Considerations for Treating Co-occurring Mental and Substance Use Disorders PDF

Regina R. Moro, PhD Author Reginald W. Name Holt, PhD. POWERPOINTS TO ACCOMPANY...

Regina R. Moro, PhD Author Reginald W. Name Holt, PhD. POWERPOINTS TO ACCOMPANY Chapter 1 Considerations for Treating Co-Occurring Mental and Substance Use Disorders © Springer Publishing Company, LLC. 1  LEARNING OBJECTIVES Recognize the prevalence of co-occurring mental and substance use disorders. Identify the etiological paradigms and risk factors for co-occurring mental and substance use disorders. Give examples of the adverse effects of co-occurring mental and substance use disorders. Distinguish screening procedures from the assessment process when evaluating clients for co-occurring mental and substance use disorders. Summarize the steps involved in the assessment process when evaluating co-occurring mental and substance use disorders. Discuss treatment approaches, guidelines, and levels of care for co-occurring mental and substance use disorders. Explain ethical and legal considerations related to counselor competencies when treating clients with co-occurring mental and substance use disorders. © Springer Publishing Company, LLC. 2  TREATMENT EVOLUTION Recognizing the existence of and developing treatment models for co-occurring mental and substance use disorders (CODs) have advanced over the past four decades. The profession has also evolved in which individuals with CODs are classified and discussed. © Springer Publishing Company, LLC. 3  TERMINOLOGY Earlier terms such as mentally ill substance abusers, substance abusing mentally ill, and mentally ill chemically addicted are outdated (Substance Abuse and Mental Health Services Administration [SAMHSA], 2020). The contemporary term co-occurring disorders (CODs), therefore, is the one preferred for this textbook because it is best defined as no specific combination of one or more mental disorders concurrently appearing alongside one or more substance use disorders (SUDs) contained within the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification system (SAMHSA, 2020). © Springer Publishing Company, LLC. 4  PREVALENCE OF CODS Approximately 7.7 million (3.3%) of adults in the U.S. have diagnosable co-occurring mental and substance use disorders (Han et al., 2017). Approximately 17.0 million adults (6.7%) had a substance use disorder that co-occurred with any mental illness (AMI) in the past year (SAMHSA, 2021). Approximately 5.7 million (2.2%) had a substance use disorder and a serious mental illness (SMI) that significantly limited/interfered with their level of functioning (SAMHSA, 2021). © Springer Publishing Company, LLC. 5  PREVALENCE OF CODS Source: Recreated with information from Key Substance Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2021, p. 35). https://www.samhsa.gov/data/report/2020-nsduh-annual-national-report © Springer Publishing Company, LLC. 6  Impact of CODs Co-occurring disorders not only impact the individual client and those around them (e.g., family members), they also negatively affect other factors including treatment and recovery outcomes, employment rates, housing security status, criminal/legal system involvement, symptom severity expression, and at its worst, suicide (SAMSHA, 2020). © Springer Publishing Company, LLC. 7  Counselor Training and Knowledge Counselors-in-training who indicate they plan to only work with clients who have mental disorders (or vice versa for substance use disorders) will be remiss if they incorrectly believe they will not need to be cross-trained on CODs. Regardless of a counselor’s preferred client population or specialization area, the informed clinician fully understands that all clients need to be screened for both mental and substance use symptomatology despite the initial chief complaint and/or self- identified presenting problem. © Springer Publishing Company, LLC. 8  Early Detection of CODs SAMHSA’s consensus panel of experts endorsed the following practices regarding the screening process of CODs: “Substance use disorder treatment providers screen all new clients for co-occurring mental disorders” (SAMHSA, 2020, p. 41). “Mental disorder treatment providers screen all new clients for any substance misuse” (SAMHSA, 2020, p. 41). © Springer Publishing Company, LLC. 9  Screening and