Harm Reduction Psychotherapy and the Treatment of Dual Disorders Northern California - Kaiser Permanente Conference

1. Harm Reduction Psychotherapy and the Treatment of Dual DisordersNorthern California -Kaiser PermanenteConference Presenter: Don McVinney, MSSW, M.Phil., ACSW, C-CATODSW, CASAC National Director of Education and Training Harm Reduction Coalition, New York mcvinney@harmreduction.org www.harmreduction.org

2. Defining the Problem of Dual Disorders • Problems in measurement and research limitations: • Data often out of date (www.samhsa.gov) • In numerous national studies, respondents were reluctant to disclose illicit drug use for fear of retribution (getting kicked out of treatment) • Much of the information about drug use is based on DAWN data (hospital ED admissions; mortality (doesn’t capture the majority of users) • Police reports (arrests)

3. Defining the Problem of Dual Disorders • Problems in terminology: • MICA; CAMI; MISA; SAMI; 3-D • Other names for this phenomenon are: • Dual diagnosis • Co-morbid disorders • Co-occurring disorders • Concurrent disorders • Co-morbidity

4. What are Dual Disorders? • Axis I Disorders: (mood, anxiety, psychotic disorders) 4 times more prevalent among alcoholics than non-alcoholics • Mood Disorders alone are two times more prevalent among alcoholics • Axis II Personality Disorders: diagnosed in 65% of opiate addicts (1985 study) • Historical gulf between mental health services and substance abuse services • Oversight and licensing issues

5. Scope of the ProblemBased on a Review of the Literature • 37% of alcohol abusers and 53% of drug users also have at least one serious mental illness • Of all people diagnosed with a mental illness, 29% abuse either alcohol or drugs • In 1993, as many as 50% of the mentally ill population were reported to have a substantial substance abuse problem. This was higher among the homeless mentally ill • In 2002, depending on the setting, prevalence rates for dual disorders ranged from 20 to 80%.

6. Overview of the Structure of the U.S. Mental Health Service System • About 15 percent of all adults and 21 percent of U.S. children and adolescents (ages 9 to 17) use services in the mental health system each year. The system is usually described as having four major components or sectors.

7. Specialty Mental Health Sector • The specialty mental health sector consists of mental health professionals such as psychiatrists, psychologists, psychiatric nurses, and psychiatric social workers who are trained specifically to treat people with mental disorders. The great bulk of specialty treatment is now provided in outpatient settings such as private office-based practices or in private or public clinics. Most acute hospital care is now provided in special psychiatric or dual diagnosis units of general hospitals or beds scattered throughout general hospitals. There is a sub-specialization in the treatment of dual disorders, usually requiring additional licenses and staffing. (Adults average 14 visits a year.)

8. General Medical/Primary Care Sector • The general medical/primary care sector consists of health care professionals such as general internists, pediatricians, and nurse practitioners in office-based practice, clinics, acute medical/surgical hospitals, and nursing homes. (Adults average 4 visits a year.)

9. Human Services Sector • The human services sector consists of social services, school-based counseling services, residential rehabilitation services, vocational rehabilitation, criminal justice/prison-based services, and religious professional counselors.

10. Voluntary Support Network Sector • The voluntary support network sector consisting of self-help groups, such as 12-step programs (AA/NA/Double Trouble/Double Winners) and peer counseling, is a rapidly growing component of the mental and addictive disorder treatment system. The Epidemiologic Catchment Area (ECA) study demonstrated that about 1 percent of the adult population used self-help groups in the early 1980s; but this figure rose to about 3 percent in the early 1990s.

