Co-occurring Substance Use And Mental Health Disorders In .
Co-occurring Substance Useand Mental Health Disordersin Adults:An Integrated Treatment Approach to Dual DiagnosisTRAINER’S MANUAL
Co-occurring Substance Use and Mental Health Disorders in Adults:An Integrated Treatment Approach to Dual DiagnosisTRAINER’S MANUALCo-occurring Substance Use and Mental Health Disorders in Adults:An Integrated Treatment Approach to Dual DiagnosisTRAINER’S MANUALCo-occurring Substance Use and Mental Health Disorders in Adults:An Integrated Treatment Approach to Dual DiagnosisTRAINER’S MANUALCo-occurring Substance Use and Mental Health Disorders in Adults:An Integrated Treatment Approach to Dual DiagnosisTRAINER’S MANUALCo-occurring Substance Use and Mental Health Disorders in Adults:An Integrated Treatment Approach to Dual DiagnosisTRAINER’S MANUAL
Co-occurring Substance Use and Mental HealthDisorders in AdultsAn Integrated Treatment Approach to Dual DiagnosisTRAINING MANUAL
Published by the Northeast Addiction Technology Transfer Center (NEATTC.)Northeast ATTC, Regional Enterprise Tower, 425 Sixth Avenue, Suite 1710, Pittsburgh, PA 15219This publication was prepared by the Addiction Technology Transfer Center (ATTC) Network under a cooperative agreementfrom the Substance Abuse and Mental Health Services Administration’s (SAMHSA), Center for Substance Abuse Treatment(CSAT). All material appearing in this publication except that taken directly from copyrighted sources is in the publicdomain and may be reproduced or copied without permission from SAMHSA/CSAT or the authors. Citation of the sourceis appreciated. Do not reproduce or distribute this publication for a fee without specific written authorization from theNEATTC. For more information on obtaining copies of this publication, call 412-258-8565.At the time of this printing, Charles G. Curie, MA, ACSW, served as the SAMHSA Administrator. H. Westley Clark, MD, JD, MPH,served as the Director of CSAT., and Catherine D. Nugent served as the CSAT Project Officer.The opinions expressed herein are the views of the ATTC Network and do not reflect the official position of the Departmentof Health and Human Services (DHHS), SAMHSA or CSAT. No official support or endorsement of DHHS, SAMHSA or CSAT forthe opinions described in this document is intended or should be inferred.
MISA TRAINER’S MANUAL DEVELOPMENTTheNorthwest Behavioral HealthNet Training Subcommittee on MISACurriculum developed this Mental Illness Substance Abuse (MISA)Trainer’s Manual in conjunction with Gannon University through a grant funded bythe Northeastern States Addiction Technology Transfer Center. Northwest BehavioralHealthNet is a consortium of 22 behavioral health agencies that provide services inErie County, PA.Kenneth Minkoff, M.D., provided Professional consultation for this project. Dr.Minkoff is the Director of Integrated Psychiatric and Addiction Services for ArbourHealth System, and the Medical Director of Choate Health Management. He is aBoard Certified psychiatrist with a certificate of additional qualifications in AddictionPsychiatry. He is a nationally known expert on dual diagnosis and the integrationof mental health and substance disorder services. He has authored and editednumerous works, including “Dual Diagnosis of Serious Mental Illness and SubstanceDisorder,” which he co-edited with Robert Drake, M.D. Dr. Minkoff is also Chair ofthe Center for Mental Health Services Public Managed Care Initiatives Panel on Cooccurring Psychiatric and Substance Disorders, and a member of the board of theAmerican Association of Community Psychiatrists. Areas of consultation expertiseinclude: psychiatric and addiction integration, managed care systems development,quality management, physician management, contracting and reimbursement,utilization management and levels of care assessment, hospital alternatives formental health, and substance use disorder.The manual development was directed by MargaretShenefelt, MSW, LSW, along with the othermembers of the Northwest Behavioral HealthnetMISA Training subcommittee. Kathleen Pae, MS,LPC, CAC, provided grant writing and MISAexpertise. Cathleen Miner Ashbaugh, M.S.,David Rosswog, M.A. and Debra Thaler, M.A.of Gannon University designed and authoredthe manual under contract with the NorthwestBehavioral Healthnet. Robert Nelson, Ed.D.,Training Director and Chair of the PsychologyDepartment of Gannon University, was an additionalconsultant to the project.ADULT CO-OCCURRING TRAINING MANUAL—1