Assessment of CODs Counselors should be aware of the difference between the two terms. It is not unusual for the words screening and assessment to be used interchangeably during informal conversations. However, it is important that counselors—especially those in training programs— understand that screening and assessment have different meanings as well as distinct procedures. © Springer Publishing Company, LLC. 10  Screening Screening is a “brief, routine process designed to identify indicators, or ‘red flags,’ for the presence of mental health, substance use, or other issues that reflect an individual’s need for treatment”(SAMHSA, 2015, p. 19). The object of screening for CODs is to ask specific questions that will yield either a “yes” or “no” response in order to identify warning signs that potentially indicates the client is experiencing mental and/or substance abuse issues (SAMHSA, 2020). © Springer Publishing Company, LLC. 11  Substance Misuse Screening Screen for acute safety risk related to serious intoxication or withdrawal. Screen for past and present substance use, substance-related problems, and substance-related disorders (i.e., SUDs and substance-induced mental disorders). Source: SAMHSA (2020) © Springer Publishing Company, LLC. 12  Mental Disorder Screening Screen for acute safety risk, including for: Suicide. Violence to others. Inability to care for oneself. Risky behaviors. Danger of physical or sexual victimization. Screen for past and present mental illness symptoms and disorders. Screen for cognitive and learning deficits. Regardless of setting, screen all clients for past and present victimization and trauma. Source: SAMHSA (2020) © Springer Publishing Company, LLC. 13  Observable Signs/Symptoms of CODs Unusual affect, appearance, thoughts, or speech Suicidal thoughts or behavior Paranoid ideation Impaired judgment and risk-taking behavior Drug-seeking behaviors Agitation or tremors Source: SAMHSA (2020) © Springer Publishing Company, LLC. 14  Observable Signs/Symptoms of CODs (continued) Impaired motor skills Dilated or constricted pupils Elevated or diminished vital signs Hyperarousal or drowsiness Muscle rigidity Evidence of current intoxication Needle track marks or injection sites Source: SAMHSA (2020) © Springer Publishing Company, LLC. 15  The Assessment Process When a client screens positive for the presence of mental health and/or substance use issues, a more formal assessment needs to be conducted to determine: The type and severity of symptoms. Understand the impact the problems have on the client’s overall level of functioning. Identify the variables influencing the development and perpetuation of the client’s issues. Make a provisional diagnosis of each mental and substance use disorder based upon the information revealed through the comprehensive assessment. Source: SAMHSA (2015) © Springer Publishing Company, LLC. 16  The Basics of Assessment Background: Family history Trauma history Domestic violence history (as either perpetrator or victim) Marital status Legal involvement history Financial status Strengths and resources Employment status Source: SAMHSA (2020) © Springer Publishing Company, LLC. 17  The Basics of Assessment (continued) Substance Use: Age of first use Primary substance(s) used, including alcohol Treatment episodes Family history of substance use problems Source: SAMHSA (2020) © Springer Publishing Company, LLC. 18  The Basics of Assessment (continued) Mental Illness: Family history of mental illness Client history of mental illness, including diagnosis, hospitalization, and other treatment Current symptoms and mental status Medications and medication adherence Source: SAMHSA (2020) © Springer Publishing Company, LLC. 19  ASAM’s Multidimensional Assessment The American Society of Addiction Medicine (ASAM, n.d.) uses the six dimensions of multidimensional assessment in order to assist in planning care and matching treatment to the client’s needs. This strengths-based, holistic biopsychosocial assessment considers each client’s current mental/substance/medical conditions, barriers/limitations, and strengths/resources/supports in order to determine the most clinically suitable level of care across the service continuum (ASAM, n.d., para 3.). © Springer Publishing Company, LLC. 20  ASAM’s Six Dimensions of Multidimensional Assessment Dimension 1: Acute Intoxication and/or Withdrawal Potential Dimension 2: Biomedical Conditions and Complications Dimension 3: Emotional, Behavioral, or Cognitive Conditions and Complications Dimension 4: Readiness to Change Dimension 5: Relapse, Continued Use or Continued Problem Potential Dimension 6: Recovery/Living Environment Source: ASAM (n.d.) © Springer Publishing Company, LLC. 21  12 Steps in The Assessment Process 1. Engage the client. 