SAMHSA TIP 42 Treatment of Co-Occurring Disorders Parts 1 & 2

SAMHSA TIP 42 Treatment of Co-Occurring Disorders Parts 1 & 2

This episode was pre-recorded as part of
a live continuing education webinar. On demand CEUs are still available for this
presentation through ALLCEUs. Register at Hey there everybody and welcome to
today’s presentation treatment of persons with co-occurring disorders
based on salsa tip 42 parts 1 & 2 now if you’ve seen some such at 42 you know
it’s a big old book so obviously we’re going to break this up into sections
that way I can hit the highlights of each section for you and you can get the
most out of it but remember you can always go to store Samsa gov that store
dot and you can order any of the Samsa publications or download all
of tip 42 as a PDF so that’s something your tax dollars have already paid for
so if you like reading you can pull that up in this hour we’re going to define
co-occurring disorders review the relevance of co-occurring disorder
research to clinical practice and familiarize ourselves with the following
terms substance use disorders mental disorders compulsive behaviors and
behavioral addictions treatment programs and systems so this is kind of an
overview or a meta concept day if you will co-occurring disorders means that a
person has a substance use disorder or an addictive disorder and a concurrent
mental health issue that is not attributable to the effects of
intoxication or withdrawal so you know if somebody is withdrawing from for
example benzodiazepines your anti-anxiety medications they are
probably going to experience a lot of anxiety when they’re coming off of that
stuff that doesn’t mean they have anxiety and to die as a peon addiction that means
that’s a side effect of the withdrawal if they are taking cocaine or
methamphetamine and they’re really amped up and really anxious that could be a
side effect of cocaine or stimulant intoxication so we want to rule out the
effects of intoxication and withdrawal now a lot of people when they sober up
you know they get the drugs out of their system still experience anxiety or
depression and that can be a result of you know an awareness of the things that
they did when they were in their addiction it also could be due to
neurotransmitter imbalances as a result of using for a long period of time with
co-occurring disorders you know the big thing is to recognize that they are
there and the book goes into a lot of detail about
differentiating but from a treatment perspective it doesn’t really matter if
they’re depressed they’re depressed and we got to deal with it because a
depressed clean person is probably not going to stay clean for very long and a
person who is actively using is probably going to intensify their mental health
issues so you know we need to deal with both of them it’s not a chicken or egg
cooker co-occurring disorder treatment provides concurrent treatment concurrent
integrated treatment for both the mental health and the substance use issue and
if you’re in a really awesome program the physical issues – so I want you to
think about the challenges that clients with co-occurring disorders present in
treatment settings and to clinicians you know think about that a little bit while
I’m talking cuz where I used to work in the residential facility a lot of our
people a lot of our clinicians were trained in working with addictions they
were not as familiar with working with mental health issues
so when mental health problems would come up sometimes they would get
misdiagnosed as someone being resistant or non-compliant sometimes the person
who was on duty wouldn’t know how to deal with them there were a lot of
challenges that we faced the opposite is true or the same thing is true if you
will in a mental health facility if someone is in a crisis stabilization
unit for example and they are also detoxing at the same time you know
detoxing can be a life-threatening event so clinicians don’t need to know how to
administer or the nurses on the unit need to know how to administer the C wha
and other instruments in order to monitor the detox process so there are
challenges and then even when you get past that you know initial detox period
clients with mental health issues especially if they have had a history of
ongoing mental health issues they may have
an exacerbation of symptoms or a relapse of their mental
this year whatever you want to call it and that will impair their ability to
potentially effectively do their substance abuse treatment so if you’re
expecting them to go to group six hours a day if they are in the middle of a
sudden major depressive disorder they may not be able to go to group six hours
a day and that’s not them being resistant that’s not being them trying
to be non-compliant that is them being in a severe state of depression so how
do we handle that do we let them sleep do we how do we engage them you know we
don’t want other clients to think well John’s getting to sleep and doesn’t have
to go to all of his groups why do I have to I heard that a lot and you know you
can’t say well John’s got major depression because that’s a HIPAA
violation so you have to figure out ways to individualize programs and tailor
programs for people and keep all of the clients in the program on board so
they’re not trying to look and say well you’re playing favorites here this
person gets this privilege I want that one too and and we have to have people
understand that each person has their own unique treatment issues that need to
be dealt with other challenges that it can present to clinicians again is a lot
