1、Integrating Dual Recovery Therapy and Medications for Co-occurring Disorders,Douglas Ziedonis, M.D., MPH Professor & Director, Division of Addiction Psychiatry Robert Wood Johnson Medical School 732-235-4341 ziedondmumdnj.edu,Todays Goals Include,Increase awareness of the SAMHSA TIP on COD (www.heal
2、th.org) Learn Dual Recovery Therapy & related assessment issues Learn how to modify MET for poly-drug, COD, HIV risk behavior Learn how to improve medication adherence and better integrate medications into psychosocial treatments Addressing Tobacco an opportunity to learn MET CASE STUDIES,Principles
3、 of COD Treatment,COD treatment is different Depends on Setting Integrate and modify mental health and addiction treatment approaches Match treatment approaches to recovery stage and motivational level Provide comprehensive dual diagnosis services across the continuum Consider a long-term treatment
4、perspective,General Treatment Issues for COD,Empathy and the therapeutic alliance Family Involvement Brief Interventions: Feedback, Advice, Choices, Optimism, Responsibility, and Follow-up Managing Resistance Monitoring for relapse / relapse prevention Detoxification Recovery Tools: treatment plan &
5、 contract, self-help groups, medications, & therapy,Excellent Resource: Strategies for Developing Treatment Programs for People with COD,SAMHSA.gov (with NCCBH & SAAS) 2003 publication available through NCADI and National Mental Health Information Center Collection of COD Training Materials Strategi
6、es and tools that public purchasers use to build integrated care systems Core competencies,Mentally Ill Chemical Abuser (MICA) vs Chemical Abuser with Mental Illness (CAMI),Type & Severity of Psychiatric Disorders Type & Severity of Substance Use Disorders Motivation to Stop Using Substances Role of
7、 Physician & Prescribing Medications Routine Mental Status Exam & Urine Testing,MICA vs CAMI (II),Continuum of Care Outreach & Case Management Residential Services: Rules & Medications HIV / Medical Services Linkage Family, Spouse, & SO involvement,Dual Recovery Therapy (DRT),Integrate and modify th
8、e best of mental health and addiction approaches Consider the impact of each disorder on the individual and traditional treatments Consider the patients stage of recovery for both illnesses and their motivation to change: Motivation Based Dual Diagnosis Treatment Model Recognizes the need for hope,
9、acceptance, and empowerment Encourage Medication Compliance,Dual Recovery Therapy Blends and Modifies,Core addiction therapy approaches Motivational Enhancement Therapy Relapse Prevention 12-step Facilitation NCADI: 1-800-SAY NO TO; www.health.org Core mental health therapy approaches Varies accordi
10、ng to MICA / CAMI specific mental health disorders or problems More case management & outreach,Dual Recovery Therapy (DRT),MET = MI + Feedback,Motivational Interviewing (Style) Empathy, Client-Centered, Respects readiness to change, embraces ambivalence Directive one problem focused (needs adaptatio
11、n for poly-drug & COD) Personalized Feedback (Content) Assessment Personalized Feedback Values / Decisional Balance: Pros & Cons Change Plan & Menu of Options,Stages of Dual Recovery,* Blending Mental Health and Addiction Perspectives * Motivation Based Treatment:Prochaska & DiClemente Stages of Cha
12、nge: Precontemplation, Contemplation, Preparation, Action, and Maintenance * MICA model: Acute Stabilization, Engagement, Active Treatment, Relapse Prevention, & Recovery,DRT for Addiction Settings,Professional Development of Staff,What is their Identity Role? How improve their Training? Do they hav
13、e the Credentials to see this group of patients and in what capacity? EX: CSATs COD Model Program Evaluation Studies Fully-Integrated vs Consultant-Integrated,ASAM PPC: 6 Dimensions Dual Diagnosis Capable vs Enhanced,SEVERITY GRID / Integrated programs Acute Intoxication / Withdrawal Biomedical Cond
14、itions or Complications Emotional / Behavioral Conditions or Complications Treatment Acceptance / Resistance Relapse / Continued Use Potential Recovery Environment,Basic Mental Health Training,Organized around six sections Focused on concrete skill acquisition Style is didactic, with discussion Incl
15、udes articles and fact sheets that complement content areas,Basic Mental Health Training Manual,Six sections addressing diagnostic issues and clinical presentations Assessment Anxiety disorders Mood disorders Personality disorders Suicide, violence and sleep problems Medications and role of counselo
16、r in supporting compliance Internet resources for each section Clinical vignettes for each section Documentation suggestions,Advanced Mental Health and Dual Recovery Therapy Training,Organized around major content areas Includes articles and fact sheets that complement content areas Focused on concr
17、ete skill acquisition Style is didactic and experiential Includes role plays and demonstrations Includes consultants for family, couples and spirituality components,COD Assessment Issues,Symptoms versus Diagnosis anxiety, depression, mania, & psychosis intoxication, withdrawal, & chronic use persona
