Integrating
Treatment for
Co-Occurring
Disorders
Brought to you by:
Presented By
TODAY’S PRESENTERS
Misti Storie
Education and Training Consultant
NAADAC, The Association for
Addiction Professionals
Cynthia Moreno Tuohy
Executive Director
NAADAC, The Association for
Addiction Professionals
TODAY’S PRESENTERS
Mary Woods, RNC, LADC, MSHS
Tim Sheehan, Ph.D.
Chief Executive Officer
Director of Institutional
Effectiveness
Hazelden Graduate School of
Addiction Studies
Westbridge Community Services
WEB CONFERENCE OBJECTIVES
 Discuss the prevalence of co-occurring disorders
in substance abuse treatment programs
WEB CONFERENCE OBJECTIVES
 Discuss the prevalence of co-occurring disorders
in substance abuse treatment programs
 Contrast co-occurring treatment with traditional
addiction treatment
WEB CONFERENCE OBJECTIVES
 Discuss the prevalence of co-occurring disorders
in substance abuse treatment programs
 Contrast co-occurring treatment with traditional
addiction treatment
 Give a rationale for integrated treatment
WEB CONFERENCE OBJECTIVES
 Discuss the prevalence of co-occurring disorders
in substance abuse treatment programs
 Contrast co-occurring treatment with traditional
addiction treatment
 Give a rationale for integrated treatment
 List instruments helpful for screening
WEB CONFERENCE OBJECTIVES
 Discuss the prevalence of co-occurring disorders
in substance abuse treatment programs
 Contrast co-occurring treatment with traditional
addiction treatment
 Give a rationale for integrated treatment
 List instruments helpful for screening
 Describe evidence-based therapies helpful in treating
co-occurring disorders
WEB CONFERENCE OBJECTIVES
 Discuss the prevalence of co-occurring disorders
in substance abuse treatment programs
 Contrast co-occurring treatment with traditional
addiction treatment
 Give a rationale for integrated treatment
 List instruments helpful for screening
 Describe evidence-based therapies helpful in treating
co-occurring disorders
 Access new training programs available through
NAADAC and Hazelden
Part One:
Introduction to
Co-occurring
Disorders
SCOPE OF PRACTICE
An Addiction Professional’s scope of practice varies
with education, training and state requirements.
With over 300 people on line today, each practitioner
should keep his or her scope of practice in mind as
we conduct this presentation.
DEFINING CO-OCCURRING
DISORDERS
 50 to 75% of all clients who are
receiving treatment for a substance
use disorder also have another
diagnosable mental health
disorder.
 Further, of all psychiatric clients with a mental health
disorder, 25 to 50% of them also currently have or had
a substance use disorder at some point in their lives.
DEFINING CO-OCCURRING DISORDERS
Co-morbidity of Substance Use and Psychiatric Disorders
Among a sample of about 10,000 adults:
13.5% had an alcohol use disorder. Of those, 36.6% also had a
psychiatric disorder.
6.1% had a drug use disorder.
Of those, 53.1% also had a
psychiatric disorder.
22.5% had a psychiatric disorder.
Of those, 28.9% also had an
alcohol or drug use disorder.
Source: Regier et al. 1990
DEFINING CO-OCCURRING DISORDERS
Psychiatric Disorders in Addiction Treatment
Two studies of Prevalence rates in addiction treatment settings had similar findings. Persons with
substance use disorders are also like to have mood and anxiety disorders.
Source: Cacciola et al, 2001; Ross, Glaser and Germanson 1988
DEFINING CO-OCCURRING DISORDERS
Addiction Treatment Provider Estimates
by Psychiatric Disorder
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Mood Disorders
Anxiety Disorders
Post-Traum atic
Stress Disorders
Antisocial
Personality
Disorders
Borderline
Personality
Disorders
Severe Mental
Illness
DEFINING CO-OCCURRING DISORDERS
Mental health disorder (MHD):
significant and chronic disturbances with “feelings,
thinking, functioning and/or relationships that are
not due to drug or alcohol use and are not the result
of a medical illness”22
 Bipolar disorder
 Social phobia
 Major depressive disorder
 Borderline personality disorder
 Schizophrenia
 Posttraumatic stress disorder
 Obsessive-compulsive disorder
DEFINING CO-OCCURRING DISORDERS
Substance use disorder (SUD):
a behavioral pattern of continual
psychoactive substance use that can
be diagnosed as either substance
abuse or substance dependence
DEFINING CO-OCCURRING DISORDERS
Co-occurring disorders (COD):
the simultaneous existence of “one or more
disorders relating to the use of alcohol
and/or other drugs of abuse as well as one
or more mental [health] disorders.”18
SEVERITY OF CO-OCCURRING DISORDERS
Co-occurring mental health disorders are often
placed on a continuum of severity.