of us were trained in one or the other most of us went to school for mental
health so we were trained in that and if you were in a great program and you’re
lucky you may have had one or two classes on substance abuse and/or eating
disorders and that was it you know there was no substance abuse assessment
learning all the pharmacology and all that kind of stuff so you’re kind of
hitting the ground running here and trying to catch up people who are
trained as addictions counselors are often only given very very cursory
training in mental health awareness now in a lot of states people who are
addictions counselors cannot diagnose mental health issues but they can screen
for them and they can say well this person you know appears to
have a concurrent mental-health issue we need to get a full assessment for that
done by a mental health clinician now as you’ll learn later in the presentation
it is ideal if programs have clinicians who are dually trained so they can
diagnose both because clients don’t like to have to go through two assessments I
wouldn’t like to have to do two assessments on the same client so it’s
important when possible that we have the assessing clinicians be capable of
diagnosing and creating treatment plans for both substance abuse and mental
health issues people with co-occurring disorders have multiple treatment issues
you’ve got the substance you’ve got the post-acute withdrawal syndrome you’ve
got whatever the mental health issues are and a lot of times people with
mental health issues not all the time but a lot of times they’re also on some
sort of psychotropic medications now some Doc’s will prescribe psychotropics
as soon as the person gets clean and in order to help them stay clean when they
get out of detox other Doc’s will you know resist vehemently providing any
sort of psychotropic medications until the person has been clean for three or
six months well if they’re clean then and the reason they were using with self
medication and now they’re clean they’re not having anything to buffer against
that depression or anxiety or bipolar so it may be harder to stay clean if they
are not medicated so sometimes we have to advocate with the physicians advocate
with the program because it’s a programmatic issue if you’re working
with physicians who are totally unwilling to consider any sort of
psychotropics until the person’s been clean for six months you know I can
understand a couple of weeks you know maybe but a lot of times it’s really
beneficial if clients are able to get on even a low dose of something right out
of detox to help them deal with the extremes of emotions
I think probably at any given time about 60% of the clients in our program were
medicated and the other 40 weren’t and that’s cool
but if somebody also has a concurrent mental health issue that you know you
look back over their history and I’ve had episodes before that could be a
relapse trigger it’s important to address that co-occurring disorders
impact treatment due to the varying course of both disorders as the
substance use improves you know as they start working on the stuff that happened
when they were in their addiction or led them to their addiction that could push
some buttons and trigger some depression some grief some anxiety some trauma
likewise people could be as they sober up when they were self-medicating they
may have been self-medicating to you know tone down the flashbacks or silence
them all together so when they’re clean they may have a flood of flashbacks and
stuff that comes up from PTSD so there are a lot of things we need to be aware
of when we’re working with people with co-occurring disorders and there are a
bunch of different strategies for working with people with co-occurring
disorders and we need to make sure that we’re willing to embrace all of them
from you know regular group psychotherapy to EMDR to medication
assisted therapy to self-help you know there’s a lot of different things out
there that we can use to create a comprehensive program an estimated 10
million Americans have a co-occurring disorder in any given year and that is a
really low number in when you look at other research that’s out there because
that number only uses people who meet DSM criteria and when tip 42 was done
that was before the dsm-5 when gambling addiction actually made the cut for the
dsm-5 so it was really only using addictions that were substance
addictions alcohol and you know marijuana and
illicit drugs it did not include nicotine addiction or eating disorders
nor did it include any of the behavioral disorders like gambling or sex addiction
or pornography gambling addiction made it into the dsm-5 sex addiction
pornography addiction they have not made it in yet but we know that they tend to
be compulsive behaviors which is the more proper term than calling it an
addiction because it doesn’t meet the criteria for substance dependence so so
that’s to say that the thing you need to remember is co-occurring disorders
affect a lot of people and it is the expectation not the exception and I’m
going to say this probably 15 times in this hour we expect that people come
into treatment for mental health or substance use disorders we expect they
have them both people with co-occurring disorders are more likely to be
hospitalized than people without them because the two things are additive when
you have somebody who is clinically depressed plus they’re you know misusing
opiates or misusing cocaine in order to self-medicate it’s more likely that
those two things are going to end up resulting in either a severe substance
