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Treatment of Persons with Co-Occurring Disorders
Based on SAMHSA TIP 42 Part 6
Host: Dr. Dawn-Elise Snipes
Executive Director: AllCEUs Counselor Education
Podcast Host: Counselor Toolbox and Addiction Counselor Exam Review

~ Identify essential programming for clients with COD
~ Explore modifications for clients with COD
~ Identify components in successful implementation of programming

Essential Programming for Clients With COD
~ Screening, Assessment, and Referral
~ Physical and Mental Health Consultation
~ Prescribing Onsite Psychiatrist
~ Medication and Medication Monitoring
~ Mental Health and Substance Use Disorders
~ Relapse Prevention
~ Psychoeducational Classes
~ Double Trouble Groups (Onsite)
~ Dual Recovery Mutual Self-Help Groups (Offsite)
Design and Implementation
~ Designing Outpatient Programs for Clients With COD
~ Group work and modifications
~ Individual work and modifications
~ Recovery support
~ Case management
~ Implementing Outpatient Programs
~ Evaluating Outpatient Programs
~ Sustaining Outpatient Programs
~ The population of persons with COD is heterogeneous in terms of motivation for treatment, nature and severity of substance use disorder (e.g., drug of choice, abuse versus dependence, polysubstance abuse), and nature and severity of mental disorder
Individual Counseling
~ Variety of approaches
~ Culturally responsive
~ Trauma informed
~ Regularly scheduled
~ Guided by the treatment plan
~ Problem: Depression
~ Goal 1: To self report a mood of 3 or above 6 out of 7 days
~ Objective 1A: Learn about the causes of depression
~ Objective 1B: Identify my symptoms of depression and what might be causing them
~ Objective 1C:…

Group Work
~ Working in Groups
~ Group therapy should be augmented by individual counseling
~ Reduce the emotional intensity of interpersonal interaction in COD group sessions
~ Because many clients with COD often have difficulty staying focused
~ Treatment groups usually need stronger direction from staff
~ Group or activity running for no more than 40 minutes.
~ Because of the need for stability, the groups should run regularly and without cancellation
~ In early recovery psychoeducational groups are usually more beneficial (Relapse prevention, PAWS, CBT/DBT Tools…)
~ Because many clients with COD have difficulty in social settings, group sizes may need to be smaller
~ Co-leaders are especially important in these groups, as one leader may need to leave the group with one member
~ Considerable tolerance is needed for varied (and variable) levels of participation depending on the client's level of functioning, stability of symptoms, response to medication, and mental status
~ Affirmation of accomplishments should be emphasized over disapproval or sanctions.
~ Negative behavior should be amended rapidly with a positive learning experience designed to teach the client a correct response to a situation
Medication Management
~ Medication Assisted Therapy
~ Opiates
~ Alcohol
~ Nicotine
~ Management of acute and post-acute withdrawal symptoms
~ Psychopharmacology

Primary Care
~ Consults or referrals to rule out mood or pain issues caused by
~ Autoimmune disorders (Fibro, Chron’s etc)
~ Liver or kidney issues
~ Diabetes
~ Sex or thyroid hormone issues (Including Low T, PMDD and hypo or hyper thyroid)
~ STDs
~ Musculoskeletal issues

Family Education
~ Particularly in cultures that value interdependence and are community and/or family-oriented, a family and community education and support group can be helpful
~ Programs must provide this instruction in an interactive style that allows questions, not in a lecture mode. The essentials of this information include:
~ The name of the disorder
~ Its symptoms, prevalence, cause
~ How it interacts with substance abuse—that is, the implications of having both disorders
~ Treatment options and considerations in choosing the best treatment
~ The likely course of the illness
~ Programs, resources, and individuals who can be helpful
Assertive Community Treatment
~ Assertive Community Treatment
~ ACT emphasizes shared decision making with the client as essential to the client's engagement process.
~ Multidisciplinary teams including specialists in key areas of treatment provide a range of services to clients.
~ Members typically include mental health and substance abuse treatment counselors, case managers, nursing staff, and psychiatric consultants.
~ The ACT team provides the client with practical assistance in life management as well as direct treatment, often within the client's home environment, and remains responsible and available 24 hours a day
Nine Essential Features of ACT

~ Services provided in the community, most frequently in the client's living environment
~ Assertive engagement with active outreach
~ High intensity of services
~ Small caseloads
~ Continuous 24-hour responsibility
~ Team approach (the full team takes responsibility for all clients on the caseload)
~ Multidisciplinary team, reflecting integration of services
~ Close work with support systems
~ Continuity of staffing
Advice to Administrators: ACT

