Stages of Change in the Treatment of Co-occurring Disorders: Creating a Congruency

1. Stages of Change in the Treatment of Co-occurring Disorders: Creating a Congruency Curtis Thornton, LMSW, CAADC, SAP Melissa Tinervia, BSW

2. The Stages of Change • Precontemplation • Contemplation • Preparation • Action • Maintenance • Relapse

3. Co-occurring Disorders and Stages of Change: Key Points • An individual is not in one stage of change; they are in multiple stages for multiple areas of life. • The stages may differ for substance use and mental health. • Each stage requires a specific type of intervention/technique. • It is critical for the worker to assist the individual in obtaining SOC congruency for substance use and mental health disorders. • Complete a comprehensive/Integrated Assessment.

4. What is Stage of Change (SOC) Congruency? • The individual is in the same (or complementary) SOC for mental health and substance use disorders. • The individual is able to apply skills to address challenges of multiple disorders. • The individual has a congruency support team consisting of self, family, peers and social service worker (if applicable).

5. Potential Sources of Barriers to Stage Congruency • Individual (Client, Patient, Member, etc…) • Support System (Family, Friends, etc…) • Social Service System (Workers, agencies, policies, etc…)

6. 10 Common Congruency Barriers/Source Impacted

7. 10 Common Congruency Barriers/Source Impacted (Cont.)

8. 10 Common Congruency Barriers/Source Impacted (Cont.)

9. Barrier: Lack of Acceptance • Unable to accept more than one diagnosis. • Thoughts and behaviors focused on supporting accepted diagnosis. • Cognitive distortion/thinking errors prevent acceptance of additional diagnoses. • Does not believe change is possible; sees self as having little influence.

10. Effective Methods in Overcoming Lack of Acceptance • Be clear about observed symptoms that led to the diagnoses. • Allow the client and supports to express thoughts and feelings about the diagnoses. • Allow time for client to establish integrated thought patterns regarding multiple diagnosis - Utilize Motivational Interviewing. • Stay away from being forceful with the diagnoses; this comes across as “labeling.”

11. Barrier: Lack of Info. • Misinformation. • Research on internet or through other means supports their accepted diagnosis. • Experiences do not allow for the shaping of alternative perspectives. • New information seen as harmful, even though it may be the beginning of growth/improvement.

12. Effective Methods in Overcoming Lack of Info. • Provide easy to understand facts about the diagnoses. WATCH OUT FOR COMPLEX TERMINOLOGY! • Learn where the client has obtained previous information. • Maintain cultural diversity among staff - Be Sure to Include Peers. • Allow safe place for client to explore alternative perspectives without fear of judgment. • Warn about the dangers of information from the internet. • StaffMUSTbe trained on Co-occurring Disorders. • Teach Mask, Mimic, Exacerbate or Independence of Co-occurring Disorders.

13. Barrier: Fear • How does this impact my future? • Does this mean I’m less than? • Did I do something wrong? • What will people think? • Am I capable of providing the appropriate service?

14. Effective Methods in Overcoming Fear • Explore the impact of diagnoses and treatment on future goals - Focus on the benefits, as opposed to perceived consequences. • Staff needs to trust in their abilities. They are hired for a reason. If there is a mutual doubt, discuss, reassess and reassign if needed. • Provide information. • Be knowledgeable and prepared to move people through the Stages of Grief.

15. Barrier: Past Experiences • “Treatment doesn’t work because it didn’t work before.” • “They are just going to give me medications.” • “My brother has Bipolar, what I have is NOT Bipolar.”

16. Effective Methods in Overcoming Past Experiences • Explore circumstance, SOC and life events related to previous attempts at change. • Discuss ‘what didn’t work’ versus ‘what has worked.’ • Discusses changes in service delivery as a result of Recovery Oriented Systems of Care. • Discuss the changes of signs/symptoms displayed by individuals. • Address real life problems initially to build rapport - Don’t be afraid of small talk.

17. Barrier: Past Diagnosis • “I am diagnosed with Manic Depression, Bipolar, Depression, Anxiety, PTSD, Opioid Dependence and VicodinDependence, and now you say I have Alcohol Dependence?” • “They tried to diagnose me with the same thing.” • “That other agency was wrong with their diagnosis.”

18. Effective Methods in Overcoming Past Diagnoses • Be patient with diagnosis; don’t over diagnose. • Assist the client in understanding that diagnoses change over time. • Assist in understanding the purpose of diagnosing. A diagnosis without a plan is a label. • Employ a recovery perspective.

19. Barrier: Cognitive/Function Impairments • Individual questions their own abilities. • Family doubts the individuals abilities and does not allow the individual the opportunity to show capabilities. • Staff is not comfortable working with the individuals with cognitive impairments.