issue or a really severe depressive episode requiring hospitalization rates
of mental health issues increase as the rate of substance disorders increases so
as we see more people becoming addicted to substances and developing compulsive
or addictive behaviors we also have seen mental health problems increasing
including depression and anxiety so principals of co-occurring disorders
treatment no wrong door no matter where someone enters the system they are able
to access help so if somebody goes to their primary care physician primary
care physician does a brief intervention and screen
and says okay we need to make these referrals if they enter through mental
health mental health person says yep I see that there’s some other issues going
on here here are the referrals we need to make
if they enter through substance same thing and even if they enter through the
jail when they go through their assessment at the jail or social
services those counselors are also trained to screen for these things and
identify if there is a potential for a presenting mental health or substance
use issue you don’t have to be licensed to screen for things you have to be
licensed to diagnose and treat so the person you know who is a case caseworker
at Social Services or a corrections officer they can do the screenings
during the intake process it doesn’t take long mutual self-help is really
important in co-occurring disorders because you know like recovering from
addictions co-occurring disorders can be really daunting to recover from and it’s
a long-term process recovery is a lifelong process
co-occurring disorders require integrated care like I said we don’t
want to have two parallel systems where somebody goes and sees their substance
abuse counselor over here on Tuesday then sees their mental health counselor
on Thursday and the two hands are not communicating with each other we want
everybody integrated ideally mental health substance and primary care
because a lot of people with mental health issues and substance use issues
also have some underlying physiological issues including you know thyroid
problems hepatitis liver problems you know there are things that happen so we
want to make sure that we’ve got the bio psycho social aspect covered
individualized approaches are used including psychotherapy
medication-assisted therapy peer support and community based resources and that’s
like everything else that includes financial counseling occupational and
educational counseling access to you know scholarships so people can get more
trained a variety of things anything else they
need to meet their needs on Maslow’s hierarchy for a high quality of life so
remember the first level is biology they need food shelter water then they need
safety they need to be feel physically and emotionally safe before they can
start working on any of the other stuff so and for a lot of people that’s not
just for themselves but they need resources to meet the needs of those
that are significant in their life so if you’ve got a parent that is trying to
recover they’re going to need access to community-based resources for childcare
for example or maybe they need access to resources for transportation to get to
treatment there’s a lot of different things out there that we need to
consider you have to look at your own locale and say what do people need in
order to access treatment to regularly come to treatment and to succeed once
they graduate from treatment in getting a you know paying job that helps them be
financially independent and you know keeps them from being overly stressed so
there’s a lot of issues there so let’s talk about the mental health stuff real
quick there are mood disorders and this is
we’re not gonna go into diagnosis today because that’s way too way much more
than an hour good English there anyway anxiety people will come in some people
have social anxiety where you know when they’re alone they typically are fine
but if they’re in a crowd with people or if they’re thinking about going into a
crowd with people they get really stressed out and a crowd depends on the
person that could be two or three people or it could be you know going to the
mall generalized anxiety means worrying about a variety of things most of the
day most every day to a level where it’s disrupting your daily functioning so
those are the two big ones you also have panic over there but we all know what
panic is depression comes in two flavors if you will you have persistent
depressive disorder which back in the day was called dysthymia and
that’s more like you’re a or you know you’re not really super depressed you’re
getting by you’re going to work you’re doing things but everything is gray
nothing really makes you happy you know you’re just getting along and this can
last for years and people just are constantly going on like that you know
that’s a tough place to be major depressive disorder is when you have
those depressive symptoms and they start interacting with or negatively impacting
life in one or more areas and you know it’s it’s significant this people don’t
typically experience a major depressive disorder and just keep going about life
on life’s terms you know they start getting really depressed really fatigued
can’t go to work and they have a hard time doing their activities of daily
living now bipolar disorder combines mania or
hypomania with depression and there are a whole different whole bunch of sets of
variations of how this can happen but mania is is just like what you probably
think about when I say it it’s when somebody gets really energized and they
