Other Drug department for a substance use disorder assessment and treatment to address the mental health and substance use disorders. Individuals may present at a substance use only program and then be referred to CCC if that agency suspects the person also has a mental health diagnosis.

Referral Sources

• The Centers for Substance Abuse Treatment identified several ways persons with Co-Occurring Disorders may be referred for COD Treatment. – Family Practitioners

• CCC provided screening and assessment services at a PCP’s office due to the high number of individuals with Substance Use Disorders and Mental Health Disorders

– Hospitals• Several of the individuals I have treated were referred after being

treated on an inpatient psychiatric unit. They presented for assessment at the hospital after suicidal ideation. They also were in withdrawal.

Referral Sources• Child Protection Services

– We frequently have clients who are referred to us after CPS opens services due to charges of neglect or abuse. If CPS suspects substance abuse problems the individuals are referred for screening and assessment. The Mental Health Disorder is often identified at this time.

• Courts/Parole/Probation– Individuals with substance related charges or charges that result

from behavior under the influence are often referred for treatment. Mental Health Disorders may be found at this time.

– Individuals may need to complete Mental Health and/or Substance Use treatment as part of their parole.

Referral Sources• Substance Use/Mental Health Treatment Providers

– As discussed earlier, individuals may show at CCC for a mental health assessment and then be referred to the Alcohol or Other Drug department for a substance use disorder assessment and treatment to address the mental health and substance use disorders. Individuals may present at a substance use only program and then be referred to CCC if that agency suspects the person also has a mental health diagnosis.

– In the 2005 DASIS report on Adolescents SAMSHA reported the most likely referral source for Adolescents with Co-Occurring Disorders was the criminal justice system.

– In the 2003 DASIS report on Adults with Co-Occurring Disorders, individuals with Co-Occurring Disorders were more likely to be referred from Substance Use only providers and Medical providers, where as Substance only clients were more likely to be referred by the criminal justice system.

Screening, Assessment, and Treatment

• The recommended treatment for people with Co-Occurring Disorders is Integrated Treatment.

• Integrated treatment involves a clinician or a team of clinicians who are trained to address both mental health and/ or substance use disorders.

• Ideally, Integrated treatment starts with the screening and assessing of both substance use disorders and mental health disorders at the same time. For substance use only treatment centers this means screening for mental health problems with the substance use assessment. Mental health only facilities need to screen for substance use problems at intake. Appropriate referrals, followed by ongoing collaboration should take place during treatment.

• However, the relationship between Co-Occurring Substance Use and Mental Health Disorders lies along a continuum, which can be addressed through different levels of integration from Minimal Coordination to Integrated Co-Occurring Treatment.


• The National Dialogue on Co-Occurring Mental Health and Substance Use Disorders– Annual meetings between the National Association

of State Mental Health Program Directors and the National Association of State Alcohol and Drug Abuse Directors.

– Developed Four Quadrant Model to understand Co-Occurring Disorders and direct levels of integration

– Model takes into consideration level of severity of symptoms, not diagnosis


• Quadrant I: Low severity of mental health and substance use disorders– Minimal Coordination can be used to address

treatment– Minimal Coordination consists of knowledge the

person being treated is receiving mental health or substance use disorder treatment by another provider but little to no interaction occurs between providers. One provider may have referred the person being treated to the other provider.


• Quadrant II: More severe mental disorder combined with less severe substance use disorder

• Quadrant II: More severe substance use disorder combined with less severe mental health disorder.

• Treatment can be addressed through consultation or collaboration– Consultation involves both treatment providers exchanging information

about the care of the person being treated. If one provider has referred to the other provider there is follow up to ensure the person being referred actually has entered into services

– Collaboration involves the development of a formal agreement between providers. The providers regularly share information about the person’s being treated care on a regular basis including progress. Roles of the providers is clearly defined in the formal agreement.


• Quadrant IV: More severe mental health disorder combined with more severe substance use disorder. – Recommended treatment is integrated treatment. The

providers are trained to address co-occurring mental health and substance use disorders. The providers, in collaboration with the person being treated, develop one treatment plan that addresses both substance use and mental health disorders. Integrated treatment can occur at different agencies. However, the providers need to meet on a regular basis to share information including progress.

12 Principles of Care

• Principle 1• Co-Occurring Disorders are to be expected in all behavioral

health settings, and system planning must address the need to serve people with COD in all policies, regulations, funding mechanics and programming. – Agencies have a responsibility to higher and train clinicians who

are capable of working with clients who have mental health and substance use disorders including screening, assessment, and treatment.

– Agencies have a responsibility to work to obtain and develop funding sources that will help meet the needs of individuals with co-occurring disorders.

12 Principles of Care• Principle 2• An integrated system of mental health and addiction services

that emphasizes continuity and quality is in the best interest of consumers, providers, programs, funders, and systems. – Client needs are what drives the treatment and treatment intensity.

What this means is that treatment providers need to be flexible in addressing these concerns. For instance if a client is being provided services by an Substance Use only facility and a Mental Health facility the agencies need to work together and not be dogmatic about how often a client is expected to participate in services. You can’t expect someone who is have flashbacks of a trauma to participate in Intensive Outpatient Treatment.


