Treating the whole person integrating care for persons with co occurring disorders
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Treating the Whole Person: Integrating Care for Persons with Co-Occurring Disorders. Thomas E. Freese, Ph.D. Beth A. Rutkowski, M.P.H. UCLA ISAP/Pacific Southwest ATTC UCLA. Ice Breaker.

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Treating the Whole Person: Integrating Care for Persons with Co-Occurring Disorders

Thomas E. Freese, Ph.D.

Beth A. Rutkowski, M.P.H.

UCLA ISAP/Pacific Southwest ATTC


Ice Breaker

  • In pairs, discuss a consumer who has experienced both mental health and substance use disorders.

  • How is this consumer unique from other mental health consumers?

  • How does the consumer present? What behaviors does he/she exhibit that are different from a consumer with mental illness only?

Introduction:What we will cover

  • Overview of the evolving field of Co-Occurring Disorders

  • What is happening in the brain?

  • Using motivational interviewing with this population—why and how

  • Importance of conducting effective screening and assessment for COD

  • Conducting a brief intervention for consumers with COD

  • Ways in which trauma and HIV impact COD

Co-Occurring Disorders

Co-occurring disorders

  • Refers to co-occurring substance use(abuse or dependence) and mental disorders

    In other words…

    consumers with co-occurring disorders have:

  • one or more disorders relating to the use of alcohol and/or other drugs of abuse and one or more mental disorders

Co-Occurring Disorders

Diagnosis of COD occurs when:

  • at least one disorder of each type can be established independent of the other and

  • is not simplya cluster of symptoms resulting from the one disorder

    Clinicians knowledge of

    both mental health and substance abuse

    is essential, but challenging to achieve

So, all of that is well and good, but…

…is dealing with drug abuse REALLY important to my job?

Prevalence of COD

  • In 2006, 5.6 million adults (2.5% of persons aged 18+) met the criteria for both serious psychological distress (SPD) and substance dependence and abuse (i.e., substance use disorder, SUD)

  • In 2006, 15.8 millionadults (7.2% of persons aged 18+) had at least one major depressive episode (MDE) in the past year

    • Adults with MDE in the past year were more likely than those without MDE to have used an illicit drug in the past year (27.7 vs. 12.9 percent)

SOURCE: 2006 National Survey on Drug Use and Health, SAMHSA.

Past Year Treatment of Adults with Both Serious Psychological Distress (SPD) and SUD (2006)

5.6 Million adults with co-occurring SPD and substance use disorder.

SOURCE: 2007 National Survey on Drug Use and Health, SAMHSA.

Past Year Treatment of Adults with Both MDE and AUD

SOURCE: 2007 National Survey on Drug Use and Health, SAMHSA.

Percentage of Adults with Past Year MDE and AUD by Age Group

SOURCE: 2007 National Survey on Drug Use and Health, SAMHSA.

Substance Use and Depression among Adults

SOURCE: 2006 National Survey on Drug Use and Health, SAMHSA.

Substance Use and Depression among Adolescents

*Aged 12-17

SOURCE: 2006 National Survey on Drug Use and Health, SAMHSA.

Adolescents with Substance Use Disorders...

•Are largely undiagnosed

•Are distributed across diverse health and social service systems

•Are more likely to be involved in the juvenile justice system

•Have higher rates of child abuse(neglect, physical and sexual abuse

•Have high co-morbidity with psychiatric conditions

Data from LA County DMH, 2007

  • 61,739 new episodes opened in DMH Directly Operated Programs:

    • 17,647 (29%) dual code field was empty (i.e., neither presence nor absence of substance use noted);

    • 44,092 episodes where dual field was completed:

      • 31,187 (71%) indicated NO substance abuse issues

      • 12,905 (29%) indicated substance abuse issues.

Prevalence and Other Data

Data now show:

  • COD are common in general adult population.

  • Increased prevalence of people with COD and programs for people with COD

  • People with COD are more likely to be hospitalized and the rate may be increasing

  • Rates of mental disorders increase as the number of substance use disorders increase

  • If we treat the SUD, we also address mental health symptoms

So, the answer is…

Yes, this really IS

important to your job!

We must address SUD in order to increase the effectiveness of mental health treatment

One Client’s Perspective

…and to complicate the picture even more…

Substance Use and Trauma

•The co-occurrence of PTSD and substance use among those in treatment is 12-34%; for women it is 30-59%.

