co-occurring disorders: a brief introduction for san luis obispo county behavioral health services...

Co-occurring Disorders:Co-occurring Disorders:A Brief IntroductionA Brief Introduction

For San Luis Obispo County For San Luis Obispo County Behavioral Health Services Behavioral Health Services

December 8, 2006December 8, 2006John Lovern, Ph.D.John Lovern, Ph.D.

What We Will Cover Today What We Will Cover Today (1 of 2)(1 of 2)

1.1. What co-occurring disorders are, how prevalent What co-occurring disorders are, how prevalent they are, and how serious they are they are, and how serious they are

2.2. How co-occurring disorders have been How co-occurring disorders have been approached in the past and how beneficial the approached in the past and how beneficial the different approaches have been.different approaches have been.

3.3. Common problems faced by clients with co-Common problems faced by clients with co-occurring disorders—case examples illustrating occurring disorders—case examples illustrating assessment, treatment, and other problems.assessment, treatment, and other problems.

What We Will Cover Today What We Will Cover Today (2 of 2)(2 of 2)

4.4. A description of integrated care.A description of integrated care.5.5. Categories of treatment programs.Categories of treatment programs.6.6. Principles and practice standardsPrinciples and practice standards7.7. Medication issues.Medication issues.8.8. Some evidence-based practices.Some evidence-based practices.9.9. Psychological trauma and co-occurring Psychological trauma and co-occurring

disorders.disorders.10.10.Comments, questions and answers.Comments, questions and answers.

What are Co-occurring Disorders?What are Co-occurring Disorders?

The term “Co-occurring Disorders” refers to The term “Co-occurring Disorders” refers to substance usesubstance use (abuse or dependence) and (abuse or dependence) and mentalmental disorders occurring disorders occurring togethertogether in one person. in one person.

Clients said to have co-occurring disorders haveClients said to have co-occurring disorders have 1.1. one or more disorders relating to the use of alcohol one or more disorders relating to the use of alcohol

and/or drugs of abuse and/or drugs of abuse andand2.2. one or more mental disorders.one or more mental disorders.

At least At least oneone disorder disorder of each typeof each type must be must be established established independently of the otherindependently of the other and is not and is not simply a cluster of symptoms resulting from one simply a cluster of symptoms resulting from one disorder (or one type of disorder).disorder (or one type of disorder).

How Prevalent are Co-occurring How Prevalent are Co-occurring Disorders?Disorders?

Studies in substance abuse settings have found Studies in substance abuse settings have found that from that from 50 to 7550 to 75 percentpercent of clients had some of clients had some type of mental disorder.type of mental disorder.

Studies in mental health settings have found that Studies in mental health settings have found that between between 20 and 5020 and 50 percentpercent of their clients had of their clients had a co-occurring substance use disorder.a co-occurring substance use disorder.

Experts in this field assert that co-occurring Experts in this field assert that co-occurring disorders should be disorders should be the expectation, not the the expectation, not the exception exception in any behavioral health setting.in any behavioral health setting.

(Source: SAMHSA’s TIP 42)(Source: SAMHSA’s TIP 42)

How Serious are Co-occurring How Serious are Co-occurring Disorders?Disorders?

Clients with co-occurring disorders require more Clients with co-occurring disorders require more complexcomplex and and expensiveexpensive care. care.

Clients with co-occurring disorders tend to have more Clients with co-occurring disorders tend to have more problems of problems of allall kinds (medical, legal, social, kinds (medical, legal, social, interpersonal, homelessness, etc.), and more (and more interpersonal, homelessness, etc.), and more (and more expensive) contacts with agencies and providers (mental expensive) contacts with agencies and providers (mental health, drug & alcohol, law enforcement, courts, health, drug & alcohol, law enforcement, courts, emergency rooms, social welfare, shelters, etc.).emergency rooms, social welfare, shelters, etc.).

Clients with co-occurring disorders tend to “fall through Clients with co-occurring disorders tend to “fall through the cracks” of the traditional treatment system and the cracks” of the traditional treatment system and develop even worse and more expensive problems.develop even worse and more expensive problems.

A clients falling between the cracks.A clients falling between the cracks.

What Approaches to Treating Co-What Approaches to Treating Co-occurring Disorders Have Been Tried?occurring Disorders Have Been Tried?