don’t need sleep you know it’s not that they don’t want to sleep it’s they don’t
need sleep and they will go for days and days and they just they can’t sleep
there they’re on a lot of times they have any of those filters for what’s
appropriate to say and what’s not appropriate to say and do those filters
are gone they just they’re very impulsive they’re doing what they want
to do they’re chasing adrenaline rushes often get doing things that can be
considered dangerous or risky hypomania presents more like somebody just being
you know they drank an entire pot of coffee that morning and they are really
revved up people who are hypomanic tend to not be nearly as impulsive but they
can seem like they’re like totally driven and have difficulty getting to
sleep and it does start causing problems in interpersonal relationships and that
so these things occur and then there’s also spur
matically episodes of depression or persistent depressive disorder so
bipolar disorder and a DD are often confused with one another so it’s
important to do an effective differential diagnosis and the
psychiatrist will probably do this or the mental health therapist but it’s
important to recognize that if someone has bipolar disorder and they’re put on
antidepressants it will likely trigger a manic episode if someone is put on
medication for bipolar disorder and they don’t seem to be reacting to it at all
you know you want to look to see if you’ve got the right diagnosis or if
they react really quickly to the antidepressant and then the
effectiveness seems to wear off antidepressants take about six weeks to
get into the system so you shouldn’t really see much of an effect in two or
three days at least two weeks before you start seeing a significant lifting and
there’s the placebo effect when people start taking a medication a lot of times
they’ll report feeling a little bit better but you shouldn’t see a complete
180 in three days with something like an SSRI and and if that does happen you
want to expect that it the person didn’t have unipolar depression but if they
responded that quickly to an SSRI they very well may have bipolar disorder so
other non personality disorders that don’t really neatly fit into a mood
disorder category a DD and ADHD we just talked about that attention deficit and
attention deficit deficit hyperactivity disorder this can happen or be diagnosed
in adults as well as children and you have a lot of impulsivity interrupting
inability to wait your turn and when my clinicians would see this a
lot of times they would identify this as disruptive resistant or oppositional
behavior in clients instead of looking at it and going you know is there
is the person in a hypomanic episode or do they have a DD ADHD
let’s sudden send them over to get a more thorough workup autism spectrum
disorders present similar to some of your psychotic disorders sometimes like
schizoid but it’s really important to remember that autism spectrum disorders
are a spectrum some people can have you know very little impact from them and be
very very high-functioning autism spectrum disorders generally do not
impact intellect at all it’s more impact sensory integration and people’s ability
to form relationships read nonverbals and feel comfortable around other people
PTSD results after a trauma there are a variety of different ways people can
develop PTSD but a lot of people in addictions treatment do have PTSD do
have a history of trauma so we do need to be aware of that because we don’t
want to reach Ramat eyes them it’s really important if your agencies on
board and but even if it’s not it’s really important to approach people who
are in treatment from a trauma-informed perspective which assumes that
everybody’s has had an experience with trauma that’s not necessarily always
true but it’s better to be safe and not reach Ramat eyes somebody then be sorry
and go well we’ll cross that bridge when we come to it and accidentally
retraumatization is kind of basically lumped together your psychotic disorders
and schizophrenia remember skis o means break it means
they’re breaking from reality as someone who is has schizophrenia if they are in
a psychotic episode they are going to be in a different reality and no amount of
reasoning or rationalization that you do with them is going to make any sense
because they are living in another reality and the best way to work with
them is to kind of step into their reality
I worked with a client who had schizophrenia um and and he was just
certain that the word the was a message from the devil and it’s really hard to
talk without saying the word the but instead of trying to rationalize with
him that you know I can say though all day long and nothing Bad’s gonna happen
to you or me you know I had to join him in his reality where that was you know
that was an alarm when you heard that word and figure out how to approach it
from there in order to develop rapport and engagement and get him where he
needed to be obviously when he was well medicated that wasn’t near an issue near
as much of an issue alcohol induced dementia is something else we need to be
aware of with any of our clients if you’re a mental health counselor and
you’ve got a client who decides to stop drinking you know they may not have ever
presented with alcoholism and that’s okay but if they’ve been drinking
heavily and they suddenly stop they can develop something called where Nikki
Korsakoff syndrome or alcohol induced dementia and it’s really important that
they get care like ASAP or the dementia and cognitive changes can become