The current edition of this curriculum was completed in the Fall of 2005 and containsthe newest information available on Co-occurring Disorders in Adults. This editionwas re-written by Margaret Shenefelt, MSW, LSW and Kathleen Pae, MS, LPC,CAC. Thanks go to Joan Leary, Alabama Manager for the Southern Coast AddictionTechnology Transfer Center, at University of Alabama-Birmingham and Kathy Seifried,Alabama Department of Mental Health, Substance Abuse Division, and the forty CoOccurring Trainers from Alabama who gave us invaluable feedback for the revisionsneeded. The second edition revision was funded and supported by the NortheastAddiction Technology Transfer Center at the Institute for Research, Education andTraining in Addictions (IRETA) in Pittsburgh, PA.Included in this manual are trainee and trainer rating and evaluation scales toprovide for ongoing improvement and adjustments by both trainers and trainees. Ifyou have questions, suggestions or need additional help as a trainer, or would like tohire a trainer for this curriculum, please contact:NEATTC/IRETARegional Enterprise Tower425 Sixth Avenue, Suite 1710Pittsburgh, PA -co-occurring.orgADULT CO-OCCURRING TRAINING MANUAL—2
AUDIO/VIDEO RESOURCE INFORMATIONCONTENT:MODULE 1Minkoff, K. (2000). Dual Diagnosis: An integrated model for the treatment of people with cooccurring psychiatric and substance disorders. A lecture by Kenneth Minkoff. BrooklineVillage, MA: Mental Illness Education Program Videos, 2000. Available at: www.kennethminkoff.com or call 1-800-343-5540.SAMHSA, Video VHS 167, When Addiction and Mental Disorders Co-Occur, 2003. Available at:www.samhsa.gov.MODULE 2Csernansky, J., Department of Psychiatry, Washington University School of Medicine, MalcolmBliss Mental Health Center. (1994). Diagnosis according to the DSM-IV: Real patients talkingabout their problems in their own words. Tapes 1-4. Produced & directed by Wohl, I., Only ChildMotion Pictures, Inc. A Newbridge Professional Program. New York: Brooks/Cole PublishingCompany.Linehan, Marsha, Pfizer Inc., Life After Trauma: What Every Person Should Know, TL334Y99, 2000.Available from: Pfizer Inc.OPTIONAL AUDIO TAPEVirtual Hallucinations, a simulation of auditory hallucinations. (1997) Janssen Pharmaceutical.No longer available from Janssen, but your local NAMI chapter will probably have a copysomewhere in their library.MODULE 3Csernansky, John, MD, Department of Psychiatry, Washington University School of Medicine, MalcomBliss Mental Health Center. (1994)“Diagnosis according to the DSM-IV: Real patients talking abouttheir problems in their own words”. Tape 3. Produced by Ira Wohl, Only Child Motion Pictures, Inc.A Newbridge Professional Program. New York; Brooks/Cole Publishing Co.ADULT CO-OCCURRING TRAINING MANUAL—3
AGENDAAGENDA MODULE 1 6 HOURS INSTRUCTION TIME Introduction (60 minutes) Historical Trends & Barriers to Integrated Treatment (30 minutes) BREAK (15 minutes) Definitions and Principles of Integrated Treatment Approach to Dual Diagnosis(90 minutes) LUNCH (60 minutes) The Process of Recovery (60 minutes) Other Models of Dual Diagnosis Treatment (30 minutes) BREAK (15 minutes) Cultural Differences: Implications for Practitioner’s Role & Intervention(75 minutes) Summary, Post-test & Evaluation (15 minutes)AGENDA MODULE 2 6 HOURS INSTRUCTION TIME Introduction (30 minutes) What is a Mental Disorder? (30 minutes) Review of DSM -IV and DSM-IV TR (30 minutes) BREAK (15 minutes) Risk Assessment (30 minutes) Multi-axial Assessment (45 minutes)ADULT CO-OCCURRING TRAINING MANUAL—4
AGENDAAGENDA MODULE 2 CONTINUED LUNCH (60 minutes) Axis I Disorders (90 minutes) BREAK (15 minutes) Axis II Disorders (45 minutes) Summary, Post-test & Evaluation (15 minutes )AGENDA MODULE 3 6 HOURS INSTRUCTION TIME Introduction & Review of Goals and Agenda (30 minutes) Definitions & Considerations: Substance Related Disorders (60 minutes) BREAK (15 minutes) Treatment Selection and Modalities (30 minutes) Substance Abuse Diagnosis in the DSM-IV-TR (60 minutes) LUNCH (60 minutes) Substance Abuse Diagnosis Continued (45 minutes) Drugs of Abuse Exercises (60 minutes) BREAK (15 minutes) Continue Drugs of Abuse Exercises (60 minutes) Summary, Post-test & Evaluation (15 minutes)ADULT CO-OCCURRING TRAINING MANUAL—5
Co-occurring Substance Use and MentalHealth Disorders in AdultsAn Integrated Treatment Approach to Dual DiagnosisMODULE ONE:Integrated Concepts and ApproachesADULT CO-OCCURRING TRAINING MANUAL / MODULE ONE—6