Four general approaches have been tried:Four general approaches have been tried:1.1. Not at allNot at all—referred out to treatment for the other —referred out to treatment for the other

problem or refused care entirely.problem or refused care entirely.2.2. Serial TreatmentSerial Treatment—one type of disorder treated at a —one type of disorder treated at a

time, in separate settings.time, in separate settings.3.3. Concurrent Concurrent oror Parallel Treatment Parallel Treatment—treatment for —treatment for

both types of disorder offered at the same time but in both types of disorder offered at the same time but in separate settings and by separate providers.separate settings and by separate providers.

4.4. Integrated TreatmentIntegrated Treatment—both types of disorder —both types of disorder assessed and treated together in specialized settings assessed and treated together in specialized settings by providers possessing competency in the treatment by providers possessing competency in the treatment of both types of disorder of both types of disorder andand integrated treatment. integrated treatment.

How Beneficial Are These How Beneficial Are These Approaches? Approaches? (1 of 5)(1 of 5)

No Treatment At All:No Treatment At All: Denial of treatment is ineffective by definition. It is Denial of treatment is ineffective by definition. It is

also unethical and could result in legal liability. (Yet I also unethical and could result in legal liability. (Yet I have heard reports that it is still taking place in this have heard reports that it is still taking place in this county in 2006.)county in 2006.)

Serial Treatment:Serial Treatment: This approach can be helpful for This approach can be helpful for

those who are not so impaired by their “secondary” disorder those who are not so impaired by their “secondary” disorder that they can wait for it to be treated after their “primary” that they can wait for it to be treated after their “primary” disorder is treated, or disorder is treated, or

those whose co-occurring disorders do not interact with one those whose co-occurring disorders do not interact with one another.another.


Serial TreatmentSerial Treatment, continued:, continued: Serial Treatment can worsen problems or Serial Treatment can worsen problems or

create new ones:create new ones: Confusion due to conflicting treatment philosophies Confusion due to conflicting treatment philosophies

held by different providers.held by different providers. Confusion due to conflicting treatment Confusion due to conflicting treatment

recommendations or priorities.recommendations or priorities. Treatment gaps arising due to communication Treatment gaps arising due to communication

problems between/among providers.problems between/among providers. Practical considerations such as scheduling, Practical considerations such as scheduling,

transportation, etc.transportation, etc.


Concurrent or Parallel Treatment:Concurrent or Parallel Treatment: This approach can be helpful for those who: This approach can be helpful for those who:

are not seriously impaired by either disorder, are not seriously impaired by either disorder, do not require inpatient or residential care, anddo not require inpatient or residential care, and are cognitively equipped to handle and integrate are cognitively equipped to handle and integrate

the two treatment experiences.the two treatment experiences.


Concurrent/Parallel TreatmentConcurrent/Parallel Treatment, , continued:continued: As with serial treatment, this approach can As with serial treatment, this approach can

worsen problems or create new ones:worsen problems or create new ones: Confusion due to conflicting treatment philosophies Confusion due to conflicting treatment philosophies

held by different providers.held by different providers. Confusion due to conflicting treatment Confusion due to conflicting treatment

recommendations or priorities.recommendations or priorities. Treatment gaps arising due to communication Treatment gaps arising due to communication

problems between/among providers.problems between/among providers. Practical considerations such as scheduling, Practical considerations such as scheduling,

transportation, etc.transportation, etc.


Integrated Treatment:Integrated Treatment: A very recent development and not standard or typicalA very recent development and not standard or typical

—yet.—yet. Essential for clients who are significantly impaired by Essential for clients who are significantly impaired by

both kinds of disorder.both kinds of disorder. Essential for clients whose mental disorder interferes Essential for clients whose mental disorder interferes

with treatment of their substance use disorder.with treatment of their substance use disorder. Essential for clients whose substance use disorder Essential for clients whose substance use disorder

interferes with treatment of their mental disorder.interferes with treatment of their mental disorder. Beneficial for Beneficial for allall clients with co-occurring disorders clients with co-occurring disorders

due to its ability to avoid problems seen with other due to its ability to avoid problems seen with other models (provider conflicts, poor provider models (provider conflicts, poor provider communication, client confusion, scheduling or communication, client confusion, scheduling or transportation problems, etc.).transportation problems, etc.).