permanent so if you notice that their evidencing symptoms of significant
cognitive decline and and/or difficulty with balance it’s important to have that
looked at obsessive-compulsive disorder is one of
those that you know we have a hard time with certain behavioral actions or
behaviors people choose that ring very true of addictions like gambling
addiction but that’s now in the DSM so we have to put it into a category
somewhere and sometimes people will put it in obsessive-compulsive disorders
because for example pornography addiction someone is constantly thinking
about pornography and in order to stop thinking about it
they need to engage in some sort of compulsive behavior such as viewing the
pornography it doesn’t fit nicely into that category
because obsessive-compulsive disorder is really more about anxiety so if I don’t
do this then something Bad’s gonna happen if I don’t check the door then
somebody’s going to break in if I don’t check the stove for the 34th time you
know maybe I left it on and the house is going to burn down that’s true obsessive
compulsive disorder issues with dementia and go back to OCD for a minute people
with OCD may self-medicate with substances in order to help them feel
like they don’t have to engage in those checking behaviors or hand-washing or
whatever it is then there’s a few issues with dementia I mentioned alcohol
induced dementia but we also have age-related dementia which is your
normal cognitive decline as people age that’s not something to necessarily be
worried about but it’s important in treatment planning because people who
are of older age may need a little bit more time processing stuff than people
who are younger because our the speed with which we process information does
decline as we get older people with Alzheimer’s are going to show some
symptoms of dementia and this these symptoms will often get worse over time
so if you’re working with somebody with Alzheimer’s you have to know how to
communicate with someone who has dementia and people with Parkinson’s
disease and you’re like well Parkinson’s disease is not a brain disease well it
kind of is the plaques that build up in Parkinson’s Parkinson’s disease cause
people who are who had the disease about 50% of them will have some
hallucinations or delusions at some time and you can see some dementia forming in
those people not all the time but it is something to be aware of if your client
has Parkinson’s or Alzheimer’s or you know if you see any other signs
of dementia it is really important to get that checked out so they can reverse
anything that’s reversible and learn how to deal with anything that’s not
reversible and then you’ve got your personality disorders and yo I have a
whole suit box about that but for the perspective of this course you may have
clients that come in with personality disorders and that means whatever their
behavior is is ego-syntonic that means it makes total sense to them they don’t
understand that they’re being over-the-top or extreme in any sort of
way and it’s pervasive throughout their life you know from eight longitudinally
from the time they were relatively young up until now you know it’s always been
present and in multiple areas not just at work or just at home but they behave
this way in multiple situations so cluster a is your audit or eccentric
behavior you’ve got your paranoid schizoid and schizotypal personality
disorders those are relatively rare it’s like I think I’ve seen two clients in
twenty years that had a cluster a personality disorder this is just
something to be aware of if their behavior doesn’t quite seem to fit if
they seem like they’re having difficulty interacting with other people they seem
withdrawn they won’t make eye contact or they seem paranoid refer for an
evaluation we want to rule out schizophrenia and anything autism
related cluster be dramatic emotional or erratic behavior this is where you’re
antisocial you’re borderline you’re histrionic and your narcissistic fall
now a lot of people a lot of people who come into substance abuse treatment who
are in active addiction or just detoxing and getting ready to start treatment
have behaviors that mimic or that would meet the criteria for these disorders
one or more of them how ever once they are not using those
behaviors go away so it can’t be a personality disorder if you if it goes
away it has to be enduring so be really careful when you’re diagnosing
personality disorders because once you give somebody a label that’s enduring it
can prohibit them from getting into certain treatment programs and send
treatment on the wrong path so make sure you differentially diagnose the
substance related behaviors the addictive behaviors the stinkin thinking
even the criminogenic thinking from a true personality disorder and then
cluster see are you’re anxious fearful and again sometimes people with autism
spectrum disorders can be misdiagnosed as having a cluster C personality
disorder so we do want to rule that out you have your avoidant dependent and
obsessive-compulsive personality disorders here avoidant is pretty
self-explanatory dependent is a person who literally just cannot make decisions
on their own they’re paralyzed to make decisions they’re afraid to make any
sort of decisions they rely on other people and if they don’t have other
people in their life that they can depend on they can’t function and it’s
way more than being codependent it is much more intense than that okay and
then we have addictive disorder so we talked about the mental health stuff so
if people have any of those that’s the mental health stuff and then they may