MODULE 1 1.291.311.321.341.351.36Pre-test (Optional)Definition of Serious Mental Illness—PA MH BulletinLevels of FunctioningMini CasesFour Categories of Client Resistant Behavior (adapted from Miller & Rollnick)Counselor Responses that Heighten Resistance(adapted from Gordon, 1970; Miller & Jackson, 1985)The Four “R’s” Other Than ResistanceStrategies for Handling Resistance(adapted from Miller & Rollnick, 1991, p 102-110)Language that may decrease resistance, adapted from O’Hanlon, 1994.VignettesStages of Change—Prochaska and DiClementeQualities Which May Complicate AmbivalenceThree Barriers to Effective Multicultural CounselingCulture ExerciseCase StudyPost-test (Optional)Module 1 EvaluationADULT CO-OCCURRING TRAINING MANUAL / MODULE ONE—7
HANDOUT 1.0 / PRE-TESTPRE-TEST1. When people present with both substance abuse and a mental illness, it is important todetermine which diagnosis is primary.TrueFalse2. “Integrated Treatment” is defined as evidence-based or correct practice for treating dualdiagnosis clients that combines techniques resulting in one “best” way.TrueFalse3. Dual diagnosis is the exception in most cases.TrueFalse4. Substance abuse and dependence are really moral issues due to personal weakness.TrueFalse5. Psychiatric diseases in substance abusers occur at about the same rate as in the normalpopulation.TrueFalse6. One must be willing to explore new methods of treatment that take into account a client’sspecific cultural differences when working with multicultural clientele.TrueFalse7. Multiple cycles of relapse usually occur before engagement in ongoing treatment can work.TrueFalse8. Motivation enhancement theory postulates that the counselor’s task is to release eachclient’s potential for change and to facilitate natural change processes already inherent inthe individual.TrueFalse9. The most significant predictor of treatment success is the presence of an empathic, hopeful,continuous treatment relationship with integrated treatment and coordination of care.TrueFalse10. There are few parallels between mental health disorders and substance disorders.TrueFalseADULT CO-OCCURRING TRAINING MANUAL / MODULE ONE—8
HANDOUT 1.2 / DEFINITION OF SERIOUS MENTAL ILLNESS—PA MH BULLETINHIGHLIGHTS OF THE MENTAL HEALTH BULLETIN—COMMONWEALTH OFPENNSYLVANIA—MARCH 4, 1994PURPOSE: to establish the Adult Priority Group for planning and service development foradults with serious mental illness.DEFINITION OF “SERIOUS MENTAL ILLNESS” INCLUDES: Persons 18 or over who currently or at any time during the past year have had a diagnosablemental, behavioral, or emotional disorder according to DSM criteria. This has resulted in functional impairment that interferes with or limits major life activities. Disorders include those listed in the DSM with the exception of“V”codes, substance usedisorders, and developmental disorders, unless they co-occur with other serious mental illness. Functional impairments affect: basic living skills (eating, bathing, dressing), instrumentalliving skills (managing money, getting around the community), and functioning in social,family and vocational contexts. These definitions are required to be used to aid in treatment planning and providing servicesunder the Center for Mental Health Services Block Grant Program. Pennsylvania used this definition to establish an Adult Priority Group: Must be 18 and meet the federal definition of serious mental illness (see above.) Must have a diagnosis of schizophrenia, major mood disorder, psychotic disorder, orborderline personality disorder Must meet at least one of the following criteria from A. (Treatment History), B. (FunctioningLevel), or C. (Coexisting Condition or Circumstance).A. TREATMENT HISTORY1. Current residence in or discharge from a state mental hospital within the past two years.2. Two admissions to community or correctional inpatient psychiatric units or crisis residentialservices totaling 20 or more days within the past two years.3. Five or more face to face contacts with walk-in or mobile crisis emergency services withinthe past two years.4. One or more years of continuous attendance in a community mental health or prisonpsychiatric service within the past two years.5. History of sporadic course of treatment as evidenced by at least three missed appointmentswithin the past six months, inability or unwillingness to maintain medication regimen orinvoluntary commitment to outpatient services.6. One or more years of treatment for mental illness provided by a primary care physician orother non-mental health agency clinician within the past two years.B. FUNCTIONING LEVEL:1. Global Assessment of Functioning Scale rating of 50 or below.C. COEXISTING CONDITION OR CIRCUMSTANCE:1. Coexisting diagnosis or psychoactive substance use disorder, mental retardation, HIV-AIDS,or sensory, developmental or physical disability.2. Homelessness3. Release from criminal detentionAny adult who has met the standards for involuntary treatment within the 12 months precedingthe assessment is automatically assigned to the high priority consumer group.Summarized from the Mental Health Bulletin, Commonwealth of Pennsylvania, Department of Public Welfare, March 4, 1994.ADULT CO-OCCURRING TRAINING MANUAL / MODULE ONE—9