An Important Point About Integrated An Important Point About Integrated Care: It is a Care: It is a SeparateSeparate Specialty Area Specialty Area

Integrated treatment providers should be Integrated treatment providers should be knowledgeable about mental illness and skilled knowledgeable about mental illness and skilled in assessing mental problems and providing in assessing mental problems and providing mental health treatment.mental health treatment.

They should also be knowledgeable about They should also be knowledgeable about addictions and skilled in assessing substance addictions and skilled in assessing substance use problems and providing addiction treatment.use problems and providing addiction treatment.

But these separate knowledge and skill sets are But these separate knowledge and skill sets are not enough. Providers should also be not enough. Providers should also be knowledgeable about and skilled in knowledgeable about and skilled in integratedintegrated assessment and treatment of assessment and treatment of co-occurringco-occurring disorders.disorders.

Common Problems that Integrated Common Problems that Integrated Care is Designed to AddressCare is Designed to Address

We will address this topic by using fictional case We will address this topic by using fictional case examples that illustrate each of the following examples that illustrate each of the following three types of problems:three types of problems:

Assessment Problems.Assessment Problems.Treatment Problems.Treatment Problems.Other Problems.Other Problems.

Assessment Problems Assessment Problems (1 of 4)(1 of 4)

Case Example 1: José presents with restless-Case Example 1: José presents with restless-ness, agitation, anxiety, and tremulousness.ness, agitation, anxiety, and tremulousness. Mental health providers may tend to suspect an Mental health providers may tend to suspect an

anxiety disorder or a manic episode.anxiety disorder or a manic episode. Substance abuse providers may tend to suspect Substance abuse providers may tend to suspect

amphetamine intoxication or sedative withdrawal.amphetamine intoxication or sedative withdrawal. Integrated care providers suspect and investigate all Integrated care providers suspect and investigate all

of these possibilities and are sensitive to the of these possibilities and are sensitive to the additional issues that clients with co-occurring additional issues that clients with co-occurring disorders may face. disorders may face.


Case Example 2: Ellen presents with depressed Case Example 2: Ellen presents with depressed mood, tearfulness, and psychomotor retardation.mood, tearfulness, and psychomotor retardation. Mental health providers may tend to suspect a mood Mental health providers may tend to suspect a mood

disorder—major depressive episode or dysthymic disorder—major depressive episode or dysthymic disorder.disorder.

Substance abuse providers may tend to suspect Substance abuse providers may tend to suspect amphetamine withdrawal or alcohol or sedative amphetamine withdrawal or alcohol or sedative intoxication.intoxication.

Integrated care providers suspect and investigate all Integrated care providers suspect and investigate all of these possibilities and are sensitive to the of these possibilities and are sensitive to the additional issues that clients with co-occurring additional issues that clients with co-occurring disorders may face. disorders may face.


Case Example 3: George presents with Case Example 3: George presents with hallucinations and paranoid ideation.hallucinations and paranoid ideation. Mental health providers may tend to suspect a Mental health providers may tend to suspect a

psychotic disorder—i.e., paranoid schizophrenia.psychotic disorder—i.e., paranoid schizophrenia. Substance abuse providers may tend to suspect Substance abuse providers may tend to suspect

amphetamine psychosis or hallucinogen intoxication.amphetamine psychosis or hallucinogen intoxication. Integrated care providers suspect and investigate all Integrated care providers suspect and investigate all



Case Example 4: Bob presents with grandiosity, Case Example 4: Bob presents with grandiosity, excess energy, and serious legal and debt excess energy, and serious legal and debt problems.problems. Mental health providers may tend to suspect bipolar Mental health providers may tend to suspect bipolar

disorder (manic phase).disorder (manic phase). Substance abuse providers may tend to suspect Substance abuse providers may tend to suspect

amphetamine intoxication and dependence.amphetamine intoxication and dependence. Integrated care providers suspect and investigate all Integrated care providers suspect and investigate all


Treatment Problems Treatment Problems (1 of 4)(1 of 4)

Case Example 5: María, in treatment for Case Example 5: María, in treatment for addiction but also with unrecognized co-addiction but also with unrecognized co-occurring major depressive disorder, is labeled occurring major depressive disorder, is labeled “resistant” and “unmotivated” by staff.“resistant” and “unmotivated” by staff.

Case Example 6: Sam, in treatment for addiction Case Example 6: Sam, in treatment for addiction but also with co-occurring paranoid but also with co-occurring paranoid schizophrenia, has difficulty tolerating group schizophrenia, has difficulty tolerating group sessions, bonding with other members of his sessions, bonding with other members of his group, and fitting in at AA meetings.group, and fitting in at AA meetings.


