Becoming a Competent Co-occurring Clinician: An Overview (Part 2)

Becoming a Competent Co-occurring Clinician: An Overview(Part 2) Presented by Jill S. Perry, NCC, LPC, CAADC, SAP May 17, 2017

Advice to the Counselor: Antisocial Personality Disorders • Confront dishonesty and antisocialbehavior directly and firmly. • Hold clients responsible for thebehavior and its consequences. • Use peer communities to confrontbehavior and foster change. JP CounselingHealing for Adults, Youth and Families

Advice to the Counselor: Psychotic Disorders • Screen for psychotic disorders and refer identified clients for further diagnostic evaluation. • Obtain a working knowledge of the signs and symptoms of the disorder • Education the client and family about the condition.• Help the client detect early signs of its re-occurrence by recognizing the symptoms associated with the disorder. JP CounselingHealing for Adults, Youth and Families

Eating Disorders • The prevalence of bulimia nervosa is elevated in women presenting for substance abuse treatment. • Studies of individuals in inpatient substance abuse treatment centers (as assessed via questionnaire) suggest that approximately 15 percent of women and 1 percent of men had an eating disorder (primarily bulimia nervosa) in their lifetime (Hudson et al) • Substance abuse is more common in bulimia nervosa than in anorexia nervosa. JP CounselingHealing for Adults, Youth and Families

Eating Disorders • Individuals with eating disorders are significantly more likely to use stimulants and significantly less likely to use opioids than other individuals undergoing substance abuse treatment who do not have a co-occurring eating disorder. • Many individuals alternate between substance abuse and eating disorders. JP CounselingHealing for Adults, Youth and Families

JP CounselingHealing for Adults, Youth and Families

Suicidality Suicidality is not a mental disorder in and of itself, but rather a high-risk behavior associated with COD, especially (though not limited to) serious mood disorders. Research shows that most people who kill themselves have a diagnosable mental or substance use disorder or both, and that the majority of them have depressive illness. JP CounselingHealing for Adults, Youth and Families

Suicide •Cognitive problem-solving styles • Underlying neurobiology • Increased rate may be related to substance use/abuse (Brent, et.al 1987, Rich et.al 1986) • Mood disorders and SUD increased risk JP CounselingHealing for Adults, Youth and Families

SUICIDALITY Teens who use marijuana have 8 times higher rate of suicidal ideation than non-marijuana users and a 16% times higher rate of suicide attempts. JP CounselingHealing for Adults, Youth and Families

Suicide • Abuse of alcohol or drugs is a major risk factor in suicide, both for people with COD and for the general population. • Alcohol abuse is associated with 25 to 50 percent of suicides. Between 5 and 27 percent of all deaths of people who abuse alcohol are caused by suicide, with the lifetime risk for suicide among people who abuse alcohol estimated to be 15 percent. JP CounselingHealing for Adults, Youth and Families

Suicide • The association between alcohol use and suicide also may relate to the capacity of alcohol to remove inhibitions, leading to poor judgment, mood instability, and impulsiveness. • Substance intoxication is associated with increased violence, both toward others and self. JP CounselingHealing for Adults, Youth and Families

Screening Screening is a formal process of testing to determine whether a client does or does not warrant further attention at the current time in regard to a particular disorder and, in this context, the possibility of a co-occurring substance use or mental disorder. The screening process for COD seeks to answer a “yes” or “no” question: Does the substance abuse (or mental health) client being screened show signs of a possible mental health (or substance abuse) problem? Note that the screening process does not necessarily identify what kind of problem the person might have or how serious it might be, but determines whether or not further assessment is warranted. JP CounselingHealing for Adults, Youth and Families

Assessment for ALL Disorders is Necessary Because... •Having one disorder increases the risk of developing another disorder; • The presence of a second disorder makes treatment of the first more complicated; • Treating one disorder does NOT lead to effective management of the other(s); • Treatment outcomes are poorer when co-occurring disorders are present. JP CounselingHealing for Adults, Youth and Families

Some Basic Assumptions (Adapted from Minkoff, 2000) •Heterogeneous population • Application of Biopsychosocial framework • Complex assessment occurs over time and begins with need to engage as many as possible • Frequent occurrence of multiple problems and mental and physical disorders • Effective interventions and treatment programs are flexible and occur in stages JP CounselingHealing for Adults, Youth and Families

Basic Assumptions, cont’d. •The person sitting before you has a history before the onset of their presenting symptoms. • The person’s early developmental history holds essential information regarding resiliencies & competencies as well as areas of deficit and risk potential JP CounselingHealing for Adults, Youth and Families

Gathering Data • History and mental status examination • Physical Examination • Self-report • Reports of family, peers, school, legal, etc. • Structured interviews and standardized tests • Laboratory test results • Drug screening JP CounselingHealing for Adults, Youth and Families

Archival Records (adapted from Meyers, et al) •Collection of prior treatment charts and/or summaries, school records, etc. is usual. • Use of standardized instruments to collect data is not common. • Data bias is more common than not, given the variance in evaluators, client’s presenting problem, domain/purview of assessor. • Such data are useful, but not complete. JP CounselingHealing for Adults, Youth and Families

Assessment Time Frames (Adapted from Meyers et al.) •Recent vs. historical data - Combination generally most useful • Lifetime timelines by key area provides data - what occurred when - developmental impact • Past week data give current functioning • Periods of time during past year give improvement vs. regression data for specific areas of functioning JP CounselingHealing for Adults, Youth and Families

ASSESSMENT DOMAINS (TIP #31) •history of substance use • medical, family & sexual histories • strengths and resources • developmental issues • mental health history • school, vocational, juvenile justice histories • peer relationships and neighborhood • leisure-time interests, hobbies, activities JP CounselingHealing for Adults, Youth and Families

