the treatment of co-occurring disorders · •make opportunities for the family to meet some of...

..

BY:

Rhonda McKillip M.Ed., LMHC, MAC, CCDC III, CDP (Ret)

Psychotherapist, International Trainer, Consultant NAADAC Approved Education Provider

Member of the Motivational Interviewing Network of Trainers (MINTie) Author of THE BASICS, SECOND EDITION:

A CURRICULUM FOR CO-OCCURRING PSYCHIATRIC AND SUBSTANCE DISORDERS Foreword by Kenneth Minkoff, MD

Officially Endorsed Text by the IC&RC (International Certification & Reciprocity Consortium) as the Study Guide for the CCDP, CCDPD, and AADC Exams

Website: rhondamckillipandthebasics.com Email: [email protected]

Behavioral Health Services Department Learning Partnership

The Treatment of Co-Occurring Disorders

Presents

County of Santa Clara Behavioral Health Services


November 15th, 2019; San Jose, California


Psychoeducation + Consistency + Groups + Implementation

BY: RHONDA MCKILLIP, M.ED., LMHC, MAC, CCDCIII, CDP (RET)

Training Material Developed & Presented By: Rhonda McKillip M.Ed., LMHC, MAC, CCDCIII, CDP (Ret)

All rights remain with Rhonda McKillip LLC; rhondamckillipandthebasics.com; [email protected]

The Treatment of Individuals With

Co-Occurring Disorders

Behavioral Health

Services Department

Learning Partnership

•

•

•

•

•

Kenneth Minkoff; Dennis Daley

• Integrated System of Care

• Universal Dual Diagnosis

Capabilities

• Principles of Empathy and

Hope

• Motivational Interviewing

Approach

• Stages of Change Model

Design

• Neurochemistry Based

Disorders

• Strength Based

• Skill Building

• Solution Focused

• Symptom

Identification

• Symptoms

Management

• Best Practices

Psychoeducation

• Group Therapy

Is a fundamental component in the integrated

treatment of individuals with co-occurring

psychiatric and substance use disorders. It’s the

only way a person can understand their

disorders, develop an individual plan of

treatment, and be empowered with the skills to

live with their disorders, as well as protect

themselves from renewed occurrences.

Yet, how can a professional present evidence-

based integrated treatment without the tools to

provide it?

Why do we even care about the causes of substance use disorders and psychiatric disorders

Ca

use

s

Understanding Disorder

Treatment of Disorder

Managing Symptoms









Organ

Defect

Adapted from: Kevin McCauley, MD; The Institute

for Addiction Study; addictiondoctor.com

Symptoms

Heart

Lack of Oxygen

Blocked

Arteries

1. Pain

2. Cell Destruction

3. Heart Attack

4. Other

Pancreas

Islet Cell

Death

No Insulin

Adapted from: Kevin McCauley, MD; The Institute for Addiction Study; addictiondoctor.com

1. Elev. Blood

Glucose

2. Blurred Vision

3. Coma

4. other

Pancreas

Islet Cell

Death

No Insulin

1. Elev. Blood

Glucose

2. Blurred Vision

3. Coma

4. other

CAUSE

Insulin

Replacement

Depression

Defect?

Adapted from: Kevin McCauley, MD; The Institute

for Addiction Study; addictiondoctor.com

Naturally

Unstable?

Wounded?

Weakness?

Addiction

Defect?

Badness?

Willpower?

Character?

Morals?

e le c t r ica l im p u lse e le c t r ica l im p u lse

N e u r o nN e u r o n

N e u r o t r a n sm it t e r

Sy n a p se

R e c e p t o rReuptake

MAO

Cortisol

ACE, DA, NE, GABA, ENK, END, SE

Synapse









Neurotransmitter Functioning Disrupted

Acetycholine thinking, memory.

mental alertness

confusion, unable to

concentrate or remember

Dopamine pleasure, emotional

stability, reward

depression, anhedonia,

lack of remorse

Norepinephrine energy, motivation,

drive, confidence

Depression, lack of

ambition, energy & drive

Serotonin mood stability,

self-esteem

lack of rational emotion,

irritable, tearfulness

GABA tranquilizer, stress

management

free-floating anxiety,

fearfulness, insecurity

Endorphins &

Enkephalins

physical & emotional

pain management,

stress control

inadequate pain

management, feeling

incomplete & inferior

• Pre-Diagnosis & Pre-Using: Low P300 Brain

Levels; Elevated Levels of Anxiety & Tension to Non-Stressful &

Stressful Stimuli; Neurochemical Imbalanced Base-Line Levels;