Case Example 7: Heather, in treatment for Case Example 7: Heather, in treatment for bulimia nervosa, is not doing well because of her bulimia nervosa, is not doing well because of her amphetamine use which providers erroneously amphetamine use which providers erroneously view as part of her eating disorder instead of as view as part of her eating disorder instead of as independently co-occurring amphetamine independently co-occurring amphetamine dependence.dependence.

Case Example 8: Michael, in treatment for Case Example 8: Michael, in treatment for bipolar disorder, is unable to control his mood bipolar disorder, is unable to control his mood swings because of his drinking, which providers swings because of his drinking, which providers erroneously view as “self-medicating behavior” erroneously view as “self-medicating behavior” instead of as independently co-occurring alcohol instead of as independently co-occurring alcohol dependence.dependence.


Case Example 9: Mario, who has co-occurring Case Example 9: Mario, who has co-occurring bipolar disorder and alcohol dependence, is bipolar disorder and alcohol dependence, is discouraged from taking his medications by discouraged from taking his medications by addiction treatment staff, and is told by mental addiction treatment staff, and is told by mental health staff that his “real” problem is his mood health staff that his “real” problem is his mood disorder, and that the drinking is secondary.disorder, and that the drinking is secondary.

Case Example 10: Edmund, who has co-Case Example 10: Edmund, who has co-occurring major depressive disorder and occurring major depressive disorder and polysubstance dependence, is denied polysubstance dependence, is denied medication by his psychiatrist until he returns to medication by his psychiatrist until he returns to the mental health clinic having been clean and the mental health clinic having been clean and sober for 30 days.sober for 30 days.


Case Example 11: Susan—who is alcohol- and drug- Case Example 11: Susan—who is alcohol- and drug- dependent, has PTSD (and possibly a dissociative dependent, has PTSD (and possibly a dissociative disorder) secondary to extreme child sexual abuse, and disorder) secondary to extreme child sexual abuse, and is HIV and HCV positive—cannot participate in PTSD is HIV and HCV positive—cannot participate in PTSD treatment because she is rarely sober; cannot participate treatment because she is rarely sober; cannot participate in addiction treatment because of crises precipitated by in addiction treatment because of crises precipitated by extremely dysphoric intrusive flashbacks that she tries to extremely dysphoric intrusive flashbacks that she tries to cope with by drinking alcohol, taking drugs, self-cope with by drinking alcohol, taking drugs, self-mutilating, binge-eating, and acting out sexually; does mutilating, binge-eating, and acting out sexually; does not keep appointments for HIV or HCV treatment; is a not keep appointments for HIV or HCV treatment; is a public health risk due to her high-risk behaviors of public health risk due to her high-risk behaviors of needle-sharing and multiple sexual partners; and is not needle-sharing and multiple sexual partners; and is not quite suicidal enough or incapable enough of caring for quite suicidal enough or incapable enough of caring for herself to be involuntarily hospitalized.herself to be involuntarily hospitalized.

Other Problems Other Problems (1 of 2)(1 of 2)

Case Example 11: During residential polydrug detox, Case Example 11: During residential polydrug detox, treatment staff notice that Jim has a serious mental treatment staff notice that Jim has a serious mental disorder. They refer him for mental health treatment, but disorder. They refer him for mental health treatment, but the earliest he can be seen by a psychiatrist is 60 days the earliest he can be seen by a psychiatrist is 60 days away—long after he will have completed detox.away—long after he will have completed detox.

Case Example 12: Jane is referred to addiction Case Example 12: Jane is referred to addiction treatment by her mental health provider, but, because treatment by her mental health provider, but, because the receptionist at the addiction treatment program (who the receptionist at the addiction treatment program (who has not been trained in how to respond to mentally ill has not been trained in how to respond to mentally ill clients) reacts to her in an insensitive manner, Jane feels clients) reacts to her in an insensitive manner, Jane feels unwelcome and leaves without making an appointment. unwelcome and leaves without making an appointment.

Other Problems Other Problems (2 of 2)(2 of 2)

Case Example 13: Mike is referred to addiction Case Example 13: Mike is referred to addiction treatment by mental health providers, but he is treatment by mental health providers, but he is homeless and without transportation, so he homeless and without transportation, so he never makes it to his appointment.never makes it to his appointment.

