Issues, Settings & Models of Care for Persons with Co-occurring Disorders

1. Issues, Settings & Models of Care for Persons with Co-occurring Disorders Arthur J. Cox, Sr., DSW, LCSW “2005 National Forum on Clinical Skill Building for Co-occurring Disorders September 22-23, 2005 Orlando, FL

2. Arthur J. Cox, Sr., DSW, LCSW • President/CEO • The Mid-Florida Center for Mental Health and Substance Abuse Services, Inc. • P. O. Box 33 • Avon Park, FL 33826 • (863) 452-6818 • Fax (863) 452-6617 • E-mail: midfloridacenter@earthlink.net • Website: www.midfloridacenter.com

3. COD Resources • SAMHSA’s Co-Occurring Center for Excellence atwww.coce.samhsa.gov • Co-Occurring Dialogues Discussion List: Membership is free and unrestricted and can be done by sending an e-mail to dualdx@treatment.org. • Co-Occurring State Incentive Grants (COSIG) and Policy Academies: see SAMHSA website for information at www..samhsa.gov • Reports (see COCE website)

4. MFC:A Fully Integrated TreatmentOrganizations for Co-occurring Disorders • One program that provides treatment for both disorders. • Client’s mental and substance related disorders are treated by the same clinicians. • Clinicians are continuously cross-trained to treat multiple disorders. • Focus is on preventing anxiety rather than breaking through denial. • Agency offers stagewise & motivational counseling. • 12 Step support groups attendance are required or available. • Psychiatric evaluations and psychpharmacotherapies are available

5. COCE Core Products and Services • The COCE Web Site www.coce.samhsa.gov • Overview papers, technical reports, and other products • Technical Assistance Direct requests to: Email: samhsacoce@cdmgroup.com Phone: 301-951-3369 • Meetings and conferences • Pilot evaluation of the Performance Partnership Grant (PPG) measure

6. Overview of Co-occurring Disorders • Prevalence & Trends • Heterogeneity & Special Populations • Shift towards Integrated Assessment and Treatment • Effective approaches, Models & Strategies • Training Needs • Recent Development at Federal, state and community levels

7. Use • drink / use to be social and on social occasions (sometimes referred to as social or recreational use) • occasionally drink or use for the intoxicating effects • drink / use occasionally, for example a couple of times a month to a couple of times per year • typically drink 1 - 2 drinks per drinking occasion, sometimes more; may leave drinks unfinished • drink or use to intoxication only occasionally; episodes of intoxication do not interfere with life functioning • have never experienced life problems as a result of drinking or using

8. ABUSE • drink or use for the effect of feeling drunk or high • frequently drink to intoxication and use to the point of significant impairment • have experienced at least one life problem associated with the use of drugs or alcohol • continue to use despite life problems associated with using • are starting to experience increased tolerance to alcohol and drugs of abuse • often drink or use alone in order to avoid hassles from family or friends • drink or use on weekends in order to avoid disruptions to work or school schedules • engage in illegal activity related to use; arrests / legal problems resulting from use • See TIP 42, PP 22-23, Burton, Cox & Fleisher-Bond, 2001

9. DEPENDENCE • drink or use because of a compulsion, (i.e. “have to”) • drink or use constantly, often daily • almost always drink to intoxication and use to the point of significant impairment • drink or use to avoid withdrawal • have experienced numerous problems in several areas of life functioning and continue to use despite these problems • suffer from the disease of addiction, marked by loss of control • have marked tolerance to alcohol and drugs of abuse • may experience withdrawal when use is discontinued • TIP 42, P.23, Burton, Cox, & Fleisher-Bond, 2001, P. 23

10. Defining Loss of Control • using more than intended or over a longer period of time than intended • unsuccessful efforts to reduce, control or discontinue use, (i.e. being unable to keep promises to self and others to quit, relapsing following treatment interventions) • excessive time spent getting substances, using them and/or recovering from their effects • continuing to use despite the presence of intense physical and/or psychological problems created or worsened by use (APA, 1994), TIP 42, PP 21-23.

11. Physiological Dependence • increased tolerance: requiring more and more of a substance in order to get the desired effect, (i.e. “I used to catch a buzz on one or two beers, now I can drink a six pack and not really feel it.”); decrease in the desired effect when the same amount of a substance is taken (APA, 1994) • withdrawal: experiencing physical symptoms of the withdrawal syndrome for the specific substance taken upon discontinuing use; the symptoms cause impairment in functioning; continuing to use a substance in order to avoid withdrawal (APA, 1994)

12. Mental Disorders . Disorders are defined by: • sets of symptoms that, • occur over time, and • lead to an inability to function the way a person wants to or is required to. • Further, they do not occur exclusively during the course of substance use, and • are not better accounted for by medical conditions

13. Classifying Mental Disorders • Psychotic Disorders: schizophrenia, all types; other psychotic disorders • Mood Disorders: depressive disorders, all types; bipolar disorders, all types • Anxiety Disorders: phobias, PTSD, generalized anxiety disorder, panic disorder • Behavioral Disorders: personality disorders, all types (clusters A, B, and C) • TIP 42, PP23-26, Burton, Cox, Fleisher-Bond 2001, PP 35-42

14. QUADRANTS OF CARE • Category I –Mental & substance related disorders are both less severe –primary health. • Category II – 50% of behavioral health clients – mental disorders – cmhc • Category III – Majority of COD – SA/MH/Jails • Category IV – Chronic MI/SA - ??? • Figure 2-1 Tip 42, p29

15. Components of Integrated Treatment: Basic Competencies* What Substance Abuse Professionals Need to Know • the nature of mental disorders and their development • symptomatology of mental disorders and other functional disorders • psychosocial difficulties resulting from mental disorders • the necessity of psychotherapeutic medications in the treatment of mental illness • effective psychiatric treatment interventions • substance abuse treatment interventions that may prove detrimental to persons with mental disorders

16. Components of Integrated Treatment What Mental Health Professionals Need to Know • the nature of addictive disorders and their treatment • symptoms and hallmarks of addictive disorders • psychosocial difficulties that arise from chronic substance use • psychotherapeutic agents that may prove detrimental to persons with substance-related disorders • effective substance abuse treatment interventions • mental health treatment interventions that may prove detrimental to persons with substance-related disorders

17. What Professionals from Both Fields Need to Know • the nature of substance abuse and mental illness as they co-occur • strategies for meeting the special treatment needs of persons with co-occurring disorders • basic competencies for assessing other functional disorders that impact the clinical picture • strategies for offering treatment interventions for other functional disorders • strategies for assessment and differential diagnosis; assessing for ‘multiple disorders’ • common myths and misconceptions about co-occurring disorders • methods for blending treatment interventions and developing competent programming • comprehensive understanding of relapse when disorders co-occur • how best to assess / treat special populations (women, youth the elderly, alternative lifestyle, HIV/AIDS, persons of color)

18. Questions • Questions and Comments from attendees