11. Service Utilization • Proportion of adult population using mental/ addictive disorder services in one year • Total Health Sector 11%* • Specialty Mental Health 6% • General Medical 6% • Human Services Professionals 5% • Voluntary Support Network 3% • Any of Above Services 15% • *Subtotals do not add to total due to overlap.Source: Regier et al., 1993; Kessler et al., 1996

12. Clinical Syndromes • Axis I: Mood Disorders • Major depression; Mania and manic episodes; Mixed; Dysthymia; Bi-polar; Cyclothymia; substance induced • Axis I: Psychotic Disorders • Schizophrenia: Paranoid; catatonic; disorganized; undifferentiated; substance induced • Delusions, hallucinations, disorganized speech (6 months or more) • Axis I: Substance Use Disorders (Abuse or Dependence)

13. Axis I • Anxiety Disorders • Panic attacks • Agoraphobia (escape anxiety) • Specific (simple) phobias: Sub-types • Social phobia • Obsessive compulsive disorder • PTSD • Acute stress • Generalized anxiety • Substance induced

14. Axis II • Personality Disorders • Cluster A: “Odd” • Paranoid; Schizoid; Schizotypal • Cluster B: “Dramatic” • Antisocial; Borderline; Narcissistic; Histrionic • Cluster C: “Anxious” • Avoidant; Dependent; Obsessive-Compulsive

15. Continuum of Substance Use • Experimental • Ritual use • Intermittent use • Social use • Binge use (operationalized as conscious, planned ‘heavy’ drug use for 5 or more days, or 5 drinks for a man, 4 for a woman in rapid succession; potentially distinct from a “slip” for someone in recovery) • Abuse DSM-IV-TR criteria • Dependence DSM-IV-TR criteria • Severely and Persistently Chemically Dependent (numerous attempts to abstain; chronic relapse)

16. Relationships Between Drug Use and Mental Illness • Those with a mental disorder can be very sensitive to the effects of drug use; not only can it be easier to lose control over drugs, it can also be harder to quit. • Like the rest of the population, a person with a mental disorder has a higher risk of abuse or dependence to drugs if there is a family history of alcohol and drug abuse. • Environmental factors such as social learning (peer pressure), setting, and the availability of drugs may contribute to drug use among mentally ill clients. • Drug use can interfere with the effectiveness of prescribed medication, increase symptoms of a mental condition, and increase relapse risk.

17. Clinical Considerations • Impact of oppression and stigma management (Being an active drug user and having a mental illness are both stigmatized identities in dominant US culture) • Drug-induced psychiatric symptoms need to be handled by making direct connections (such as dealing with paranoia) • Poly-substance dependence • Developmental issues (adolescents versus aging) • Higher rates of HIV and Hep C among IDU’s; psychosocial issues related to testing and medication adherence need to be addressed (development of drug-resistant strains of HIV) • Cultural issues and cultural competence (SES and classism; race and racism, ethnicity and ethnocentrism; LGBT clients and homophobia)

18. Guidelines for Intervention • Dual Focus: Ideally, both should be treated simultaneously, in an integrated manner, rather than consecutively. • If the client wants to stop using, assess symptoms of withdrawal and the need for detox (alcohol and benzodiazepine withdrawal can be life-threatening): Medical detox; ambulatory detox; social detox. • Treatment for this population should take a gradual approach based on the Stages of Change. Those with dual disorders may have to proceed at their own pace in the treatment process (individualized treatment plans).

19. Guidelines for Intervention • Abstinence may be a goal of the program and it may be the stated goal of the client but it should not be a pre-condition for dually diagnosed clients to enter treatment. • The potential for relapse and its prevention should be standardized in treatment programs • A person with dual disorders may or may not fit into traditional 12-Step groups • Medication adherence monitoring issues • Education about drug interactions: street drugs and psychotropic medications • Side effects • Overdose potential and overdose prevention needs to be integrated into treatment

20. Outcome Data for Abstinence-Based Treatment • Relapse, not abstinence, is the most common outcome following substance abuse treatment • Numerous studies find two-thirds relapse within 90 days of completing treatment • Overall rates of abstinence for treatment not correlated with modality of treatment (inpatient or outpatient); rates are similar (about 30% achieve and maintain abstinence)

21. Harm Reduction Psychotherapy: Assessment • Assess the impact of substance use and mental illness on psychosocial functioning • Assessment of clients strengths and deficits • Interventions based on assessment of drug-related harm, harmful behaviors, or psychosocial functioning

22. Harm Reduction Psychotherapy Principles • Cessation of drug use does not have to be the first goal of intervention • Abstinence is an excellent form of harm reduction if the client wants to stop using drugs • Many clients have not made a decision to stop or may state they wish to continue to use drugs, but still need assistance • Service providers can be effective helpers with clients anywhere along the continuum of drug use • Service providers meet clients where they are, not where we would like them to be