18、lity factors symptom scales and diagnostic tools Primary versus Secondary ? Self-Medication ?,Assessment Strategies,Time-line (prior history) Prior mental health, addiction, & dual diagnosis treatment Information from Significant Others Family History Changes while in Treatment,Dual Recovery Status
19、Exam,Assess Both Psychiatric and Addiction Issues, including motivation Cravings / Thoughts Last substance use 12-Step & Treatment Involvement Current Mental status Medication Compliance,Suicide Assessment,Current suicidal thoughts, intent, and plan History of suicide attempts (eg, lethality of meth
20、od, circumstances) Family history of suicide History of violence (eg, weapon use, circumstances) Intensity of current depressive symptoms Current treatment regimen and response Recent life stressors (eg, marital separation, job loss) Alcohol and drug use patterns Psychotic symptoms Current living si
21、tuation (eg, social supports, availability of weapon),SAD PERSONS: a mnemonic for assessing suicide risk,Sex (male) Age (elderly or adolescent) Depression Previous suicide attempts Ethanol abuse Rational thinking loss (psychosis) Social supports lacking Organized plan to commit suicide No spouse (di
22、vorced widowed single) Sickness (physical illness),Motivation to Change,Motivation to address substance abuse, take medications and acknowledge mental illness Internal versus External Motivation Decisional Balance, Change Ruler, Quit Date, etc Motivationalinterviewing.org Stages of Change (Prochaska
23、 & DiClemente): Precontemplation, Contemplation, Preparation, Action, Maintenance Motivation varies by substance and setting Alcohol, Cocaine, Marijuana, Nicotine Inpatient, ER, and Outreach,Problems & Disorders NOT to Forget,Sub-threshold Depression &Anxiety Disorders PTSD Adult ADHD & Learning Dis
24、ability Social Anxiety Disorder Eating Disorders Axis II Anger Compulsive Behaviors (sex, gambling, codependence, work, food, spending, etc),Treatment Planning,How organize? disorders, sub-threshold / problems, etc By individual treatment needs & program menu of options Motivational Level? Client Pr
25、eference? Level of Care? Include ongoing assessment / monitoring, medication options, and therapy options Co-occurring issues mental illness, medical problems, prevention (HIV, COD, other) Couple/SO & Family involvement Follow-up / Referrals HOW INVOLVE client and family in the treatment planning pr
26、ocess? (MET Change Plan),Example,Major Depression Ongoing assessments (BDI, others) Ongoing assessment of SI Follow-up for addiction, anxiety, Axis II problems Medications Reviewed Options interest in taking a med (motivational level) Therapy (program level and modalities and specific type of therap
27、y) Ex. Low intensity Treatment group therapy once per week; individual therapy Couples / Family,Teaching Mental Illness Treatment Issues to Substance Abuse Counselors,Concrete Tools versus Style Mood Management Thought Diary (STEP work) Assertiveness / Role Play Practical Self-Help Skills / Behavior
28、al Shaping Counter-transference management MET easier to do with MI or Tobacco Couples / Family interventions Psychiatric medications, MD teamwork, & med compliance,Limitations of depression: modifying addiction treatment,Lower self-efficacy Lower motivation and inertia Difficulties managing mood /
29、affect Worsening Coping Skills Cognitive Distortions Maladaptive Interpersonal Skillsavoidance or antagonism,Integrated Treatment for Mood and Substance Use Disorders (2003),Westermeyer J, Weiss R, and Ziedonis D John Hopkins University Press Hardcover (0-8018-7199-9) $39.95 ($31.96 with 20% discoun
30、t mention code NAF) 1-800-537-5487,Psychosocial Treatments For Depression,Cognitive TherapyFeeling Good by Burns Behavioral Therapy Interpersonal Therapy Psychodynamic Therapy,Dual Recovery Therapy: CBT STEP WorksheetBased on CBT principles of self-monitoring and cognitive restructuringShould be us
31、ed to target problematic emotional responses Should be reviewed thoroughly in sessionGive clear rationale for assignmentClient should complete at home after an upsetting incident and bring to next session,Dual Recovery Therapy: CBT STEP WorksheetSituationThoughtEmotion Persuasive reply,Dual Recovery
32、 Therapy: CBT STEP WorksheetSituation:What was the external event?Who else was there?When did it happen?Where did it happen?,Dual Recovery Therapy: CBT STEP WorksheetThought what was the clients self-talk?Should be a complete sentenceDistinguish between thoughts and feelings Can guess if not recalle
33、d precisely,Dual Recovery Therapy: CBT STEP WorksheetEmotionUsually a single feeling wordNot an evaluation or attributionAsk client to elaborate and describe feeling,Dual Recovery Therapy: CBT STEP WorksheetPersuasive reply - what could client say in response to thought? Should be:Realistic in conte