Case Example 14: Dan’s mental health provider, Case Example 14: Dan’s mental health provider, Ellen, has a strong countertransference reaction Ellen, has a strong countertransference reaction to Dan because Dan resembles Ellen’s alcoholic to Dan because Dan resembles Ellen’s alcoholic father.father.

What is Integrated Care? What is Integrated Care? (1 of 3)(1 of 3)

The client participates in The client participates in oneone program that program that provides treatment for provides treatment for bothboth disorders. disorders.

The client’s mental and substance use disorders The client’s mental and substance use disorders are treated by the are treated by the samesame clinicians. clinicians.

The clinicians are trained in psychopathology, The clinicians are trained in psychopathology, assessment, and treatment strategies for assessment, and treatment strategies for bothboth mental mental andand substance use disorders. substance use disorders.

The clinicians offer substance abuse treatments The clinicians offer substance abuse treatments tailored for clients who have severe mental tailored for clients who have severe mental disorders.disorders.


The focus is on preventing anxiety rather The focus is on preventing anxiety rather than breaking through denial.than breaking through denial.

Emphasis is placed on trust, Emphasis is placed on trust, understanding, and learning.understanding, and learning.

Treatment is characterized by a slow pace Treatment is characterized by a slow pace and a long-term perspective.and a long-term perspective.

Providers offer stagewise and motivational Providers offer stagewise and motivational counseling.counseling.


Supportive clinicians are readily available.Supportive clinicians are readily available. Twelve-Step groups are available to those Twelve-Step groups are available to those

who choose to participate and can benefit who choose to participate and can benefit from participation.from participation.

Neuroleptics and other pharmacotherapies Neuroleptics and other pharmacotherapies are indicated according to clients’ are indicated according to clients’ psychiatric and other medical needs.psychiatric and other medical needs.

((TIP 42TIP 42, p. 45), p. 45)

Categories of COD ProgramsCategories of COD Programs Dual Diagnosis Dual Diagnosis CapableCapable (DDC-CD or DDC-MH). (DDC-CD or DDC-MH).

DDC-CD Welcomes individuals with chemical dependency (CD) DDC-CD Welcomes individuals with chemical dependency (CD) whose conditions are stable; makes provision for comorbidity in whose conditions are stable; makes provision for comorbidity in program mission, screening, assessment, treatment planning, program mission, screening, assessment, treatment planning, staff training, etc.staff training, etc.

DDC-MH is similar to the above in a mental health (MH) DDC-MH is similar to the above in a mental health (MH) treatment setting.treatment setting.

DDE=Dual Diagnosis DDE=Dual Diagnosis EnhancedEnhanced (DDE-CD or DDE-MH). (DDE-CD or DDE-MH). DDE-CD is a CD program that is enhanced to accommodate DDE-CD is a CD program that is enhanced to accommodate

individuals with subacute symptomatology or moderate disability; individuals with subacute symptomatology or moderate disability; enhanced MH staffing and programming, etc.enhanced MH staffing and programming, etc.

DDE-MH is similar to the above in a MH setting.DDE-MH is similar to the above in a MH setting.

COD Program ModelsCOD Program Models Continuous Integrated Case Management.Continuous Integrated Case Management. Continuous Recovery Support.Continuous Recovery Support. Emergency Triage/Crisis Intervention.Emergency Triage/Crisis Intervention. Crisis Stabilization Beds.Crisis Stabilization Beds. Psychiatric Inpatient Unit or Partial Hospital.Psychiatric Inpatient Unit or Partial Hospital. Detoxification Programs.Detoxification Programs. Psychiatric Day Treatment.Psychiatric Day Treatment. Addiction Intensive Outpatient (IOP), Partial, Addiction Intensive Outpatient (IOP), Partial,

Residential.Residential. Psychiatric Housing Programs:Psychiatric Housing Programs:

Abstinence-expected (dry).Abstinence-expected (dry). Abstinence-encouraged (damp).Abstinence-encouraged (damp). Consumer-choice (wet).Consumer-choice (wet).