2. Identify and contact collaterals (family, friends, other providers) to gather additional information. 3. Screen for and detect CODs. 4. Determine quadrant (based on severity of corresponding disorder) and locus of responsibility. 5. Determine level of care. 6. Determine diagnosis. Source: SAMHSA (2020) © Springer Publishing Company, LLC. 22  12 Steps in The Assessment Process (continued) 7. Determine disability and functional impairment. 8. Identify strengths and supports. 9. Identify cultural and linguistic needs and supports. 10. Identify problem domains. 11. Determine stage of change. 12. Plan treatment. Source: SAMHSA (2020) © Springer Publishing Company, LLC. 23  Client Safety Screening Tools Ask Suicide-Screening Questions Beck Scale for Suicide Ideation Columbia-Suicide Severity Rating Scale Suicide Behaviors Questionnaire-Revised Humiliation, Afraid, Rape, and Kick *NOTE: Refer to chapter 1 for references for each instrument. © Springer Publishing Company, LLC. 24  Mental Disorders Screening Tools Mental Health Screening Form-III Modified Mini Screen Patient Health Questionnaire-2 [for depressive disorders] Generalized Anxiety Disorder 7-item Primary Care PTSD Screen for DSM-5 Brief Symptom Inventory Life Stressor Checklist-Revised Trauma Screening Questionnaire *NOTE: Refer to chapter 1 for references for each instrument. © Springer Publishing Company, LLC. 25  Substance Misuse Screening Tools 10-item Drug Abuse Screening Test Alcohol Use Disorders Identification Test Alcohol Use Disorders Identification Test-Concise CAGE Questionnaire Adapted to Include Drugs Michigan Alcoholism Screening Test Alcohol, Smoking, and Substance Involvement Screening Test Simple Screening Instrument for Substance Abuse CRAFFT Screening Tool for Adolescent Substance Abuse *NOTE: Refer to chapter 1 for references for each instrument. © Springer Publishing Company, LLC. 26  Co-Occurring Disorder Screening Tools Co-Occurring Disorders Screening Instrument for Mental Disorders The Mini International Neuropsychiatric Interview Psychiatric Diagnostic Screening Questionnaire *NOTE: Refer to chapter 1 for references for each instrument. © Springer Publishing Company, LLC. 27  Mental Disorders Assessment Tools DSM-5 Cross-Cutting Symptom Measures Symptom Checklist 90–Revised Patient Health Questionnaire-9 [for depressive disorders] The PTSD Checklist for DSM-5 *NOTE: Refer to chapter 1 for references for each instrument. © Springer Publishing Company, LLC. 28  Substance Use Assessment Tools Addiction Severity Index Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised Clinical Institute Narcotic Assessment Scale for Withdrawal Symptoms Clinical Opiate Withdrawal Scale *NOTE: Refer to chapter 1 for references for each instrument. © Springer Publishing Company, LLC. 29  CODs Assessment Tools Psychiatric Research Interview for Substance and Mental Disorders *NOTE: Refer to chapter 1 for references for each instrument. © Springer Publishing Company, LLC. 30  Assessing Readiness for Change Processes of Change Questionnaire University of Rhode Island Change Assessment Scale *NOTE: Refer to chapter 1 for references for each instrument. © Springer Publishing Company, LLC. 31  Establishing a Therapeutic Relationship 1. Develop and use a therapeutic alliance to engage clients in treatment. 2. Maintain a recovery perspective. 3. Ensure continuity of care. 4. Address common clinical challenges (e.g., countertransference, confidentiality). 5. Monitor psychiatric symptoms (including symptoms of self-harm). 6. Use supportive and empathic counseling; adopt a multiproblem viewpoint. 7. Use culturally responsive methods. 8. Use motivational enhancement. 9. Teach relapse prevention techniques. 