HANDOUT 1.7A / DIFFERENT LEVELS OF FUNCTIONINGComplicated Chemical DependencyPsych-Low, Substance-HighPatients with alcoholism or drug addiction who have significant psychiatric symptomatologyand/or disability but who do not have serious and persistent mental illness. This categoryincludes individuals who have both substance-induced psychiatric disorders and substanceexacerbated psychiatric disorders. Psychiatric syndromes found in this category include: Anxiety/Panic Disorder Depression/Hypomania Psychosis/Confusion PTSD Symptoms Suicidality Violence Symptoms Secondary to Misuse/Abuse of Psychotropic Medication Personality Traits/DisorderSubstance Abusing Mentally IllPsych-High, Substance LowPatients with serious and persistent mental illness, which is complicated by substance abuse,whether or not the patient sees substances as a problem. Schizophrenia Major Affective Disorders with Psychosis Serious PTSDSubstance Dependent Mentally IllPsych-High, Substance-HighPatients with serious and persistent mental illness, who also have alcoholism and/or drugaddiction and who need treatment for addiction, for mental illness, or for both. This may includesober individuals who may benefit from psychiatric treatment in a setting which also providessobriety support and twelve step programs.Substance Abuse & Non Severe PsychopathologyPsych-Low, Substance-LowPatients, who usually present in outpatient settings with various combinations of psychiatricsymptoms and patterns of substance misuse and abuse, but not clear-cut substance dependence. Anxiety Depression Family ConflictADULT CO-OCCURRING TRAINING MANUAL / MODULE ONE— 10
HANDOUT 1.7B / LEVELS OF FUNCTIONING & TREATMENT PLANNING—MINI-CASESNICOLE: Twenty-eight years of age, married for eight years, and the mother of two children inelementary school, Nicole has watched her drinking patterns change over the previous severalyears. She had been a social drinker since high school, but her consumption has changedin nature during her years of marriage. She was drinking not only socially, but also in theafternoons by herself. She awakened one morning and realized that even before she got outof bed, she was thinking of that first drink. Nicole’s marriage is deteriorating as her drinkingworsens. Intimacy is gone, and Nicole describes herself as “sinking deeper into a pit”, not havingany interest in her relationships, career, or children. She has noticed changes in her eating andsleeping patterns and has experienced suicidal thoughts.JOE: Joe was released from the state hospital five years ago, when his psychotic symptomsof delusions and hallucinations became manageable with medication and the services of anintensive case manager. He is currently unemployed, lives in his own apartment, and attendsa day treatment program sporadically. Joe’s case manager noticed a change in his functioningthree months ago, when Joe began a friendship with a neighbor. He began expressingdissatisfaction with his social situation and frustration about not feeling able to hold a job ordate. He missed several appointments and became unreliable on his medication. During a homevisit, Joe’s ICM found Joe intoxicated with a large supply of alcohol in his home. Joe was off hismedication and presenting disorganized thought and behavior as well as suicidal ideation.MELODY: By the time she was admitted to the hospital, Melody was talking a mile a minute. Hermovements were rapid and erratic. At the slightest provocation, she flew into a rage. She hadnot slept in three nights and her eyes gleamed with intense excitement. In obtaining a historyfrom Melody’s mother, the therapist found that this was Melody’s second manic episode in thelast 6 months. Melody was attending the local community college and struggling academicallyand socially. She experienced weeks of lethargy, sadness, and lack of motivation. Melody’smother also reported that Melody had been arrested twice for cocaine possession and that herdrug use began in early adolescence with marijuana use and progressed to cocaine use morerecently. She has relapsed from two residential treatment stays