Principles and StandardsPrinciples and Standards

Next, we will cover aspects of the Minkoff Next, we will cover aspects of the Minkoff Model for assessment and treatment of Model for assessment and treatment of co-occurring disorders:co-occurring disorders: The Nine Principles, andThe Nine Principles, and The Eight Practice StandardsThe Eight Practice Standards

The Nine Principles The Nine Principles (1 of 4)(1 of 4)

1. Dual diagnosis is an 1. Dual diagnosis is an expectationexpectation, not an , not an exception.exception.

2. The population of individuals with co-occurring 2. The population of individuals with co-occurring disorders can be organized into disorders can be organized into four subgroupsfour subgroups based on high and low based on high and low severityseverity of each type of of each type of disorder (see next slide).disorder (see next slide).

3. Treatment success involves formation of 3. Treatment success involves formation of empathic, hopeful, integrated treatment empathic, hopeful, integrated treatment relationships.relationships.


The Four QuadrantsThe Four Quadrants

Quadrant IQuadrant ILow Severity MI Low Severity MI

Low Severity SUDLow Severity SUD

Quadrant IIQuadrant IIHigh Severity MI, Low High Severity MI, Low

Severity SUDSeverity SUD

Quadrant IIIQuadrant IIILow Severity MI, High Low Severity MI, High


Quadrant IVQuadrant IVHigh Severity MI, High High Severity MI, High



4. Treatment success is enhanced by maintaining 4. Treatment success is enhanced by maintaining integrated treatment relationships providing disease integrated treatment relationships providing disease management interventions for management interventions for bothboth disorders disorders continuouslycontinuously across multiple treatment episodes, across multiple treatment episodes, balancing case management support with detachment balancing case management support with detachment and expectation at each point in time.and expectation at each point in time.

5. Integrated dual primary diagnosis-specific treatment 5. Integrated dual primary diagnosis-specific treatment interventions are recommended.interventions are recommended.

6. Interventions need to be matched not only to diagnosis, 6. Interventions need to be matched not only to diagnosis, but also to phase of recovery, stage of treatment, and but also to phase of recovery, stage of treatment, and stage of change.stage of change.


7. Interventions need to be matched according to level of care and/or 7. Interventions need to be matched according to level of care and/or service intensity requirements, utilizing well-established level of care service intensity requirements, utilizing well-established level of care assessment methodologies.assessment methodologies.

8. There is no single correct dual diagnosis intervention, nor single 8. There is no single correct dual diagnosis intervention, nor single correct program. For each individual, at any point in time, the correct correct program. For each individual, at any point in time, the correct intervention must be individualized, according to subgroup, intervention must be individualized, according to subgroup, diagnosis, stage of treatment or stage of change, phase of recovery, diagnosis, stage of treatment or stage of change, phase of recovery, need for continuity, extent of disability, availability of external need for continuity, extent of disability, availability of external contingencies, and level of care assessment.contingencies, and level of care assessment.

9. Outcomes of treatment interventions are similarly individualized, 9. Outcomes of treatment interventions are similarly individualized, based upon the above variables and the nature and purpose of the based upon the above variables and the nature and purpose of the intervention. Outcome variables include not only abstinence, but intervention. Outcome variables include not only abstinence, but also amount and frequency of use, reduction in psychiatric also amount and frequency of use, reduction in psychiatric symptoms, stage of change, level of functioning, utilization of acute symptoms, stage of change, level of functioning, utilization of acute care services, and reduction of harm.care services, and reduction of harm.

The Eight Practice StandardsThe Eight Practice Standards (1 of 3)(1 of 3)

1. Welcoming Expectation.1. Welcoming Expectation. Expect comorbidity and engage clients in an empathic, hopeful, Expect comorbidity and engage clients in an empathic, hopeful,

welcoming manner.welcoming manner.

2. Access to Assessment.2. Access to Assessment. Access to services should not require clients to self-define as Access to services should not require clients to self-define as

MH or SUD before arrival; eliminate barriers; deny no client MH or SUD before arrival; eliminate barriers; deny no client treatment based on disorders.treatment based on disorders.

3. Access to Continuing Relationships.3. Access to Continuing Relationships. Initiate and maintain empathic, hopeful, continuous treatment Initiate and maintain empathic, hopeful, continuous treatment

relationships—even if treatment recommendations are not relationships—even if treatment recommendations are not followed.followed.

4. Balance Case Management and Care with Expectation, 4. Balance Case Management and Care with Expectation, Empowerment, and Empathic Confrontation.Empowerment, and Empathic Confrontation.