10. Use repetition and skill building to address deficits in functioning. Source: SAMHSA (2020) © Springer Publishing Company, LLC. 32  Treatment of CODs Before evidenced-based treatment strategies are implemented, the therapeutic relationship must be positively established. This is supported by research indicating a strong working alliance is correlated with positive recovery outcomes (Scanlon et al., 2022). © Springer Publishing Company, LLC. 33  Therapeutic Alliance Development 1. Develop and use a therapeutic alliance to engage clients in treatment. 2. Maintain a recovery perspective. 3. Ensure continuity of care. 4. Address common clinical challenges (e.g., countertransference, confidentiality). 5. Monitor psychiatric symptoms (including symptoms of self-harm). 6. Use supportive and empathic counseling; adopt a multiproblem viewpoint. 7. Use culturally responsive methods. 8. Use motivational enhancement. 9. Teach relapse prevention techniques. 10. Use repetition and skill building to address deficits in functioning. Source: SAMHSA (2020) © Springer Publishing Company, LLC. 34  Treatment Types for CODs Co-occurring-capable Co-occurring-enhanced Complexity-capable Source: SAMHSA (2020) © Springer Publishing Company, LLC. 35  Providing Integrated Care Despite the program type, those offering integrated services for the treatment of co- occurring mental and substance use disorders are more effective that those who address each disorder sequentially (within the same healthcare system) or simultaneously (in separate healthcare systems). Sources: NIDA (2020); SAMHSA (2020) © Springer Publishing Company, LLC. 36  Six Guiding Principles in Treating CODs Use a recovery perspective. Adopt a multiproblem viewpoint. Develop a phased approach to treatment. Address specific real-life problems early in treatment. Plan for the client’s cognitive and functional impairments. Use support systems to maintain and extend treatment effectiveness. Source: SAMHSA (2020) © Springer Publishing Company, LLC. 37  Additional Guidelines for Counselors Providing access (using a “no wrong door” approach). Completing a full assessment. Providing an appropriate level of care. Achieving integrated treatment. Providing comprehensive services. Ensuring continuity of care. Source: SAMHSA (2020) © Springer Publishing Company, LLC. 38  Recognizing Special Population Needs Counselors should not only be knowledgeable of the vulnerabilities associated with these groups, but they should also know how to design interventions that meet the complex needs of at-risk clients. Certain populations who have a greater risk of developing CODs and experiencing poorer treatment outcomes include: Military personnel (active duty and veterans) Clients who identify as women People experiencing homeless Individuals involved in the criminal legal system People with diverse racial and ethnic backgrounds Source: SAMHSA (2020) © Springer Publishing Company, LLC. 39  Treatments for Substance Use Disorders Pharmacotherapies/Medication-Assisted Treatment Cognitive-Behavioral Therapy Contingency Management Interventions/Motivational Incentives Community Reinforcement Approach (CRA) Plus Vouchers Motivational Enhancement Therapy 12-Step Facilitation Therapy Family Behavior Therapy Source: NIDA (2018a) © Springer Publishing Company, LLC. 40  Treatments for CODs Cognitive Behavioral Therapy (CBT) Dialectical Behavioral Therapy (DBT) Assertive Community Treatment (ACT) Therapeutic Communities (TCs) Contingency Management (CM) or Motivational Incentives (MI) Source: NIDA (2018b) © Springer Publishing Company, LLC. 41  ASAM’s Continuum of Care Once the multidimensional biopsychosocial assessment has been completed, the information is used to identify the most clinically appropriate level of care based upon the client’s current needs. Although not fully comprehensive or descriptive, each available level of care is shown here as a reference point. Prevention/Early Intervention Level 1: Outpatient Level 2: Intensive Outpatient/Partial Hospitalization Level 3: Residential/Inpatient Level 4: Intensive Inpatient Source: ASAM (n.d.) © Springer Publishing Company, LLC. 42  Ethical and Legal Considerations The American Counseling Association (ACA) is the main organization who develops the guidelines to inform the ethical practice of professional counselors, counselor supervisors, trainers, and educators, as well as counselors-in-training (2014, p. 3). In addition to ACA’s code of ethics, counselors should uphold all state and