Excessive High-Frequency EEG Brain Activity…

• Acute System & Using: Low Initial Response to

Intoxication; Difficulties Prioritizing External Stimulus; Greater

Reduction in Stress Reactions; Exceptionally Rewarding Using

Experience; Significant Increased Endorphin Levels; Reduced

MAO; Enhanced Neurotransmitter Activity for Longer Time; Re-

Uptake Interruption; Neo-Adaptation; Development of Tolerance;

Reduced Cortisol Levels; Brain Chemistry Changes & Cravings

• Re-Occurring & Post-Using: Down Regulation

of “Feel Good” Neurotransmission; Acute & Post Acute WD

• Major Depression: serotonin & norepinephrine

deficiencies; dysregulation of neural circuits responsible for

regulating mood, thinking, sleep, appetite, behavior…

• Bipolar Disorder: irregularities & imbalances in

activity of certain brain circuits; higher than average overall brain

metabolic activity yet reduced activity in the left prefrontal activity;

increased activity in NE & dopamine

• Anxiety Disorders: Significant irregularities and

dysfunctions in the brain; lower levels of Cortisol resulting in

overabundance of Epinephrine & NE; High levels of CRF…

• Schizophrenia: irregular neuron connections in fetal

development; over-activity in dopamine receptors; mis-

communication between frontal lobes & other parts of brain…









• Nutrition

• Relaxation

• Exercise

• Talk Therapy

• Balance in All Areas

• Expressing Emotions

• Active & Positive Life

• Support Groups

• Stress Management

Cerebral Cortex:

Controls Thinking, Speech,

Judgment, Information

Processing

Midbrain:

Controls Emotion

Primitive Brain:

Controls Breathing,

Heartbeat, Survival

Brain

“Wakes Up”

From

Bottom Up

Drugs

Suppress

Brain Activity

From Top

Down









Characteristics of Self-Esteem

Self-Acceptance Self-Nurturing

Self-Worth Self-Guidance

Self-Feeling Self-Determination

Self-Focus Self-Healing

Self-Growth Self-Love

Values & Boundaries

•

•

•

•

1 Have a Sense of Humor

2 Learn to Laugh

3 Stay In Touch With Your “Inner Clown”

4 Learn to Play

5 Read or Expose Yourself to Humorous

Material









Stressors – Importance and Control

Important & Uncontrollable

________________

Important & Controllable

________________

Unimportant & Uncontrollable

________________

Unimportant & Controllable

_________________

“How important is it?” “Can I control this event?”

• Symptom Management

• Treat as if Never Clear

• Connections with Docs

• Client Connection & Preparation

Emotional Recovery

Attending Meetings

Getting a Sponsor

Working the Twelve Steps

Reading Inspirational Literature

Being of Service to Others

Deepen Contact With Spiritual Side and Higher Power

• Honesty

• Trust

• Kindness

• Forgiveness

• Cooperation

• Patience









S

• If distrust has been earned – expect It.

• Help your family learn about your recovery.

• Invite family to join in group meetings.

• Be open yourself to “meeting” your family again.

• Make opportunities for the family to meet some of your

new friends in recovery.

• Make one family member a “partner in recovery.”

• Do as much as you can for yourself. But when there is

a legitimate need, don’t be too proud to ask the family

for help.

• Remember: Recovery depends on the person in

recovery, not on the attitudes or actions of their family.

Essential in any profession – most especially in

the treatment of chronic disorders. Consistency

must include the educational content, treatment

focus, and the therapeutic approach from one

professional to another, from agency to agency,

and from group to group. Yet, how can we

connect the evidence-based science to the

service delivery?

Clients rated the

alliance as the best predictor of

engagement and outcome

(William Miller & Steve Rollnick – 2013)









• Sounds like…• What I’m hearing

is…• Must be…• I would think you…• Like a…• Almost as if…• You…• You are…• Your belief is that…• Your fear is that..

• You’re thinking…

• So you are saying…• Your feeling that…• For you, it’s a matter of…• I would imagine you…• It seems to you…• Through your eyes…• From your point of view…• The thing that bothers you is…• You’re not terribly happy about..

• You’re not much concerned

about…• I’m really getting that you… Prochaska & DiClemente, 1992

• Justified Uncertainty

• Unjustified Certainty

• Justified Certainty

• Unjustified UncertaintyDr. Shaw, Kitsap County, Washington

I have not the right to want to

change another is I am not

open to be changed.