for substance abuse. Melody laterconfirmed that she used cocaine to escape and sought a heightened state when she was feelingdepressed.JAKE: Jake is an unemployed construction worker who is unmarried. He has fathered threechildren with his girlfriend. He is able to work when work is available, but he doesn’t go outof his way to look for extra jobs. He sees his children only when his relationship with hisgirlfriend is going well. He reports drinking about a six pack of beer a night, and lately says heis beginning to get weird feelings of his heart beating fast and his breathing getting weak. Hereports feeling as though he is having a heart attack. Upon numerous visits to the clinic, hisphysician has not found any physical basis for his feelings. He doesn’t believe it, but the clinicreferred him for mental health services.ADULT CO-OCCURRING TRAINING MANUAL / MODULE ONE— 11
HANDOUT 1.18 / FOUR CATEGORIES OF CLIENT RESISTANT BEHAVIOR(ADAPTED FROM MILLER & ROLLNICK, 1991, P. 101-102)1. ARGUING: The client contests the accuracy, expertise or integrity of the therapist. Challenging: The client directly challenges the accuracy of what the counselor has said Discounting: The client questions the counselor’s personal authority and expertise Hostility: The client expresses direct hostility toward the counselor.2. INTERRUPTING: The client breaks in and interrupts the counselor in a defensive manner. Talking over: The client talks while the counselor is still speaking. Cutting off: The client
ADULT CO-OCCURRING TRAINING MANUAL — 3 AUDIO/VIDEO RESOURCE INFORMATION CONTENT: MODULE 1 Minkoff, K. (2000). Dual Diagnosis: An integrated model for the treatment of people with co-occurring psychiatric and substance disorders. A lecture by Kenneth Minkoff. Brookline Village, MA: Mental Illness Education Program Videos, 2000. Available at: www.
Guidelines for Effective Integrated Dual Diagnosis Treatment Based on clinical and research experience, a team of experts in co-occurring substance use . A national consensus expert panel was appointed for co-occurring disorders, which issued a consensus report (Managed Care Initiative Panel on Co-Occurring Disorders, 1998).
Prevalence of Substance Misuse & Abuse (2011) 20.6 million persons ( 12 years) classified as 'substance dependence' or 'substance abuse' in past year (8% of population) 14.1 million - alcohol 3.9 million - illicit drugs . Substance Dependence or Abuse in the Past Year among
consumers with co-occurring disorders. Up to 56 percent of people with the most serious mental illnesses have a co-occurring substance use disorder within their lifetime (Regier et al., 1990). Therefore, within specialty mental health and substance use clinical settings, it is the norm rather than the exception to see consumers with co-
2. Assessment and Diagnosis in Substance Use Disorder 3. Epidemiology of Substance Use 4. Acute Effects of Alcohol, Opioid and Cannabis Use 5. Health Hazards of Long Term Alcohol, Opioid and Cannabis Use 6. Treatment Principles and Issues in Manage-ment of Substance Use Disorder - An Overview 7. Pharmacotherapy of Substance Use Disorder 8.
The Co-Occurring Center for Excellence (COCE), funded through the Substance Abuse and Mental Health Services Administration (SAMHSA), is a leading national resource for the field of co-occurring mental health and substance use . Eating disorders Sleep disorders Impulse-control disorders Adjustment disorders ersonality disorders P Disorders .
Quiz 10 a) The substance has unusual thermal properties. b) The substance must be cooler than its environment. c) The substance must be a gas. d) The substance must be an imperfect solid. e) The substance undergoes a change of phase. a) 62.8 C b) 36.3 C c) 15.7 C d) 4.2 C e) 0.0 C 4. Heat is added to a substance, but its temperature does not increase. Which of the following statements is .
Additionally, substance use can contribute to poor physical and mental health outcomes later in life, impacting an individual's ability to properly function and be a contributing member of society. Risk factors5 for early substance use include the following: Family history of substance use Parental substance use and/or favorable parental
lic perceptions of the criminal courts by focusing on a few basic topics. We begin by discussing where the courts fit in the criminal justice system and how the public perceives the courts. Next, attention shifts to the three activities that set the stage for the rest of the book: Finding the courthouse Identifying the actors Following the steps of the process As we will see .