• Up to two-thirds of men and women in substance abuse treatment report childhood abuse or neglect.

•People with PTSD and substance abuse are vulnerable to repeatedtraumas.

•Becoming abstinent from substances does not resolve PTSD; some symptoms may become worse with abstinence.

•Treatment outcomes for those with PTSD and substanceabuse are worse than for those with substance abuse alone.

Substance Use and HIV

•By 2010, HIV/AIDS will have caused moredeaths than any disease outbreak in history.

• “HIV is spread by unsafe behaviors that mental health care providers are often in the best position to identify and address.” **

•Individuals with Severe Mental Illness (SMI) are disproportionatelyaffected by HIV/AIDS.

•Persons with HIV/AIDS and who have a mental illness have special needs.

**McKinnon, K. 1999. Psychiatric Services, 50 (9) 1225-1228.

So, How Do We Treat COD?

TIP 42

Guiding Principles and Recommendations

Six Guiding Principles (SAMHSA, TIP 42)

•Employ a recovery perspective

•Develop a phased approach to treatment

•Address specific real-life problems early in treatment

•Plan for cognitive and functional impairments

Delivery of Services (SAMHSA, TIP 42)

•Provide access

•Complete a full assessment

•Provide appropriate level of care

•Achieve integrated treatment

-Treatment Planning and Review


•Provide comprehensive services

•Ensure continuity of care

Vision of Fully Integrated Treatment

•One program that provides treatment for both disorders

•Mental and substance use disorders are treated by the same clinicians

•The clinicians are trained in psychopathology, assessment, and treatment strategies for both disorders

Vision of Fully Integrated Treatment (continued)

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

•Providers offer motivational counseling

• 12-Step groups are available to those who choose to participate

•Pharmacotherapies are utilized according to consumers’ psychiatric and other medical needs

• Sensitivity to issues of trauma,culture, gender, and sexualorientation

Consumer Improvement Strategies

  • Increase the focus on consumer satisfaction and consumer perception of care

  • Increase the use of behavioral enhancement techniques (use of positive reinforcement techniques).

  • Increase the use to strategies to increase consumer access to care and appreciation of care (eg. NIATx)

  • Increase measurement of service effectiveness and greater provider accountability


Provider/practice barriers

  • Differing practice styles

  • Differing practice cultures and language

  • Difficulty in matching provider skills with patient needs

  • Heavy reliance on physician services

  • Tension between direct patient care services (reimbursable) and integrative (non-reimbursable) services


Provider/practice barriers

  • Lack of recognition of provider limitations

  • Lack of MH knowledge in PC providers and lack of health knowledge in BH providers

  • Lack of clinical competence in integrated service models (MH/SU and BH/PC) and selection of proper integration model based on practice context

  • Differing coding and billing systems

  • Provider resistance


Addiction: A Brain Disease

Putting Drug Use into Context with other Mental Disorders

Onset of Mental Health Disorders

  • Oppositional Defiance: 5yo

  • Attention Deficit Disorder-ADHD: 1.3-2.4 yo

  • Anxiety Disorders: 3.8 yo

  • Conduct Disorder: 5.6 yo

  • Depression: 10.1 yo

  • Schizophrenia-affective disorders: mid-teens to mid-thirties

Typical Progression of Use

FAS---Substance use in-uterus

No Social

Use Experimentation Use Use Abuse Dependence


0-2 3-5 6-8 9-10 11-12 13-14 15-16 17+

Infant Child Pre- Adolescent


Mental Health Disorder’s onset----------------------------------

What are we talking about?

Alcoholism/Addiction Major Mental Disorders

Both heredity and environment play a role

Characterized by chronicity and “denial”

Affects the whole family

Progresses without treatment

Feelings of shame and guilt

Inability to control behavior and emotions

Often seen as a moral issue

Leads to feelings of despair and failure

Biological, psychological, social and spiritual components

Collision of Symptomology

Differential Diagnosis is essential for accurate assessment. Is the presenting problem affected by a medical condition or substance?

Is it depression or alcohol, prescription pain killer, heroin use?

Is it ADHD or is it methamphetamine, cocaine use?

Is it bipolar disorder or cocaine use?

Is it schizophrenia or methamphetamine use?

Is it PTSD or polysubstance use?

