“I Don’t need help: Managing the Chaos of the Adult Child.”

1. “I Don’t need help: Managing the Chaos of the Adult Child.” Monica L. Weil, Psy.D., Suzanne Holland, RN, MN, CS, and Nancy Carter

2. ASSESSMENT:ASAM PPC-2R(American Society of Addiction Medicine-evaluation of level of care requirements for individuals with co-occurring disorders.) • Five areas of risk must be considered related to this dimension.

3. ASAM FIVE AREAS OF RISK • Suicide potential and level of lethality • Interference with addiction recovery efforts (The degree to which a patient is distracted from addiction recovery efforts by emotional, behavioral and/or cognitive problems and conversely, the degree to which a patient is able to focus on addiction recovery)

4. ASAM, cont. • Social functioning • Ability for self-care • Course of illness (a prediction of the patient’s likely response to treatment)

5. LEVEL OF CARE • LEVEL OF CARE IS BASED ON ASSESSMENT • INTENSIVE CASE MANAGEMENT AND INPATIENT CARE FOR MOST SEVERE • Outpatient substance dependency treatment and mental health counseling for less severe. Must now consider “Stages of Change.”

6. STAGES OF CHANGE • Developed by James Prochaska and Carlo DiClemente in the late 1970’s early 1980’s at the University of Rhode Island during a study of how smokers gave up smoking. We now apply it to: • Weight loss • Drug and alcohol dependence • Co occurring disorder • Chronic disease management such as diabetes and high blood pressure and other areas of concern.

7. Stages of Change-Stage One • Preconemplation • Stage of denial • Individuals are not thinking seriously about changing. • May be defensive in this stage • “I don’t know why my mother thinks I have a problem. I don’t have any problem. She has the problem.

8. Stages of Change – Stage Two • Contemplation • Individuals are now aware there have been some consequences due to their actions • They may be able to consider the possibility of changing, but are ambivalent. • They are thinking about pros and cons of their behavior. • This stage may take a couple of weeks or a lifetime. This is an important stage in terms of bonding with the health care professional.

9. Stages of Change – Stage Three • “I am ready. I’ve got to change. What can I do.?” • Gathering information on obtaining help • Taking small steps towards change • Attempting to determine the correct course of treatment for them • This is an important stage. If it is skipped, the individual may feel like they have not accepted their new lifestyle.

10. Stages of Change – Stage Four • Action/Willpower • Individual is now actively taking steps to change their behavior and they believe they can change. • This is the shortest of all the stages, though the length of time does vary. Average length of time is six months. • Develop plans for internal and external pressures that may lead to slips or relapse. • Open to receiving help from others.

11. Stages of Change – Stage Five • Maintenance • Goal is to maintain recovery. • Individual’s remind themselves of how much progress they have made. • They remain aware of what the are in recovery for. What is meaningful. • Let go of old behavior patterns and replace them with new ones that allow them to live a healthy lifestyle.

12. Stages of Change – Stage Six • Relapse • More common to have at least one relapse then no relapse at all. • Individuals may experience sense of failure that can undermine their recovery. • Time to analyze how the relapse occurred…what happened? What is the opportunity for learning? • Return to the action stage or maintenance stage and utilize tools of recovery.

13. Stages of Change – Stage Seven • Transcendence • Individual now can reflect, has maintained abstinence and understands the connection between distorted thinking, emotions and behavior patterns. • The old behavior patterns are no longer the “norm.” In fact, the individual is now a “new” person that does not need the old behavior patterns.

14. Vignette #1: Tony Tony is a 38 year old white male who has been diagnosed with schizoaffective disorder. He uses methamphetamine, cocaine, alcohol and marijuana regularly. He has lived with his parents for his entire adult life. His only work experience is the occasional odd job. His parents are in their sixties and he is an only child. His father has received treatment for colon cancer and his mother has been diagnosed with moderate depression. Tony receives outpatient mental health treatment and tells his doctor that the medication reduces his voices. Over the past five years he has had several exacerbations and been hospitalized for short periods. He has been referred to the clinic’s substance abuse counselor, however he states that his alcohol and drug use is not a problem for him and he refuses to attend Dual Diagnosis Anonymous meetings or meet with the substance abuse counselor regularly.

15. Vignette #1: Tony A while ago he agreed to be admitted to a residential drug treatment program but left after three hours. His parents call Tony’s doctor frequently complaining about his behavior at home. They report that neighbors complain that Tony steals from them. Tony has a bad temper when he uses drugs and threatens them if they do not accede to his wishes. He has stolen property and has stolen from them. They are reluctant to evict him from the home because they are afraid of what would happen to him. In any case Tony refuses to leave. The parents state that they are too stressed to attend NAMI and Al-Anon meetings. They state that they expect the mental health system to provide more services for their son and to “fix” his problem.

16. Vignette #2: Donna Donna is a 25 year old female with a diagnosis of bipolar disorder. She also uses alcohol, methamphetamine and marijuana. She lives at home with her parents but is gone for periods of time when she is “partying.” She also has part-time work as an exotic dancer. She receives outpatient mental health care infrequently and is not always compliant with her medication. She has been hospitalized from time to time however her behavior when she is discharged reverts to the same pattern. Her parents call her doctor frequently stating concern over client’s risky drug and sexual behavior. They are also concerned because when she is off her medications and using she sometimes drops cigarettes at home and forgets to put them out. They want the doctor to “lock her up so she will be safe.” When client comes in to see her psychiatrist she denies drug problems and states that her parents are “trying to run my life.”

17. Vignette #3: Mary Mary is a 52 year old female who has been diagnosed with bipolar disorder for many years. Over the years she has required medication adjustments necessitating hospitalizations from time to time. She has struggled with an alcohol problem for most of her adult life. Her symptoms of bipolar illness have worsened recently and she has been working with her therapist and her doctor to make efforts to stabilize her condition. She has been sober and is attending DDA meetings at the clinic in addition to other therapy groups. She has been compliant with her medications. Her adult daughter is a source of stress for her. She calls her frequently every day and if Mary does not answer the phone the daughter will drive over to check on her. The daughter has attended several family sessions with Mary and her therapist. She states that she needs to be this involved with her mother in order to keep her safe. She has been encouraged to reduce her involvement in her mother’s life and to focus on her own.

18. Vignette #3: Mary Recently, her mother was hospitalized. She had been unable to sleep for a few days and drank a bottle of wine and took some antidepressant pills in order to sleep. At a family session a week later Mary was very remorseful at her lapse. Her daughter raged at the therapist. “See what happens when I don’t watch over her – this hospitalization is your fault.”