~ Provide intensive outreach activities.
~ Use active and continued engagement techniques with clients.
~ Employ a multidisciplinary team with expertise in substance abuse treatment and mental health.
~ Provide practical assistance in life management (e.g., housing), as well as direct treatment.
~ Emphasize shared decision-making with the client.
~ Provide close monitoring (e.g., medication management).
~ Maintain the capacity to intensify services as needed (including 24-hour on-call, multiple visits per week).
~ Foster team cohesion and communication; ensure that all members of the team are familiar with all clients on the caseload.
Case Management
~ Serves as a central point of contact for multiple agencies/providers
~ Provides outreach and engagement activities
~ Brokers community-based services/ Advocates for client access
~ Provides some support/counseling services
~ Assists clients in system navigation
~ Can be:
~ Counselor
~ Broker
~ Intensive Case Manager
~ Volunteer

Case Management
~ Examples of ICM activities and interventions include
~ Engaging the client in an alliance to facilitate the process and connecting the client with community-based treatment programs
~ Assessing needs, identifying barriers to treatment, and facilitating access to treatment
~ Offering practical assistance in life management and facilitating linkages with support services in the community
~ Monitoring progress
~ Providing counseling and support to help the client maintain stability in the community
~ Crisis intervention
~ Assisting in integrating treatment services by facilitating communication between service providers
Multilevel Services
~ Detox
~ Residential
~ Partial Hospitalization
~ Intensive Outpatient
~ Low Intensity Intensive Outpatient
~ Outpatient (individual)
~ Outpatient/Intervention Level Groups
~ Aftercare
Program Implementation
Involve Clients In Treatment/Program Design
~ Some guidelines for involving client/consumers include:
~ Form a Consumer Advisory Group.
~ Include both current clients from the program and past clients.
~ Elect a client representative to discuss client concerns with staff.
~ Provide a staff liaison to help coordinate client meetings and to provide a continuing link to staff.
~ Hold regular meetings and phone conferences.
~ Provide incentives to clients for participation.
~ Solicit input on a variety of matters and in an ongoing way.
~ Involve clients in meaningful projects.
~ When client input is solicited and received, consider it respectfully, respond appropriately, and give the client feedback.
Train Staff
~ Differing perspectives regarding the characteristics of the person with COD
~ The nature of addiction and mental disability
~ The interactive effects of both conditions on the person and his or her outcomes
~ Recognizing and understanding the symptoms of the various mental disorders
~ Understanding the relationships between different mental symptoms, drugs of choice, and treatment history
~ Individualizing and modifying approaches to meet the needs of specific clients and achieve treatment goals
~ Accessing services from multiple systems and negotiating integrated treatment plans
~ Staff burnout

Improve Adherence

~ Improving Adherence of Clients With COD in Outpatient Settings
~ Use telephone or mail reminders.
~ Provide reinforcement for attendance (e.g., snacks, transportation).
~ Increase the frequency and intensity of the outpatient services offered.
~ Develop closer collaboration between referring staff and the outpatient program's staff.
~ Reduce waiting times for outpatient appointments.
~ Have outpatient programs designed particularly for clients with COD.
~ Provide clients with case managers who engage in outreach and provide home visits.
~ Coordinate treatment and monitoring with other systems of care providing services to the same client.
Data Collection / QI
~ Data can be used to improve programs.
~ Define the operational goals of the program in terms of the client behaviors for which change is sought.
~ Locate and/or develop instruments that can be used to assess client functioning in the areas of concern for outcome
~ Develop a plan for data collection
~ Develop a plan for data analysis and reporting
~ Develop a plan for integration of results and rapid cycle change

Best practice integrated treatment concepts
~ Continuous cross-training of professional and nonprofessional staff
~ Empowerment of clients to engage fully in their own treatment
~ Reliance upon motivational enhancement concepts
~ Culturally appropriate services
~ A long-term, stagewise perspective addressing all phases of recovery and relapse
~ Strong therapeutic alliance to facilitate initial engagement and retention
~ Group-based interventions as a forum for peer support, psychoeducation, and mutual self-help activities
~ A side-by-side approach to life skills training, education, and support
~ Community-based services to attend to clinical, housing, social, or other needs
~ Fundamental optimism regarding “hope in recovery” by all staff
~ Clients with COD may need some minor adjustments to programs including
~ More individualization
~ More structure
~ Slower pace
~ More comprehensive services
~ Implementation of programming should involve
~ Client input
~ Staff cross training
~ Data collection and CQI