A Major Reason People

Take a Drug is They Like

What It Does to Their Brains

…Hoping to Change their Brain

Initially, A Person Takes A Drug

Hoping to Change their Mood,

Perception, or Emotional State


The Brain Undergoes Tremendous Changes During Development

Increase of brain activity that accompanies

the growth of the brain, in the same patient, from the age of 1 to 12 months.

Information taken from NIDA’s Science of Addiction

Continuing Brain Development During Adolescence

  • Strengthening the Circuitry

    Synaptic connections are strengthened

  • Pruning Unused Connections

    - Adolescent brain is in a unique state of flux

    -Neurons are eliminated, pruned and shaped

    - This process is influenced by interactions with the outside world (Seeman, 1999)

    - Pruning occurs from back to front so frontal lobes mature the last.

  • Other brain areas are also growing during adolescence (e.g., sub-cortical areas, receptors)

Continuing Brain Development

Early in development, synapses are rapidly created and then pruned back. Children’s brains have twice as many synapses as the brains of adults.(Shore, 1997)

Brain Development Ages 5-20 years

  • MRI scans of healthy children and teens compressing 15 years of brain development (ages 5–20).

  • Red indicates more gray matter, blue less gray matter.

  • Neural connections are pruned back-to-front.

  • The prefrontal cortex ("executive" functions), is last to mature.

Information taken from NIDA’s Science of Addiction

Gagtay, N., et al. PNAS, 101, 8174-8179

The interaction between the developing nervous system and drugs of abuse leads to:

  • Difficulty in decision making

  • Difficulty understanding the consequences of behavior

  • Increased vulnerability to memory and attention problems

  • This can lead to:

  • Increased experimentation

  • Substance addiction

  • (Fiellin, 2008)

Young Brains Are Different from Older Brains

Alcohol and drugs affect the brains of adolescents and young adults differently than they do adult brains

Adolescent rats are more sensitive to the memory and learning problems than adults*

Conversely, they are less susceptible to intoxication (motor impairment and sedation) from alcohol*

These factors may lead to higher rates of dependence in these groups

(Hiller-Sturmhöfel and Swartzwelder, 2004)

Triggers and Cravings

Human Brain

Triggers and Cravings

Ivan Petrovich Pavlov

Triggers and Cravings

Pavlov’s Dog

Classical Conditioning: Addiction

  • Over time, drug or alcohol use is paired with cues such as money, paraphernalia, particular places, people, time of day, emotions

  • Through classical conditioning these cues are paired with pleasurable effects of the drug (“high”).

  • Eventually, exposure to cues aloneproduces drug or alcohol cravings or urges that are often followed by substance abuse

Development of Craving Response

Entering Using Site

AOD Effects

Use of AODs


Blood Pressure


Development of Craving Response

Mild Physiological Response

Entering Using Site

 Heart Rate

 Breathing Rate

 Energy

 Adrenaline Effects

AOD Effects

Use of AODs


Blood Pressure


Development of Craving Response

Entering Using Site

Powerful Physiological Response

AOD Effects

Use of AODs


Blood Pressure


 Heart Rate

 Breathing Rate

 Energy

 Adrenaline

Development of Craving Response

Thinking of Using

Entering Using Site

Powerful Physiological Response

AOD Effects

Use of AODs


Blood Pressure


 Heart Rate

 Breathing Rate

 Energy

 Adrenaline

Development of Craving Response

Thinking of Using

AOD Effects


Blood Pressure


Cognitive Process During Addiction

Relief From







Increased Energy

Increased Social Confidence

Increased School/Work Output

Increased Thinking Ability

Weight Loss/Gain


Loss of Family


Severe Depression




May Be Illegal

May Be Expensive

Hangover/Feeling Ill

May Miss Work/School

Relief From Fatigue

Relief From Stress

Relief From Depression


Effecting Change through the Use of Motivational Interviewing

How can MI be helpful for us in working with our consumers/patients?

The successful MI therapist is able to inspire people to want to change

Use of MI can help engage and retain consumers in treatment

Using MI can help increase participation and involvement in treatment (thereby improving outcomes)

What Causes a Person to be Judged “Motivated”

  • The person agrees with us

  • Is willing to comply with our recommendations and treatment prescriptions

  • States desire for help

  • Shows distress, acknowledges helplessness

  • Has a successful outcome

Definition of Motivation

The probability that a person will enter into, continue, and comply with change-directed behavior

Motivational Interviewing

Elicit behavior change

Respect autonomy

A patient-centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

Tolerate patient ambivalence

Explore consequences

Enhancing Motivation for Change Inservice Training

Based Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatment

Where do I start?