• Principle 3• The integrated system of care must be accessible from

multiple points of entry (i.e., no wrong door) and be perceived as caring and accepting by the consumer. – To the best of their ability agencies have a responsibility to

help clients overcome barriers to treatment. Collaboration with other agencies is vital to overcoming these barriers. This may mean meeting the client at their home.

– All staff, including receptionists and billing staff, need to be able to greet individuals with Co-occurring disorders in a respectful manner.


• Principle 4• The system of care for COD should not be limited

to a single “correct” model or approach.– Square pegs don’t fit round holes. Therefore we can’t

take clients and expect them to fit certain treatment models. We need flexibility within and between service agencies to best meet client needs.

– Quality improvement is a fundamental aspect of this principle and needs to be ongoing at an organizational and community level.


• Principle 5• The system of care must reflect the importance of

partnership between science and service, and support both the application of evidence and consensus-based practices for persons with COD and evaluation of the efforts of existing programs and services.– It is important to be utilizing interventions and protocols that

are well supported by research or that the fields as a whole agree upon as being acceptable.

– Encourage your system of care to allow you to access continuing education in scientifically validated treatments.


• Principle 6• Behavioral health systems must collaborate with

professionals in primary care, human services, housing, criminal justice, education, and related fields in order to meet the complex needs of persons with COD. – Clients with Co-Occurring Disorders have multiple needs

that we alone cannot address. – Service agencies, medical providers, criminal justice

systems, social welfare systems need to collaborate to help people address these needs. This can occur through sharing of resources, programs, or creating task forces.

12 Principles of Care• Principle 7• Co-occurring disorders must be expected when evauate4ing any

person, and clinical services should incorporate this assumption into all screening, assessment, and treatment planning. – While not every agency or provider will specialize in treating people

who Co-occurring disorders, all treatment providers should be able to at least recognize co-occurring disorders and be able to assist clients in entering into appropriate treatment.

– If persons with co-occurring disorders are receiving treatment at separate agencies the two clinicians needs to meet regularly to manage the clients needs. They need to have an understanding how the two disorders can interact and affect each other.

12 Principles of Care• Principle 8• Within the treatment context, both co-occurring disorders

are considered primary. – Mental Health and Substance Use Disorders interact, thus one

disorder can trigger a relapse to the other disorder. – Sometimes clients may be making progress in managing one

disorder, but struggling with managing the other disorder. – We need to meet the client where the client is at in addressing

there needs. If the mental health symptoms are causing the most problems these need to be addressed. Sometimes we need to work on the substance use more than the mental health.


• Principle 9• Empathy, respect, and belief in the individual’s capacity

for recovery are fundamental provider attributes. – Clients aren’t just receiving treatment. They are an essential

part of the team. Their perspective of what will work, what is happening to them matters.

– Because of the double stigma of having mental health disorders and substance use disorders clients are likely to feel unwanted and demoralized. Part of treatment is helping them to feel valued as persons and capable of change.


• Principle 10• Treatment should be individualized to

accommodate the specific needs, personal goals, and cultural perspectives of unique individual in different stage of change. – We need to meet people where they are at in

terms of readiness to change. – We need to work toward what clients want, not

what we necessarily believe is best for them.

12 Principles of Care• Principle 11• The special needs of children and adolescents must be explicitly

recognized and addressed in all phases of assessment, treatment planning, and service delivery. – Treatment needs to take into consideration that adolescents are still

developing. Therefore, interventions need to be tailored to accommodate this reality.

– What may be deemed inappropriate at one age may be normal at another age.

– It is important to engage family for all individuals who have co-occurring disorders. The importance of this is even higher for adolescents whose families may play a role in the creation or maintenance of the problem.


• Principle 12• The contribution of the community to the course of

recovery for consumers with COD and the contribution of consumers with COD to the community must be explicitly recognized in program policy, treatment planning, and consumer advocacy. – People with Co-occurring disorders suffer from the stigma of

having a mental illness as well as the substance use disorder. – Advocacy is an essential part of treatment in helping clients

find employment, housing, and participating in society as much as possible.

Treatment

• How do we go about treating individuals who have co-occurring disorders. The key is meeting the person where he or she is at in terms of what they want, motivation to change, and understanding of the problems.

• One model for providing treatment is the Stages of Change Model Developed by Drs. James Prochaska and Carlo DiClemente

Stages of Change

• As outlined in Treatment Improvement Protocol 35 Enhancing Motivation for Change the Stages of Change are– Precomtemplation– Contemplation– Preparation– Action– Maintenance

Stages of Change

• Precontemplation– Individuals in the Precontemplation Stage reject

the idea there is a problem or minimize the problem severity. Also, individuals in this stage are likely to be present for assessment due to court order, threats to lose their job, or family pressure. Thus, they tend to blame others. With people who have co-occurring disorders this can happen with one or both disorders.