5. Integrated Dual Primary Treatment.5. Integrated Dual Primary Treatment. Each disorder receives appropriate diagnosis-specific Each disorder receives appropriate diagnosis-specific

and stage-specific treatment, regardless of the status and stage-specific treatment, regardless of the status of the comorbid condition.of the comorbid condition.

6. Stage-Wise Treatment:6. Stage-Wise Treatment: Acute Stabilization.Acute Stabilization. Motivational Enhancement.Motivational Enhancement. Active Treatment.Active Treatment. Relapse Prevention.Relapse Prevention. Rehabilitation and Recovery.Rehabilitation and Recovery.


7. Early Access to Rehabilitation.7. Early Access to Rehabilitation. Clients who request assistance with housing, jobs, Clients who request assistance with housing, jobs,

socialization, and meaningful activity are provided socialization, and meaningful activity are provided access even if they are not initially adherent to MH or access even if they are not initially adherent to MH or SUD treatment recommendations.SUD treatment recommendations.

8. Coordination and Collaboration.8. Coordination and Collaboration. Consistent collaboration between all treaters, family Consistent collaboration between all treaters, family

caregivers, and external systems is required.caregivers, and external systems is required. Collaboration with families should be considered an Collaboration with families should be considered an

expectation for all individuals at all stages of change.expectation for all individuals at all stages of change.

Medication Guidelines for CODsMedication Guidelines for CODsfrom Minkoff, et al (1998)from Minkoff, et al (1998)

““Psychopharmacology for people with co-Psychopharmacology for people with co-occurring disorders is best performed in occurring disorders is best performed in the context of an ongoing, empathic, the context of an ongoing, empathic, clinical relationship that emphasizes clinical relationship that emphasizes continuous reevaluation of both diagnosis continuous reevaluation of both diagnosis and medication, and artful utilization of and medication, and artful utilization of medication strategies to promote better medication strategies to promote better outcome of both disorders.” outcome of both disorders.”

Medication Guidelines Medication Guidelines (2 of 3)(2 of 3)

Maximize outcome of two Maximize outcome of two primaryprimary disorders: disorders: For diagnosed psychiatric illness, the most clinically For diagnosed psychiatric illness, the most clinically

effective psychopharmacologic strategy available, effective psychopharmacologic strategy available, regardless of the status of the comorbid substance regardless of the status of the comorbid substance disorderdisorder..

For diagnosed substance disorder, appropriate For diagnosed substance disorder, appropriate psychopharmacologic strategies may be used as psychopharmacologic strategies may be used as ancillary treatments to support a comprehensive ancillary treatments to support a comprehensive program of recovery, program of recovery, regardless of the presence of a regardless of the presence of a comorbid psychiatric disorder comorbid psychiatric disorder (although taking into (although taking into account the individual’s cognitive capacity and account the individual’s cognitive capacity and disability).disability).

Medication Guidelines Medication Guidelines (3 of 3)(3 of 3)

Priorities:Priorities:1.1. Establish medical and psychiatric safety in Establish medical and psychiatric safety in

acute situations.acute situations.2.2. Maintain stabilization of severe and/or Maintain stabilization of severe and/or

established psychiatric illness.established psychiatric illness.3.3. Use medication strategies to promote or Use medication strategies to promote or

establish sobriety.establish sobriety.4.4. Diagnose and treat less serious psychiatric Diagnose and treat less serious psychiatric

disorders that may emerge once sobriety is disorders that may emerge once sobriety is established.established.

Diagnosis-Specific Diagnosis-Specific Recommendations Recommendations (1 of 2)(1 of 2)

Schizophrenic Disorders:Schizophrenic Disorders: Atypical neuroleptics; clozapine may reduce Atypical neuroleptics; clozapine may reduce

substance abuse.substance abuse. Bipolar Disorders:Bipolar Disorders:

Second and third generation mood stabilizers Second and third generation mood stabilizers (valproate, lamotrigine).(valproate, lamotrigine).

Gabapentin and topiramate may also be useful.Gabapentin and topiramate may also be useful. A significant population will still respond to lithium.A significant population will still respond to lithium.

Depressive Disorders:Depressive Disorders: No particular category of antidepressant is specifically No particular category of antidepressant is specifically

recommended or contraindicated.recommended or contraindicated.