34、ntReassuring in toneConcise Personally meaningful,Anger Management for Substance Abuse and Mental Health Clients,SAMHSA pub: SMA 02-3756 Events Cues Strategies Anger Control Plans (timeout formal or informal, talk to friend, conflict resolution, exercise, 12-Step meetings, explore primary feeling be
35、neath anger) The Aggression Cycle: EscalationExplosionViolencePost Anger and the Family: How Past Learning Can Influence Present Behavior Relaxation Interventions (breathing, muscle relaxation, exercise, meditation, music, etc),Anger Management (continued),Cognitive Restructuring: ABCD Model and Tho
36、ught Stopping Activating event Belief System Consequences (feelings) Dispute (examine your beliefs and expectations and are they unrealistic or irrational? Assertiveness Training & Conflict Resolution Model Communication Skills Interventions ID problem, feelings, impact of the problem, decide whethe
37、r to resolve conflict, work for resolution),Specific Psychosocial Treatments For COD with Other Psychiatric Disorders,PTSD: Behavioral Therapies - Seeking Safety Lisa Najavitz Bipolar: Family / Psychoeducation - Roger Weiss Schizophrenia: Social Skills Training, Case Management / ACT Social Anxiety
38、Disorder Behavioral Therapy,Couples and Family Therapy,Intervention Request Assessment of interactions & changes with usage status (wet, damp, and dry) Couples and Family Treatment Enhancing Treatment Compliance Alanon / 12-Step Meetings ACOA, Co-dependence, Sex Addiction, role in family of origin,I
39、ntegrating Spirituality into Treatment (Miller W.APA, 1999),Mindfulness and Meditation Prayer Values, Spirituality, and Therapy Spiritual Surrender Acceptance and Forgiveness Evoking Hope Serenity,Complementary Approaches,Acupuncture Hypnosis Herbs Meditation Qi-Gong: Meditation, Deep Breathing, Yog
40、a The Arts: art and musicDrumming, NAF ETC,Schizophrenia and Addiction,Keep medicating the psychosis,Adapt to Features of Disorders: Example of Schizophrenia,Heterogeneous group Positive and Negative Symptoms Therapeutic Alliance Cognitive Deficits Low Motivation Low Self-Efficacy Limited Interperso
41、nal Skills More Cravings during Withdrawal,More complications with co-occurring addiction and mental illness,Greater fluctuations in mental status Increased suicide risk Worse medication compliance Questionable reports on substance use Increased episodic homelessness Greater chance of doing violence
42、 and being the victim of traumatic events Greater incidence of illegal activities,Assertive Community Treatment,Team structure with integration of clinical and case management roles, team responsibility Staff : patient ratio Regular contact Direct interventions to maintain concrete services After ho
43、urs service with an on-call team Occupational rehabilitation with job placement Provision for Appropriate Housing,Relapse Prevention Good one to blend with MH CBT approaches,LIKE Identifying cues / triggers for substance use or cravings / thoughts = ID early warning signs of mental illness recurrenc
44、e Goal to improve self-efficacy to handle specific people, places, things, moods Examples: Drug refusal skills Seemingly irrelevant decisions Managing moods / thoughts Stimulus control Medication & Treatment adherence / compliance,Social Skills Training CBT example used in Schizophrenia,Liberman, Be
45、llack, and other models Problem Solving and Communication Skills Behavioral Learning Principles Symptom and Medication Management Asking others for help and exploring new interests Identifying healthy and unhealthy relationships Discussion of family relationships,The Use of Role Plays: Behavioral Le
46、arning,Setting up the Role Play (discreetly) Problem to Solve Non-verbal and Verbal Communication “Modeling” by peers “Coaching” by therapist All provide Positive Feedback Sandwich Homework is to try to do learned approach outside of treatment,Dual Recovery Anonymous: modifying 12-Step for COD,Dual
47、Recovery Anonymous: Modified 12-Step Recovery concepts supports increased sense of hope and connection to others Shared Experience (experience, strength, and hope) Recovery is not cure, but rather a way of living a meaningful life within the limitations of schizophrenia, depression, addiction, or an
48、y combination Recovery is a process of restoring self-esteem and a symbol of a personal commitment to growth, discovery, and transformation,Working a 12-Step Program,Abstinence goal assumed Working the Steps Sponsor, mentor or guide Group support and involvement Spirituality & Spiritual Guides Daily
49、 Reading and Reflections Self-Evaluation Time to Celebrate Health Care (when address tobacco?) Integrate Complementary Approaches,MET and Psychiatric Disorders Clinical Applications Transition from inpatient to outpatient treatmentTreatment adherenceEnhancing motivation for MH and SA disordersEnhanc
50、ing medication compliance,MET = MI + Feedback,Motivational Interviewing (Style) Empathy, Client-Centered, Respects readiness to change, embraces ambivalence Directive one problem focused (needs adaptation for poly-drug & COD) Personalized Feedback (Content) Assessment Personalized Feedback Values / Decisional Balance: Pros & Cons Change Plan & Menu of Options,