Stages of Change• Precontemplation Interventions• The main therapeutic interventions at this stage come from Motivational

Interveiwing. – Explore what people like and don’t like about using substances. – Raise awareness through psycho education on the problem and self –evaluation.– Explore the individuals perspective of the problem– Explore how the behavior is affecting others– Reinforce change is up to the individual.– Focus on building a relationship with the individual. Explore the person’s values

and goals. The values and goals can be used to develop discrepancy with the substance use and mental health behaviors.

– People in this stage may be stuck due to feeling demoralized and stigmatized. Need to explore how they have made changes in the past to support self-efficacy. Any small change needs to be affirmed.

Stages of Change

• Contemplation– People in this Stage of Change are ambivalent

about making changes. – People can remain in Contemplation for along

time. – I compare this to straddling a wood fence– The therapist’s job is to help the person become

uncomfortable with the status quo, while respecting their rights not to change.

Stages of Change• Contemplation Interventions• Therapists need to continue to use Motivational

Interviewing Interventions– The main task is to make a decision about whether to change.

The decisional balance exercise is very important at this point. – Review what the person likes and does not like about change. – Explore what the person would like if they did change. – Explore what the person would not like if they did change. – What would likely happen if they did not change: 1 year, 5 years

from now. How does this affect not only them but others.

Stages of Change

• Preparation– Individuals in this Stage of Change are ready to change, but

they don’t have a plan as of yet. – Sometimes people will take steps to change at this point that

don’t produce long lasting effects. To family members this may appear as though the person does not really want to change. However, it is more like going clothes shopping. You don’t pull the first thing you see off the rack and buy it. You try it out. Does it fit? How does it feel? Do you have shoes, pants, or a shirt that match what you are looking to buy? It is appropriate for the occasion at which you are planning to where it?

Stages of Change

• Preparation Interventions– The main task is the development of a Change

Plan• Specifies what changes are to be made, why they will

be made, specific steps the person will make including how often and when, who can help and how, what could interfere and how they would address this, how they will know the plan is working, and what they will do if the plan is not working

– Need to continue to support Self-Efficacy

Stages of Change

• Action– Individuals in this stage are enacting their change plan

• Interventions including helping the individual to identify triggers and high risk situations, develop coping skills including thought reframing, relaxation skills, social skills, assertiveness skills.

• It is very important for individuals to have a support group that can help promote change. Family and mutual self help support geared toward recovery are vital at this time.

Stages of Change

• Maintenance– New behaviors have become second nature – The problem is there are no clear defined operational

definitions for knowing this has taken place. • DSM Specifies such as in partial or full remission could be

helpful here. – Person is not only looking to prevent relapse, but also

to focus on developing a new life by identifying and working on new goals and engaging in new hobbies

Stages of Change

• Maintenance Interventions– Relapse Prevention education and monitoring for

relapse warning signs– Stress management techniques and education on

balancing life style– Development of plan on how to handle relapse if

it were to occur. Key point to reframe relapses and slips as learning opportunities not signs of failure.

Stages of Change

• It is important to remember people can be at different stages of motivation for their mental health and substance use issues. It is important to know which stages they are in at the time and meet them there.

• Also it is important to remember people recycle through the stages. They are most likely to go back to Precontemplation or Contemplation when this occurs. As a clinician you will need to meet the person where they are at again while also exploring what lead to the person returning to an earlier stage.

The End

• Questions and Comments

References• American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, Text

Revision (4th ed.). Washington, DC: American Psychiatric Association.• Grant, B.F. et. al. (2004) Co-occurrence of 12-Month Alcohol and Drug Use Disorders and Personality

Disorders in the United States, Archives of General Psychiatry, 61, 361-368. Downloaded From: http://archpsyc.jamanetwork.com/ on 06/02/2013

• Grant, B.F. et. al. (2004) Prevalence and Co-occurrence of Substance Use Disorders and Independent Mood and Anxiety Disorders, Archives of General Psychiatry, 61, 807-816.

• Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. 35. HHS Publication No. (SMA) 12-4212. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999.

• Center for Substance Abuse Treatment. Overarching Principles To Address the Needs of Persons with Co-Occurring Disorders. COCE Overview Paper 3. DHHS Publication No. (SMA) 0604165 Rockville, MD. Substance Abuse and Mental Health Service Agency, 2006.

• Center for Substance Abuse Treatment. Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders. DHHS Publication No. (SMA) 07-4152. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2006, reprinted 2007.

http://archpsyc.jamanetwork.com/

References• SAMHSA (2002) Report to Congress. http://www.samhsa.gov/reports/congress2002/chap1ucod.htm#3

accessed 5/27/13.• SAMSHA (2003) Admissions of Persons with Co-Occurring Disorder; 2000. The DASIS Report,

http://www.oas.samhsa.gov/2k3/dualTX/dualTX.pdf, accessed 5/27/13.• SAMSHA (2005) Adolescents with Co-Occurring Psychiatric Disorders :2003. The DASIS Report,

http://oas.samhsa.gov/2k5/youthMH/youthMH.pdf, accessed 5/27/13.

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Co-Occurring Disorders

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