Diagnosis-Specific Diagnosis-Specific Recommendations Recommendations (2 of 2)(2 of 2)

Anxiety Disorders: Anxiety Disorders: Benzodiazepines for acute situations and detox only.Benzodiazepines for acute situations and detox only. For anxiety: clonidine, venlafaxine, SSRIs, For anxiety: clonidine, venlafaxine, SSRIs,

gabapentin, valproate, topiramate, atypical gabapentin, valproate, topiramate, atypical neuroleptics, buspirone.neuroleptics, buspirone.

Attentional Disorders:Attentional Disorders: Bupriprion, SSRIs, Strattera (atomoxatine).Bupriprion, SSRIs, Strattera (atomoxatine).

Addictive Disorders:Addictive Disorders: Disulfiram, naltrexone, acamprosate, methadone, Disulfiram, naltrexone, acamprosate, methadone,

LAAM, buprenorphine.LAAM, buprenorphine.

Some Evidence-Based PracticesSome Evidence-Based Practices

Stages of Change/Motivational Interviewing.Stages of Change/Motivational Interviewing. Harm Reduction.Harm Reduction. Mutual Self-Help Programs.Mutual Self-Help Programs. Consumer-Delivered Services.Consumer-Delivered Services. Specialty Courts (Drug Court, Mental Health Specialty Courts (Drug Court, Mental Health

Court, Co-occurring Disorders Court).Court, Co-occurring Disorders Court). Specialized Services for Homeless Populations.Specialized Services for Homeless Populations. Group Treatment.Group Treatment. Family Treatment.Family Treatment.

Psychological Trauma and Psychological Trauma and Co-occurring DisordersCo-occurring Disorders

Many studies link childhood trauma to both Many studies link childhood trauma to both mental illness and addiction.mental illness and addiction.

One particularly striking study is called the ACE One particularly striking study is called the ACE Study (Study (http://http://www.acestudy.orgwww.acestudy.org), in which ), in which 17,000 patients of Kaiser-Permanente were 17,000 patients of Kaiser-Permanente were assessed for number of different types of assessed for number of different types of Adverse Childhood Experiences and subsequent Adverse Childhood Experiences and subsequent medical, mental health, and addiction problems. medical, mental health, and addiction problems.

Some results of this study appear on the next Some results of this study appear on the next slides.slides.

Definition of Adverse Childhood Definition of Adverse Childhood ExperiencesExperiences

Growing up (prior to age 18) in a household Growing up (prior to age 18) in a household with: with:

(score 1 point for 1 (score 1 point for 1 or moreor more incidents in each category) incidents in each category) Recurrent physical abuse. Recurrent physical abuse. Recurrent emotional abuse. Recurrent emotional abuse. Sexual abuse. Sexual abuse. An alcohol or drug abuser. An alcohol or drug abuser. An incarcerated household member. An incarcerated household member. Someone who is chronically depressed, suicidal, Someone who is chronically depressed, suicidal,

institutionalized or mentally ill. institutionalized or mentally ill. Mother being treated violently. Mother being treated violently. One or no parents. One or no parents. Emotional or physical neglect. Emotional or physical neglect.

Adverse Childhood Experiences Adverse Childhood Experiences and Smoking (Tobacco)and Smoking (Tobacco)

Adverse Childhood Experiences Adverse Childhood Experiences and COPDand COPD

Adverse Childhood Experiences Adverse Childhood Experiences and Addictionand Addiction

Adverse Childhood Experiences Adverse Childhood Experiences and Attempted Suicideand Attempted Suicide

Your NeedsYour Needs

Times are changing, and we can no longer act as if co-Times are changing, and we can no longer act as if co-occurring disorders were rare or insignificant.occurring disorders were rare or insignificant.

You are going to be in the vanguard of a movement to You are going to be in the vanguard of a movement to overhaul service delivery in this county.overhaul service delivery in this county.

You are facing a large task, and you will need to be You are facing a large task, and you will need to be equipped to accomplish it.equipped to accomplish it.

What will your needs be?What will your needs be? Professional Educational PersonalProfessional Educational Personal

We will be considering this question in the Needs We will be considering this question in the Needs Assessment portion of this program.Assessment portion of this program.

Questions/Answers/CommentsQuestions/Answers/Comments

Thank-you for your attention.Thank-you for your attention. Now, please let me know your thoughts, Now, please let me know your thoughts,

observations, questions, dilemmas, fears, observations, questions, dilemmas, fears, suspicions, hopes, etc.suspicions, hopes, etc.

co-occurring disorders: a brief introduction for san luis obispo county behavioral health services...

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