Co-Occurring Disorders

1. Co-Occurring Disorders Quadrants and Stages of Change

2. Objectives • Gain knowledge and understand quadrants’ terminology, stages of change, addiction severity, and seriousness of mental disorder • Identify and determine appropriate treatment placement based on co-occurring profile • Identify and determine appropriate treatment recommendations and referrals

3. DEFINITIONS

4. Co-Occurring Disorder (1) • Co-Occurring Disorder: • Presence of two or more independent disorders/diseases that exist in the life of a person • Each disorder/disease has a life of its own and is NOT dependent on the other for its cause or continuation • Diagnoses interact with each other, either exacerbating or inhibiting the specific symptoms or behaviors

5. Substance Abuse(2) • Substance Abuse: Maladaptive patterns of substance use, including clinical impairment or distress as manifested by one or more of the following within a 12 month period: • Failure to fulfill major role obligations • Use in hazardous situations • Use despite negative consequences

6. Substance Use Dependence(3) • Substance Use Dependence: • Addiction is a primary, chronic disease with biological, psycho-social, and environmental factors influencing its development and manifestation • Progressive and fatal • Maladaptive patterns of substance use, including impairment or distress

7. Substance Use Dependence (3 continued) • Manifested by (three or more): • Increased tolerance • Withdrawal • Inability to control use, even with negative consequences • Preoccupation with substance use • Important social, occupational, or recreational activities given up or reduced

8. Psychiatric Disorder (4) • Psychiatric Disorder • Includes numerous diagnoses of though and mood disorders • Health conditions of the brain characterized by alterations of perception, mood, or behavior (or some combination) • Associated with distress and/or impaired functioning

9. Psychiatric Disorder (4 continued) • Alterations in thinking, mood, or behavior that give rise to a host of symptoms and problems that can lead to • Heightened risk of pain • Loss of freedom • Disability and even death

10. Mild Psychopathology (5) • Mild Psychopathology: • Few, if any, symptoms in excess of those required to make diagnosis • Symptoms result in no more than minor impairment in social or occupational functioning

11. Severe Psychopathology: Many symptoms in excess of those required for diagnosis OR Several symptoms are severe OR Symptoms result in marked impairment in social or occupational functioning Severe Psychopathology (6)

12. Four Quadrant Model (7) • The Four Quadrant Model is a viable mechanism for categorizing individuals with co-occurring disorders for purposes of: • Service planning and • System responsibility

13. PART 2 CO-OCCURRING DISORDERS SUB-GROUPS

14. Co-occurring Disorder Sub-groups

15. Examples of Sub-groups and Specific Treatment Interventions

16. Quadrant 1 Low and Low (low substance abuse and mild-to-moderate psychopathology) • Clients not usually in public mental health system, can maintain employment and usually have health insurance • Have periodic combinations of psychiatric symptoms (e.g. anxiety, depression, family conflict) and • May abuse substances but not develop substance dependence

17. Low & Low treatment interventions • Addiction education • Outpatient – individual and/or family sessions • Psychiatric assessment and medication evaluation, if appropriate

18. Quadrant 2 Low and High (low substance abuse and serious and persistent psychopathology) • Schizophrenia, major affective disorders, serious post-traumatic stress disorder (PTSD), and severe personality disorders • Individuals usually appear in the mental health system • Clients do not usually view substance abuse as a problem

19. Low and High treatment interventions • Addiction education – harm reduction and relapse prevention • Empathic confrontation contracting approach • Inpatient psychiatric stabilization • Ongoing psychiatric treatment, including medication, if appropriate

20. Quadrant 3 High and Low (high/significant substance use disorder and mild-to-moderate psychopathology • Most likely client in public mental health system • Due to substance use disorder, often lacks ability to sustain employment, often involved in legal system, and may have lost housing • Depression, bipolar disorder (stabilized), PTSD symptoms, personality disorders, and mild anxiety and panic disorders

21. High and Low treatment interventions • Detoxification followed by residential or intensive outpatient treatment • Addiction education – abstinence-oriented and relapse prevention approach • Empathic confrontation contracting approach

22. High and Low treatment interventions continued • Encourage recovery (12 step) support network • Family education (Al-Anon) • Ongoing psychiatric treatment, including medication, if appropriate

23. Quadrant 4 High and High (significant substance use disorder and serious and persistent psychiatric disorders) • This client benefits from high structure • Structure must be consistent • This may include: • Inpatient care • Residential program • Partial hospitalization program

24. High and High treatment interventions • Substance-enhanced psychiatric inpatient setting • Addiction education-harm reduction and relapse prevention approach • Empathic confrontational contracting approach

25. High and High treatment interventions continued • Ongoing motivational interviewing and engagement • 0ngoing psychiatric treatment, including medication, if appropriate

26. PART 2 STAGES OF CHANGE DEFINITIONS AND TASKS* * DiClimente and Prochaska

27. Stages of Change Pre-contemplation   Contemplation  Preparation   Maintenance Action     

28. 1. Pre-contemplation • This stage is one in which individuals are: • Unconvinced they have a problem OR • Are unwilling to consider they have a problem OR • Need to change TASK: Increase awareness of need to change

29. 1. Pre-contemplation example Jane gets tired of everyone nagging her to stop smoking. It is bad enough that she can’t smoke in restaurants any more, that the cost of cigarettes went up, and now she has to go outside to smoke. Jane wonders, “How do they expect me to finish my projects on time if I keep getting up to go outside to smoke?”

30. 2. Contemplation • In this stage, a person is: • Actively considering the possibility of change • Most persons are evaluating options, but are not ready to take action yet TASK: Increase the positive benefits of change and decrease the negative consequences

31. 2. Contemplation example John has lost 2 jobs in the past year and both have been due to lateness, absences, and missed project deadlines. John is wondering if his drinking with the boys on the weekend is beginning to affect his ability to focus. He realizes that he misses mostly Mondays and deadlines due to his continual headaches. John thinks, “Maybe I’ll consider cutting down on my drinking.”

32. 3. Preparation • This stage is when a person: • Makes a commitment to change AND • Starts initial plans actually to change his or her behavior TASK:Begin planning and make a commitment to start the change

33. 3. Preparation example Joseph has been thinking about losing weight, but he just hasn’t been able to start exercising as he used to. He has done some sit-ups for a few mornings the last 2 weeks and has gone to the gym twice. Joe called a couple of his friends to see if they would be interested in starting cycling at least once a week on weekends.

34. 4. Action • Once a person takes effective action to make change, he or she is considered to be in the action stage. At this stage: • Actual behavior change begins to occur • New ways of dealing with situations are learned • Avoiding relapse is attempted TASK: Implementing and revising the plan as necessary

35. 4. Action example Mary is so proud of herself! She contacted AA and has gone to 3 meetings. She has not had any alcohol in the past 10 days. She no longer goes to “happy hour” with her friends at work and her boss commented that her work has improved.

36. 5. Maintenance • In this stage, a person: • Begins to consolidate the behavior into her or his regular lifestyle • Integrates his or her thinking and actions into a new way of living TASK: Integrate the changes into a daily lifestyle

37. 5. Maintenance example Paul can hardly believe he hasn’t been admitted to the hospital in the last 2 years. He is working with a case manager, seeing his therapist, and taking his medication. Since his last suicide attempt and diagnosis of bipolar disorder, he has been involved with support groups to address his mental illness. He is very proud that his relationship with his family has continued to improve.