have an addictive disorder in the DSM 5 we have substances that are can be
diagnosed as addictions and you are looking for substance dependence or
substance withdrawal it’s not considered abuse or dependence any more they kind
of lumped it all together in the dsm-5 and gambling gambling is the only behavioral
addictive behavior that is made it into the dsm-5 internet gaming disorder has
been made a diagnosis of interest which means it hasn’t quite made it in but
they’re considering maybe adding it for the next iteration of the DSM so that’s
something to be aware of that they are adding new behavioral addictions but
right now this only applies to internet gaming not internet surfing not
pornography just gaming things that are not in the dsm yet that we often see
meet the criteria for addiction I mean you can look through the criteria and go
yep this person meets all that criteria sex addiction pornography addiction and
shopping addiction you know those are three big ones there are other things
but we do see these a lot eating disorders and food related issues are
not considered addictions so we although they often very very often co-occur with
substance use disorders it’s important to recognize that they are not
addictions bulimia co-occurs with alcoholism about sixty percent of the
time so that just kind of gives you an idea about how frequently they co-occur
so criteria for addiction like I said a lot of times some of these behavioral
things also meet these criteria so think about them as we’re going through them
used for longer than intended so if you’re using cocaine and you intend to
use for you know an afternoon and you end up going on a three-day bender there
you go the same thing with pornography you know
if you intend to get on the internet for an hour and before you know it you know
18 hours the past you got longer than intended spending more money than
intended on the drugs or and this can can also include and spending more time
than intended getting it using it or recovering from the effects of it we
look at all three things so you can spend more money than intended if you’re
using cocaine for example and you end up using for three days you’re going to
spend more money than you would have spent in four hours you also have a lot
more time invested in it failed efforts to cut down or quit this can be true for
gambling pornography gaming or substances giving up important
activities in order to engage in that behavior you know again sometimes if
people are addicted to it if it gives them that dopamine rush they’re going to
be willing to forego other things that are important to them in order to engage
in that behavior development of a tolerance means what worked for you six
months ago doesn’t quite give you the same rush
anymore we see that in substances obviously we see that in gambling where
people start out and they’re happy playing the nickel slots and then they
move up and they’re playing you know much larger or more risky games the same
thing we see with pornography people will start with you know
middle-of-the-road pornography and as they watch it more and more they get
habituated to it and they need something that’s more exciting and that’s when
they start exploring things that are more risk
more shocking than they initially did physiological or psychological
withdrawal obviously if you quit using a substance you’re gonna have a
physiological withdrawal um you know 99% of the time with a psychological
withdrawal it means the person becomes anxious edgy irritable because they
can’t access their substance and it’s freaking them out and we do see this a
lot with gambling internet gaming and pornography and and some other things
and negative consequences in one or more areas of life related to the addiction
so if you’re using and it’s causing you financial problems if it’s causing
problems in your relationship if it’s causing you to be less productive or get
in trouble at work if it’s causing you legal problems you
know those are all problems that and and you continue to do it then we’re
starting to look at meeting the criteria for addiction if you go out drinking and
get pulled over with a DUI not that I’m saying it’s a good thing but if you do
and then that’s your wake-up call and you don’t drink anymore
okay that’s one thing if you go out drinking you get your DUI and that but
you continue to drink and drive you know after that then we’re looking more at an
addiction because you know that the penalties are only going to get worse
but you do it anyway so when we’re considering where to put
people in terms of treatment we look at the American Society of addiction
medicine a SAM levels of care 0.5 is early intervention these are your
community outreach your group you know your two or three times the week groups
that people can go to level one is outpatient and that can be up to three
hours of outpatient a week either group or individual level two is IOP which is
for four to 15 hours per week usually mostly group and PHP or partial
hospitalization which is 16 to 40 hours per week again usually mostly group
obviously with PHP the person engaging in treatment almost like a
full-time job residential treatment if PHP is not cutting it
residential is the next step and this means that there’s somebody awake and
supervising 24 hours a day but not necessarily a doctor residential is
often has a doctor on call and medical staff on call but the overnight shift it
doesn’t have any medical staff on it or it’s very few level 4 is your medically
managed intensive inpatient and this can be your inpatient detox where you’ve got