federal laws as well as adhere to the applicable ethical guidelines based upon their professional credentials (e.g., training, certification, and licensure requirements). © Springer Publishing Company, LLC. 43  Counselor Competencies Areas 1. Understand the transtheoretical model and client readiness to change 2. Use motivational interviewing/motivational enhancement therapy skills 3. Understand and use relapse prevention model and skills 4. Understand how to use the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5. Understand the effects of level of functioning and degree of disability 6. Apply knowledge of psychotropic medications 7. Use integrated models of assessment, intervention, and recovery 8. Develop and implement an integrated treatment plan 9. Involve the client and other collaterals 10. Help clients expand social networks and support systems Source: SAMHSA (2020) © Springer Publishing Company, LLC. 44  Summary Although individual counselors may have a preference when working with certain client populations, they will inevitably encounter clients at risk of having CODs. Thus, they should be prepared to evaluate for and detect the presence of CODs. Counselors should also be knowledgeable of: Best-practice guidelines for linking clients to appropriate services Implementing evidenced-based treatments within the counselor’s scope of practice and credentials. Various resources have been references for counselors looking to expand their knowledge of and competencies for treating clients who have CODs. © Springer Publishing Company, LLC. 45  References American Counseling Association. (2014). 2014 ACA code of ethics. https://www.counseling.org/docs/default-source/default-document-library/2014-code-of-ethics-finaladdress.pdf American Society of Addiction Medicine. (n.d.). About The ASAM Criteria. Retrieved July 28, 2022, from https://www.asam.org/asam-criteria/about-the-asam-criteria Han, B., Compton, W. M., Blanco, C., & Colpe, L. J. (2017). Prevalence, treatment, and unmet treatment needs of US adults with mental and substance use disorders. Health Affairs, 36(10), 1739-1747. https://doi.org/10.1377/hlthaff.2017.0584 National Institute on Drug Abuse (2018a, January). Principles of drug addiction treatment: A researched-based guide. (3rd ed.). U.S. Department of Health and Human Services, National Institutes of Health. https://nida.nih.gov/download/675/principles-drug-addiction-treatment-research-based-guide-third-edition.pdf?v=74dad603 627bab89b93193918330c223 National Institute on Drug Abuse (2018b, August). Comorbidity: Substance use disorders and other mental illnesses drugfacts. U.S. Department of Health and Human Services, National Institutes of Health. https://nida.nih.gov/publications/drugfacts/comorbidity-substance-use-disorders-other-mental-illnesses National Institute on Drug Abuse (2020, April). Common comorbidities with substance use disorders research report. Department of Health and Human Services, National Institutes of Health. https://www.ncbi.nlm.nih.gov/books/NBK571451/ © Springer Publishing Company, LLC. 46  References Scanlon, F., Hirsch, S., & Morgan, R. D. (2022). The relation between the working alliance on mental illness and criminal thinking among justice- involved people with co-occurring mental illness and substance use disorders. Journal of Consulting and Clinical Psychology, 90(3), 282-288. https://doi.org/10.1037/ccp0000719 Substance Abuse and Mental Health Services Administration (2015). Screening and assessment of co-occurring disorders in the justice system. (HHS Publication No. PEP19-SCREEN-CODJS). U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. https://store.samhsa.gov/sites/default/files/d7/priv/pep19-screen-codjs.pdf Substance Abuse and Mental Health Services Administration (2020). Substance use disorder treatment for people with co-occurring disorders: Treatment improvement protocol (TIP) 42. (SAMHSA Publication No. PEP20-02-01-004). U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-02-01-004_Final_508.pdf Substance Abuse and Mental Health Services Administration (2021). Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health (HHS Publication No. PEP21-07-01-003, NSDUH Series H-56). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/report/2020-nsduh-annual-national-report © Springer Publishing Company, LLC. 47