BIOLOGIC MEASURES(adapted: Meyers et al.) • Urinalysis and blood-alcohol content • Other biologic measures may be needed (e.g., lithium levels, checking ADHD medication responses, etc.) JP CounselingHealing for Adults, Youth and Families

Screening and Assessment •Routine questions regarding - Depression - Suicidal ideation and behavior - Anxiety - Aggressive behavior - Current and past MH/SU treatment • Questions about psychiatric and behavioral problems should cover every major diagnostic group JP CounselingHealing for Adults, Youth and Families

Purposes of Assessment • Establish a working relationship • Engage the client • Demystify the process • Engage Family • Assess Competencies, Capacities & Resiliencies JP CounselingHealing for Adults, Youth and Families

Purposes of Assessment - continued • Assess & Evaluate Resistance, Motivation, Readiness for Change • Assess & Evaluate Severity of Illness • Substance Use Disorder • Psychiatric / Mental Health Disorder • Develop Provisional DSM Diagnostic Picture • Develop Provisional Plan of Action • Goals • Objectives JP CounselingHealing for Adults, Youth and Families

Other Services Needed (Meyers, et al) • Determine need for multidimensional services • Consider • Living conditions, • Other family issues/needs, • Other agencies already involved/needing to be involved, • What supports will be necessary and must be coordinated in order to support treatment efficacy 31

Purposes for Family Involvement • Learn about client from family perspective • Mutual education and redefinitions • Define substance use in the family context • Establish/re-establish parental influence • To decrease family’s resistance to treatment 32

Family Involvement, continued • To assess interpersonal function of drug use • To interrupt non-useful family behaviors • Identify and implement change strategies consistent with family’s interpersonal functioning and cultural identity • Provide assertion training for children and any high-risk siblings 33

Culturally Competent Treatment One definition of cultural competence refers to “the capacity of a service provider or of an organization to understand and work effectively with the cultural beliefs and practices of persons from a given ethnic/racial group” • Cultural sensitivity is being “open to working with issues of culture and diversity” (Castro et al. 1999, p. 505). Viewed as a point on the continuum, however, a culturally sensitive individual has limited cultural knowledge and may still think in terms of stereotypes. • Cultural competence, when viewed as the next stage on this continuum, includes an ability to “examine and understand nuances” and exercise “full cultural empathy.” This enables the counselor to “understand the client from the client’s own cultural perspective” (Castro et al. 1999, p. 505). • Cultural proficiency is the highest level of cultural capacity. In addition to understanding nuances of culture in even greater depth, the culturally proficient counselor also is working to advance the field through leadership, research, and outreach (Castro et al. 1999, p. 505). JP CounselingHealing for Adults, Youth and Families

Characteristics of Culturally Competent Treatment Programs(Gains Center: Working Together for Change, 2001) • Family (as defined by culture) seen as primary support system • Clinical decisions culturally driven • Dynamics within cross-cultural interactions discussed explicitly & accepted • Cultural knowledge built into all practice, programming & policy decisions • Providers explore person’s level of assimilation/acculturation JP CounselingHealing for Adults, Youth and Families

Characteristics of Culturally Competent Treatment Programs, cont.(Gains Center: Working Together for Change, 2001) • Respect for cultural differences • Creative outreach services to underserved • Awareness of different cultural views of treatment/help-seeking behaviors • Program staff work collaboratively with community support system • Treatment approaches build on cultural strengths & values of minorities • Ongoing diversity training for all staff • Providers are of similar backgrounds to those they serve JP CounselingHealing for Adults, Youth and Families

Medication Considerations • Abstinence vs. Harm reduction - Drug-medication interactions - Untreated psychiatric illness JP CounselingHealing for Adults, Youth and Families

Medication Management Guidelines • Safety profile • Provide information • Closely monitor medication compliance • Monitor treatment effectiveness JP CounselingHealing for Adults, Youth and Families

With the support available from better medication regimens, many people who once would have been too unstable for substance abuse treatment, or institutionalized with a poor prognosis, have been able to lead more functional lives. JP CounselingHealing for Adults, Youth and Families

In addressing COD, it is also important to look at medication costs when addressing the issue of equitable allocation of resources. In the three States reviewed, the estimated costs for those with mental disorders only and with COD was about $400 to $600 per person per year. However, clients with substance use disorders only generally do not get prescription medication therapy; their medication spending range was $100 to $200 JP CounselingHealing for Adults, Youth and Families

Summary of Assessment • An ongoing process that informs treatment strategies, care plan • Involves all relevant sources and resources • Multifunctional engagement, data gathering, planning, and monitoring strategy • Utilizes relevant clinical and standardized approaches • Assessment never ceases. Although formal assessment occurs at the beginning of the treatment process, alterations to treatment are made based on subsequent assessed data.

Empathetic Detachment • Vicarious Trauma • Enmeshment • Enabling • Self-Care JP CounselingHealing for Adults, Youth and Families

Person-centered assessment JP CounselingHealing for Adults, Youth and Families

Sensitivity to culture, gender and sexual orientation JP CounselingHealing for Adults, Youth and Families

Trauma sensitivity JP CounselingHealing for Adults, Youth and Families

Trauma screening JP CounselingHealing for Adults, Youth and Families

Safety screening JP CounselingHealing for Adults, Youth and Families

Identify and contact collaterals (Family, Friends, Other Providers) to gather additional information JP CounselingHealing for Adults, Youth and Families

Becoming a Competent Co-occurring Clinician: An Overview (Part 2)