20. Effective Methods in Overcoming Cognitive/Functional Impairments • Make a comprehensive assessment and then meet individuals “where they are at.” • No “should’s” or “need to’s” • Assess the whole person • Assist individuals in building their self esteem through strength based case planning; maintain family meetings if possible. • Have materials appropriate for multiple learning levels.

21. Barrier: Lack of Resources • Individual does not know how to identify/find the available resources. • Available resources are outside of the individual’s accessibility. • Fewer support groups for Co-occurring Disorders- Not always welcome at AA and NA meetings.

22. Effective Methods in Overcoming Lack of Resources • Make services accessible/ remove barriers. • Ensure continuity of care; Parallel and Sequential methods are least desirable. • Utilize support systems to maintain and extend service effectiveness. • Develop programs that fill in service gaps. • COLLABORATE WITH OTHER PROVIDERS!!!!!!!

23. Barrier: Lack of Time • Standardized units may not meet needs of individuals with Co-occurring Disorders(i.e. an hour may be too much or too little time to address the individual needs). • Transportation may not be readily available. • Between services and supports, the individual may be overwhelmed with time commitments. • Services may interfere with other needed services offered elsewhere, or other responsibilities.

24. Effective Methods in Overcoming Lack of Time • Identify the appropriate level of care: Individual counseling, group counseling, family intervention, case management, residential treatment, intensive outpatient, contingency management, legal intervention. • Invite individual into a teamwork relationship - Adapt plan as needed. • Don’t rush services. • Be flexible.

25. Barrier: Lack of Trust • The individual may have had trusted information disclosed in the past. • Individual and Supports may be embarrassed about information shared in sessions. • Providers may assume minimization/maximization of signs/symptoms.

26. Effective Methods in Overcoming Lack of Trust • Non-judgmental approach. • Maintain confidentiality; discuss with client each time information is shared. • Share only relevant information. • Normalize the abnormal - Show individual and supports that what they have experienced is a normal reaction to an abnormal situation. • Appropriate use of self disclosure (Professional Use).

27. Barrier: Treatment Approaches • Individual may have had previous treatment experiences that were less than satisfactory. • Approaches that are not individualized. • Judgment on effectiveness of treatment (i.e. wanting a quick fix).

28. Effective Methods in Overcoming Treatment Approaches • Provide a phased approach/comprehensive array of services. • Limit your influence on the recovery plan; focus on client’s needs/wants in his/her own words. Include family in recovery planning. • Utilize multiple models based on individual’s strengths.

29. In Summary • Co-occurring Disorders exist. Staff must be trained on how to enhance congruency. • In order to achieve SOC congruency we cannot only identify barriers - WE MUST CREATE SOLUTIONS TO REMOVE THEM! • Solutions require a team approach including client, worker, family, community and other social service providers. WE NEED A COMMON LANGUAGE.

30. Bibliography • Arias, A. J., & Kranzler, H. R. (2008). Treatment of Co-Occurring alcohol and other drug use disorders [Electronic version].Alcohol Research & Health, 1-9. • August, J. L., & Flynn, A. (2007, March 5). Applying stage-wise treatment to a mixed-stage Co-occurring disorders group. American Journal of Psychiatric Rehabilitation, 10(1), 53-63. doi:10.1080.15487760601166357 • DiClemente, C. C., NiDecker, M., & Bellack, A. S. (2008). Motivation and the stages of change among individuals with severe mental illness and substance abuse disorders. Journal of Substance Abuse Treatment, 34, 25-33. doi:10.1016/j.jsat.2006.12.034

31. Bibliography (cont.) • Drake, R. E., O'Neal, E. L., & Wallach, M. A. (2008). A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders. Journal of Substance Abuse Treatment, 34, 123-138. doi:10.1016/j.jsat.2007.01.011 • El-Mallakh, P. (1998, April). Treatment models for clients with Co-occurring Addictive and Mental Disorders. Archives of Psychiatric Nursing, 7(2), 71-80. • Mueser, K. T., & Gingrich, S. Treatment of Co-Occurring psychotic and substance use disorders. Social Work in Public Health,28(3-4), 424-439. doi:10.1080/19371918.2013.774676

32. Bibliography(cont.) • Sacks, S. (2007, June 5). Brief Overview of Screening and Assessment for Co-occurring Disorders. International Journal of Mental Health Addiction, 7-17. doi:10.1007/s11469-007-9098-0 • SAMHSA. (2008). Substance Abuse Treatment for persons with Co-Occurring Disorders (Tip 42 ed., pp. 117-160). Rockville, MD: U.S. Department of Health and Human Services.