What you dodepends on where the consumer is in the process of changing

The first step is to be able to identify where the consumer is coming from

Stages of ChangeProchaska & DiClemente








Helping People Change

Motivational Interviewing is the process of helping people move through the stages of change

1. Precontemplation


Not yet considering change or

is unwilling or unable to change.

Primary Task:

Raising Awareness

6. Recurrence


Experienced a recurrence

of the symptoms.

Primary Task:

Cope with consequences and

determine what to do next

2. Contemplation


Sees the possibility of change but

is ambivalent and uncertain.

Primary Task:

Resolving ambivalence/

Helping to choose change

Stages of Change:Primary Tasks

5. Maintenance


Has achieved the goals and is

working to maintain change.

Primary Task:

Develop new skills for

maintaining recovery

3. Determination


Committed to changing.

Still considering what to do.

Primary Task:

Help identify appropriate

change strategies

4. Action


Taking steps toward change but

hasn’t stabilized in the process.

Primary Task:

Help implement change strategies

and learn to eliminate

potential relapses

Building Motivation OARS(the microskills)

  • Open-ended questioning

  • Affirming

  • Reflective listening

  • Summarizing

The goal is to elicit and reinforce

self-motivational statements (Change Talk)

Use the Microskills of MI to:

Express Empathy

Acceptance facilitates change

Skillful reflective listening is fundamental

Ambivalence is normal

Use the Microskills of MI to:

Develop Discrepancy

Discrepancy between present behaviors and important goals or values motivates change

Awareness of consequences is important

Goal is to have the PERSON present reasons for change

Decisional Balance

Use the Microskills of MI to:

Avoid Argumentation

Resistance is signal to change strategies

Labeling is unnecessary

Shift perceptions

Peoples’ attitudes are shaped by their words, not yours

Support Self-Efficacy

Belief that change is possible is an important motivator

Person is responsible for choosing and carrying out actions to change

There is hope in the range of alternative approaches available

Use the Microskills of MI to:

Providing Feedback

Elicit (ask for permission)

Give feedback or advice

Elicit again (the person’s view of how the advice will work for him/her)

Screening and Assessing for COD

What can be determined through the screening and assessment process?

  • The interplay between the substance use and the mental health problem

  • The degree to which each disorder interferes with functioning and is situational or social

  • The frequency, intensity and duration of use and associated diagnosis (i.e., substance abuse or dependence)


‘The Secret in the Pocket’

Please write down one personal experience, that you have determined to keep to yourself. This can be an experience or character flaw that you are NOT proud of. YOUR SECRET.

A word or phrase that will help identify this experience to you and you alone.


Appreciating the ‘difficult to tell….’

Before we begin to ask questions, we need to:

  • understand and appreciate the DIFFICULT process of sharing what is considered personal and private

  • understand the processes whereby individuals communicate ‘family secrets’ and information to strangers

    We need to review what we see as

    healthy, intrapersonal non-disclosure versus

    unhealthy, self destructive secret-keeping

Tasks of Addiction Counselor and/or Mental Health Clinician:

  • Our responsibility is to provide the best, most comprehensive assessment and treatment for clients

  • This requires a complete and thorough assessment

  • Balance timeframes between completing necessary forms and paperwork and providing Best Practice

  • Those who struggle with COD need an ally who has a complete understanding of the problem

  • Services must move at the pace set by the client

When do I bring up ‘the topic’

  • Ensure that sufficient rapport has been established with the client

  • Embed questions about substance use and mental health into the overall assessment

  • Completing paperwork and broaching specific topics may be two different events

“Tips for Communicating”

“Talking with clients about their medication”

What for?

  • Prevent/warn Pt about interactions W/ foods, alcohol and other drugs, medications, pregnancy, etc.

  • Inform about the need for lab tests for some medications

  • What to expect: positive outcomes & potential side effects

What for?

  • Stress reducer (control, knows what to expect, understands the importance of:

    • Taking medication

    • Avoid interactions

    • Schedules

    • Combinations of medication

    • etc.


  • Untreated psychiatric problems are a common cause for treatment failure in substance abuse and mental health treatment programs

  • Supporting clients with mental illness in continuing to take their psychiatric medications can significantly improve substance abuse treatment outcomes

Talking with Clients about their Medication

  • 5-10 minutes every few sessions:

    • Taking care of their mental health will help prevent relapse

Talking with Clients about their Medication

  • 5-10 minutes every few sessions:

    • How their psychiatric medication is helpful?