(Martin Burber)

Prochaska & DiClemente, 1992

• Pre-contemplation: You may think this is an

issue, but I don’t, and even if I do, I don’t want to deal

with it, so don’t bug me.

• Contemplation: I’m willing to think with

you, and consider if I want to change, but have no

interest in changing, at least not now.

• Preparation: I’m ready to start changing but I

haven’t started, and I need some help to know how to

begin.

By Chris Cline, M.D., MBA & Kenneth Minkoff, M.D.; ziapartners.com

• Early Action: I’ve begun to make some

changes, and need some help to continue, but I’m

not committed to maintenance or to following all

your recommendations.

• Late Action: I’m working toward maintenance,

but I haven’t gotten there, and I need some help to

get there.

• Maintenance: I’m stable and trying to stay that

way, as life continues to throw challenges in my

path.

By Chris Cline, M.D., MBA & Kenneth Minkoff, M.D.; ziapartners.com









Precontemplation

Contemplation

Action

Maintenance

Preparation

Empathy

Explore and Amplify

Ambivalence

Clarify, Plan &

Set Goals

Relapse Prevention

Monitor & Set

New Goals

Relapse Reframe & Drop Back

• How important is it for you right now to make

this change (the specific target behavior)?

• On a scale from 0-10 (where 1 is not important & 10 is

extremely important?) …what number would you give

yourself?

0__ 1___2___ 3__ 4___ 5___ 6____7____8____9___10

Follow-up Importance Scale Questions

• “And why are you at ____ and not a ____(a lower

number than stated)?”

• Example: “A six? Could you talk more about why you

are at a six and not a four?” “What might happen that

could move you from ____to (a higher number)?”

• If you did decide to change, how confident are you that

you would succeed?

• On a scale from 0-10 …what number would you give

yourself?

0__ 1___2___ 3__ 4___ 5___ 6____7____8___9___10Follow-up Confidence Scale Questions

“You are a four? What would it take

for you to move from a four to a five?”

• Today, how sure (self-efficacy) are you if you decide to

make this change that you will be able to do that? Rate 0-

10: 0- I’m not sure at all; 10- I’m very sure.

• Today, how ready are you to change your _______?

• Today, how willing are you to change your_______?

• Today, how able are you to change your _________?

Not so good things

about _?_(not

changing):

Good things

about__?__

(not changing):

1.____________________

2.____________________

Not so good things

about ______?____

(changing):

Good things

about___?___

(changing):

1.____________________

2.____________________

1.______________________

2.______________________

1.______________________

2.______________________

Crucial in the treatment setting and their

importance can’t be overemphasized. Group

interaction allows a person to “experience”

recovery in a group of their peers. What is

successfully learned, practiced, and internalized

in a group setting can be transferred into the

living community post-treatment. Yet, how do we

provide treatment to individuals with varying

diagnoses, acuity, and severity of symptoms?

• Keeps Honesty & Accountability

• Gives New Perspectives

• Breaks Through Isolation & Shame

• Gets the Story Right

• Sheds Illusions

• Produces Lasting Benefits of Telling a Truthful Story









• Listening

• Clarifying

• Saying

• Feedback

• Direct

Communication

• Openness

• Taking Responsibility

• Trust

• Involvement

• Staying in the Here &

Now

• Give and Take

Listening Skills

Listen From the Heart

Listen for Details

Pay Attention If the Person Is Expressing

Facts or Feelings

Use Silence When You Do Not

Know What to Say

Listen for More Than Words

Listen to What Is Not Being Said

Listen Objectively Use Short Responses

Listen for the Main Idea Listen Twice as Much

Focus Fully on What Someone is Saying

• Awareness of My Own

Behavior

• Applying Insight Of Own

Behavior

• Experiment With Own

Behavior

• Contribute to The

Group’s Awareness of

Itself

• Problem Solving

Effectiveness

• Group Maintenance

• Making The Group a Part of

Life

• Contribute to Others Sharing

• Contribute to the Process of

Group

• Group Diagnostic Ability

• Overall Effectiveness as a

Group

These principles, treatment focus,

educational content, and therapeutic

approach are only helpful to those

seeking services when they are

implemented.

Rhonda McKillip, LLC

M.Ed., LMHC, MAC, CCDCIII, CDP (RET)

rhondamckillipandthebasics.com

[email protected]

the treatment of co-occurring disorders · •make opportunities for the family to meet some of...

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