a nurse that’s on duty 24 hours a day and a doctor that comes in every day or
it can be a crisis stabilization unit again where there’s a nurse on duty you
know there’s always medical personnel there round-the-clock 24 hours a day 365 so determining where to put people there
are four quadrants of care category one the mental health and the substance
abuse are both mild so the person is probably going to either go to early
intervention or outpatient and you know they can address kind of whatever they
they need to category two the mental health is moderate to severe but the
substance abuse is still mild so a lot of times they will go to outpatient or
even intensive outpatient for mental health and the therapist will understand
and address the substance abuse issues but they’re not significant enough to
need a specialty program for substance abuse category three the mental health
is mild but the substance abuse is moderate to severe and this is where you
often see people who are in IOP PHP or residential and and these are the things
that we treat there and then category for the mental health is severe and the
substance abuse is severe you’ve got somebody who is really in jeopardy of
harming themselves either through substance use or because their mental
health is not controlled and this is often in intensive inpatient
hospitalization for category four so recovery oriented systems of care is
where we want people to go like I said we don’t want parallel systems so what
types of services do we need to provide comprehensive continuous integrated
systems of care that means we all have to be on the same page and communicating
I know it’s it’s laughable sometimes but we need to make our best effort so these
systems include substance abuse treatment mental health services medical
services pain management parenting education financial counseling
occupational and educational resources and case management in addition to other
things but you know those are the big eight that need to be there so we’ve
talked a lot about co-occurring disorders and mental health issues
co-occurring disorders treatment means providing concurrent services to meet
them mental health as well as the addiction needs of the individual
addiction recovery needs of the individual we don’t want them to have to
go to different places to get their needs met now some ancillary services
may need to be contracted out for example we worked with clients we were a
co-occurring capable facility where I used to work but we didn’t have anybody
trained in EMDR and we occasionally had someone who had intense PTSD who wanted
to try MDR so we would need to refer out to an EMT our therapist but we had
contacts and we had that net out there so we weren’t struck stuck going I don’t
know what to do we always had support and that network
to rely on co-occurring disorders treatment recognizes the reciprocal
impact of each disorder on the other and and again true to tip 42 that means
mental health and substance abuse but you know I’m hoping they come out with a
new tip pretty soon that also recognizes the impact of physical issues such as
chronic pain on the other two issues because people when they’re in chronic
pain off and get frustrated and depressed they
can get anxious feeling they’ll never get any better they can get angry lots
of other stuff and they can self medicate the pain and/or the mood issues
with substances so you know I do see the three of those things co-occurring a lot
overlooking the mental health or the substance abuse in diagnosis or
treatment just sets the person up for relapse so let’s not do that
co-occurring disorders treatment is integrated and attends to the whole
person not just the substance not just the mental health but also their
interpersonal relationships and their housing that whole as low vien hierarchy
clinicians have an ethical responsibility to be educated in both
mental health as well as substance abuse issues and treatments even if they’re
not skilled in treating one or the other so you know maybe you’re a mental health
clinician and you haven’t been trained in motivational interviewing or some of
the other substance abuse best practices that’s okay you still need to know what
they are because if you’ve got a client who’s in substance abuse treatment you
need to understand what they’re doing over there to understand how it’s gonna
impact your course of treatment likewise substance abuse counselors need to
understand what happens in mental health counseling if they’re working with
somebody who’s seeing you know multiple clinicians so there are going to be five
more videos in this series and they will all be on the playlist tip 42
co-occurring disorders on our YouTube channel at all CEUs calm /youtube to see
you used for this presentation you can go to all CEUs comm slash podcast CEUs
where you can find a direct link to the class associated with this presentation
alrighty everybody thank you for joining me and I will see you tomorrow for part
three well this was parts 1 & 2 because I was able to squeeze them together so
we’ll be doing parts 3 tomorrow if this podcast helps you help your clients or
yourself please support us by purchasing your CEUs at all CEUs com or getting
your agency to sponsor and sewed a direct link to the on-demand
CEUs for this podcast is it all CEUs dot-com / podcast CEUs that’s all CEUs
comm / podcast CEUs to sponsor an episode of counselor toolbox and reach
over 50,000 clinicians per week go to all CEUs com / sponsor thank you

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