Talking with Clients about their Medication

  • “How many doses have you missed?”

  • Have you felt or acted different on days when you missed your medication?

  • Was missing the medication related to any substance use relapse?

  • “Why did you miss the medication? Did you forget, or did you choose not to take it at that time?” Without judgment

Medication Adherence: Common Reasons for Missing Doses

  • 5-10 minutes every few sessions:

    • Taking a pill every day is a hassle

Medication Adherence: Common Reasons for Missing Doses

  • 5-10 minutes every few sessions:

    • Everybody on medication misses taking it sometimes


Medication Adherence: Common Reasons for Missing Doses

  • For clients who forgot:

    • Keep medication where it cannot be missed

Medication Adherence: Common Reasons for Missing Doses

  • For clients who forgot:

    • Alarm Clock

Medication Adherence: Common Reasons for Missing Doses

  • For clients who forgot:

    • Mediset

Talking with Clients about their Medication

  • For clients who admit to choosing NOT to take their medication:

    • Acknowledge they have a right to choose NOT to use any medication

    • They owe it to themselves to make sure their decision is well thought out

    • They need to discuss it with their prescribing physician

    • What is the reason for choosing not to take the medication?

    • Don’t accept “I just don’t like pills”. Tell them you are sure they wouldn’t make such an important decision without having a reason

Medication Adherence: Common Reasons for Missing Doses

  • Don’t believe they ever needed it; never were mentally ill

Medication Adherence: Common Reasons for Missing Doses

  • Don’t believe they need it anymore; cured

Medication Adherence: Common Reasons for Missing Doses

  • Don’t like the side effects

Medication Adherence: Common Reasons for Missing Doses

  • Fear the medication will harm them

Medication Adherence: Common Reasons for Missing Doses

  • Struggle with objections or ridicule of friends and family members

Medication Adherence: Common Reasons for Missing Doses

  • Feel taking medication means they’re not personally in control

Talking with Clients about their Medication

  • Explore the triggers or cues that led to the undesired behavior

Talking with Clients about their Medication

  • Why the undesired behavior seemed like a good idea at the time?

Talking with Clients about their Medication

  • Review the actual outcome resulting from their choice

  • Did their choice get them what they were seeking?

Talking with Clients about their Medication

Strategize with clients about what they could do differently in the future


Review the “Talking with Clients about their Medication” slides. Choose one of the common reasons why clients do not take their medications.

In groups of 3 (counselor, client, observer), role play a client who is non-adherent and a counselor working with the patient to explore reasons and strategize solutions. The observer should watch the dynamics and the client’s responses to the counselors use of the guidelines, and provide the counselor with feedback.

Assessing Risk Factors

Factors affecting risk for involvement with substance use

Assessing Individual Risk Factors

Favorable attitudes towards the use of substances

Early age of onset of substance use

Gender: Males more likely to abuse substances than females

Genetics: Family history of substance abuse

History of sexual/physical abuse


Assessing Psychological Risk Factors



Childhood ADHD or conduct disorder

Antisocial Personality Disorder

Failure to complete high school

Poor occupational achievement

Low frustration tolerance

Internalized racism/sexism/heterosexism

Assessing Sociocultural Risk Factors

Social network

Friends/coworkers that use

Alcohol/drug use integrated into family culture

Socioeconomic Status (SES)

High crime rate/ “culture of violence”

Degree of acculturation

Assessing HIV Risk Behaviors

  • Two broad categories:

    • Sexual risk behaviors

      • How comfortable are you asking questions about explicit sexual behaviors that are high risk for transmission/infection with HIV and other STI’s?

    • Injection drug use

      • Much higher risk of HIV & hepatitis among injection users – highlights the importance of assessing route of administration of drug use

Understanding the impact of age…

  • It is often difficult for us to approach people who are different in age (much younger or much older)

  • Not all young people act out and not all old people are depressed.

  • Age often brings out our assumptions and biases

    • “She looks like my grandma, she couldn’t be using drugs.”

    • “He’s only 10, substance abuse cannot be an issue.”

Contact Your and

Thomas E. Freese, Ph.D.

Beth A. Rutkowski, M.P.H.

Thank you for your time!


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