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Co-occurring Alcohol and Other Drug and Mental Health Conditions in

Alcohol and other Drug Treatment Settings

Session 4: Management and

Treatment

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Comorbidity Guidelines Refer to:

Chapters 7 and 8 Appendix C – Case Studies Appendices D, Q to Ee

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Management vs Treatment Management of symptoms of mental

illness to allow AOD treatment to continue with minimal disruption to retain clients in treatment

Treatment refers to evidence-based practice for working with comorbidity

Suggested treatments may be beyond scope of some AOD workers – awareness only

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Managing Comorbidity

Comorbid mental health symptoms can be managed and controlled whilst the client undergoes AOD treatment

Consider whole person (from psychological, physical and socio-demographic perspectives) when managing symptoms of comorbid mental conditions

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Managing Comorbidity

Suicide risk should be monitored throughout treatment

Motivational enhancement, simple CBT-based strategies, relaxation and grounding techniques can be useful in managing AOD use as well as mental health conditions

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Managing Comorbidity

Symptoms of trauma, grief, loss can be managed through anxiety management strategies and open discussion with client

When dealing with more challenging clients ensure safe environment, set clear boundaries and place strong emphasis on engagement and rapport building

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Managing Suicidality

“Dos and Don’ts”

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Managing Symptoms of Depression

“Dos and Don’ts”

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CBT and Symptoms of Depression

Cognitive restructuring Pleasure and mastery events scheduling Goal setting Problem solving

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Cognitive Restructuring

A. Antecedent –Event that triggers automatic thoughts

B. Beliefs about event – Automatic thoughts

C. Consequences – feelings/behaviours that result from thoughts

D. Disputing automatic thoughts – look for evidence to support/disprove these thoughts

E. Alternative explanation – Rational alternatives to the automatic thought

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Anxiety, Panic or Agitation

“Dos and Don’ts”

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Managing Symptoms of anxiety, panic or agitation

Progressive muscle relaxation Controlled or abdominal breathing Calming response Visualisation and imagery Grounding

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Managing Symptoms of Trauma

“Dos and Don’ts”

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Managing Grief and Loss

“Dos and Don’ts”

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Phases of Aggression(Source: NSW Department of Health 2007)

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Managing Aggression

LListen actively AAcknowledge the problem/situation SSeparate from others SSit down IIndicate possible options EEncourage client to try these options

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Managing Aggression

“Dos and Don’ts”

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Managing Symptoms of Psychosis

“Dos and Don’ts”

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Managing Personality Disorder Symptoms

“Dos and Don’ts”

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Managing Cognitive Impairment

Techniques for problem-solving, planning, sequencing or decision-making difficulties Be clear and explicit in direction Encourage rehearsal of sequences Encourage routines Teach step-by-step decision-making and

problem-solving Use timetables and other aids to help client

plan

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Managing Cognitive Impairment

Techniques for slow information processing Summarise and repeat important points; have

client relay these back to you Encourage questions Go slowly

Techniques for poor attention/concentration Stress important points, repeat if necessary Minimise distractions

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Managing Cognitive Impairment

Techniques for poor memory Use memory aids, routines and written

instructions Make sessions at routine times Limit amount of information covered, repeat

key points, and go slowly Remind the client of appointments and key

points

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Treatment of Comorbidity

Good treatment requires a good therapeutic alliance which includes client choice (including not to be involved in treatment)

Some interventions have been designed for treatment of specific comorbidities; however, interventions have not been well researched

In absence of research on comorbid disorders, recommended to use most effective treatments for each disorder

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Treatment of Comorbidity

Both psychosocial and pharmacological interventions have been found to have some benefit in treatment of comorbidities

When pharmacotherapy is used, this should be accompanied by supportive psychosocial interventions

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Models of Care

Sequential treatment

Parallel treatment

Integrated treatment

Stepped care

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Motivational Interviewing with

Co-occurring Disorders Increasing research base for applying MI

with clients with co-existing disorders “Spirit” of MI can be useful for engaging

clients to address both MH and AOD concerns

Principles and strategies for using MI detailed in Appendix D of Comorbidity Guidelines

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Cognitive Behavioural Techniques

Evidence-based treatment approach used in both AOD and MH settings

Particularly useful for managing symptoms of anxiety and depression

Underpinnings of Relapse Prevention in both AOD and MH contexts

See Appendix Q of Comorbidity Guidelines for an overview of techniques for using

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Other Treatment Approaches

Psychosocial groups Self-help groups Mindfulness training Contingency management.

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Medications

Medications form part of evidence-based practice in treatment of mental health concerns.

Stabilising on appropriate medications and continued use whilst in AOD treatment can be essential to successful outcome for both AOD and MH

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Commonly Prescribed Medications

Antidepressants Mood stabilising medications Anti-anxiety Medications Antipsychotic Medications

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Medication Adherence

Making regimes as simple as possible Giving clear instructions Associating medication with predictable

daily events such as meal times Using pill dispensing containers with

daily organisers Using alarms

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Medication Adherence

Acknowledge any reluctance to take medications and allow client to express these concerns

Motivational interviewing, contingency management and CBT have been shown to be particularly useful in improving medication compliance

Facilitate discussion with medication prescriber if necessary

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In sum…

Range of approaches for managing symptoms of mental illness within AOD treatment settings

Treatment of co-existing disorders can occur within AOD settings

Further training in specific treatment approaches is recommended

Refer to Chapters 7 and 8 and Appendices in Guidelines for further information