23. Harm Reduction PsychotherapyModels of Intervention • Harm Elimination/Abstinence • Recovery Readiness • Moderation Management and Controlled Use • Substitution Therapy • Relapse Prevention, Overdose Prevention • Alternative approaches (acupuncture)

24. Model: Harm Elimination • Goal is to assist clients in achieving and maintaining abstinence • Used in drug treatment programs, some abstinence-based housing programs (“dry” housing), and abstinence-oriented mental health programs

25. Model: Recovery Readiness • Model: work with clients/consumers who are actively using alcohol/drugs and help them achieve abstinence/recovery in a particular time period (usually three to six months) • Applied in many dual disorder programs, usually focused on how alcohol/drug use exacerbates psychiatric symptoms and interferes with medication adherence • Applied in AIDS services organization, targeting how drug use interferes with practicing safer sex

26. Model: Controlled Use • Goal: To reduce the harm by reducing consumption (using less) or controlling episodes/situations of use (using only on weekends) • Applied in self-help support groups (Moderation Management; www.moderation.org), some harm reduction/needle exchange programs, some diagnostic housing programs (“damp” housing) and some dual disorder programs

27. Model: Substitution Therapy • Goal: Replace one drug with higher associated risk with another drug of lower risk (heroin isn’t quality controlled; methadone is pharmaceutically pure and dispensed in a clinic by trained medical providers) • Application: Methadone Maintenance; nicotine replacement strategies: patches, nicotine enhanced chewing gum, inhalers; physician-prescribed drugs

28. Model: Relapse Prevention • Goal: To prevent return to drug use following a period of successful abstinence • Applied in drug treatment and dual disorder programs (outpatient as well as inpatient) • Objectives: Understand high-risk behavior and high-risk situations (cognitive-behavioral)

29. Model: Overdose Prevention • Goal: To prevent death or negative health consequences • Applied in needle exchange programs with active users; drug treatment and dual disorder programs as part of relapse prevention strategies (message: avoid mixing drugs); increasingly in jails and prisons in pre-release programs

30. Model: ‘Alternative” approaches • Goal: Ancillary, supportive services to active and former drug users, including the dually disordered • Applications: Acupuncture programs; massage therapy; herbal remedies such as teas and tonics

31. Harm Reduction PsychotherapyObjectives Objectives to attain goals of reducing harm: • Stages of Change Model (Prochaska & DiClemente) • Motivational Interviewing to engage clients in the process of change • Solution focused

32. Evaluation and Feedback • Ongoing review of progress to clarify if goals have been attained • Clarify or redefine goals if necessary • Reinforce motivation to change

33. Modalities of Interventions • Group • All group counseling models have some benefits, but there is higher efficacy with professionally facilitated groups: dual focused harm reduction groups; cognitive-behavior groups (anxiety and mood disorders); psycho-educational groups (psychotic disorders) • Lesser benefits seem to be derived from self-help/mutual aid groups; support groups (hypothesis: perhaps not enough structure or guidance) • Individual counseling: Interpersonal relational theory; cognitive-behavioral theory

34. Harm Reduction: A Positive Service Delivery Model • Finding solutions to reduce harm • Overcoming barriers • Advocating for the needs of clients • Be aware of existing resources

35. Resource: Assistance with Discrimination Issues • The Americans with Disabilities Act (ADA) is a legal tool to fight discrimination. Any person who believes he or she has experienced employment discrimination based on a psychiatric disability has a right to file an administrative "charge" or "complaint" with the U.S. Equal Employment Opportunity Commission (EEOC) or with a State or local anti-discrimination agency. • U.S. Equal Employment Opportunity Commission1801 L Street, NWWashington, DC 20507Phone: 202-663-4900www.eeoc.gov • U.S. Department of Justice950 Pennsylvania Avenue, NWCivil Rights DivisionDisability Rights Section - NYAVEWashington, D.C. 20530ADA Information Line: 800-514-0301; (TDD) 800-514-0383www.usdoj.gov