 Non-severe: early in the continuum and can include
mood disorders, anxiety disorders, adjustment
disorders and personality disorders.
 Severe: include schizophrenia, bipolar disorder,
schizoaffective disorder and major depressive
disorder.
SEVERITY OF CO-OCCURRING DISORDERS
The classification of “severe
and non-severe” is based
on a specific diagnosis and
by state criteria for Medicaid
qualification but can vary
significantly based on
severity of the disability and
the duration of the disorder.
QUADRANTS OF CARE
high
III
high substance use
severity and low mental
health disorder(s)
severity
IV
high substance use
severity and high mental
health disorder(s)
severity
I
low substance use
severity and low mental
health disorder(s)
severity
II
low substance use
severity and high mental
health disorder(s)
severity
Substance use
severity
low
low
high
Mental health disorder(s) severity
Part Two:
What is Co-occurring
Treatment and How
is It Different from
Traditional Addiction
Treatment?
MODELS OF TREATMENT
 Clients with co-occurring
disorders have historically
received substance abuse
treatment services in isolation
from mental health treatment
services.
 As more research on co-occurring disorders began to
be conducted, the many limitations this approach places
on the client and his or her success in treatment began
to surface.
MODELS OF TREATMENT
A twenty-eight year-old-woman named Anita entered an addiction
treatment center where she was assessed as having alcohol
dependence. Six months earlier, Anita had been diagnosed with
major depressive disorder and was prescribed medication by her
family doctor. At the treatment facility, it was recommended that
Anita be re-assessed and treated, if necessary, at a mental health
clinic, located nearby in town. What model of treatment does
this scenario represent?
 single model of treatment
 sequential model of treatment
 parallel model of treatment
 integrated model of treatment
MODELS OF TREATMENT
 Single model of care - It was believed that once the “primary
disorder" was treated effectively, the client’s substance use
problem would resolve itself because drugs and/or alcohol were
no longer needed to cope.
 Sequential model of treatment - acknowledges the presence of
co-occurring disorders but treats them one at a time.
 Parallel model of treatment - mental health disorders are
treated at the same time as co-occurring substance use
disorders, only by separate treatment professionals and often at
separate treatment facilities.
INTEGRATED MODEL OF TREATMENT
Integrated model of treatment
an approach to treating co-occurring disorders that
utilizes one competent treatment team at the same
facility to recognize and address all mental health and
substance use disorders at the same time.
INTEGRATED MODEL OF TREATMENT
The integrated model of treatment can best be
defined by following seven components:
1) Integration
INTEGRATED MODEL OF TREATMENT
The integrated model of treatment can best be
defined by following seven components:
1) Integration
2) Comprehensiveness
INTEGRATED MODEL OF TREATMENT
The integrated model of treatment can best be
defined by following seven components:
1) Integration
2) Comprehensiveness
3) Assertiveness
INTEGRATED MODEL OF TREATMENT
The integrated model of treatment can best be
defined by following seven components:
1) Integration
2) Comprehensiveness
3) Assertiveness
4) Reduction of negative consequences
INTEGRATED MODEL OF TREATMENT
The integrated model of treatment can best be
defined by following seven components:
1) Integration
2) Comprehensiveness
3) Assertiveness
4) Reduction of negative consequences
5) Long-term perspective
INTEGRATED MODEL OF TREATMENT
The integrated model of treatment can best be
defined by following seven components:
1) Integration
2) Comprehensiveness
3) Assertiveness
4) Reduction of negative consequences
5) Long-term perspective
6) Motivation-based treatment
INTEGRATED MODEL OF TREATMENT
The integrated model of treatment can best be
defined by following seven components:
1) Integration
2) Comprehensiveness
3) Assertiveness
4) Reduction of negative consequences
5) Long-term perspective
6) Motivation-based treatment
7) Multiple psychotherapeutic modalities
BENEFITS OF AN INTEGRATED MODEL
OF CARE
Benefits of an Integrated
Model of Care
 Reduced need for coordination
BENEFITS OF AN INTEGRATED MODEL
OF CARE
Benefits of an Integrated
Model of Care
 Reduced need for coordination
 Reduced frustration for clients
BENEFITS OF AN INTEGRATED MODEL
OF CARE
Benefits of an Integrated
Model of Care
 Reduced need for coordination
 Reduced frustration for clients
 Shared decision-making responsibilities
BENEFITS OF AN INTEGRATED MODEL
OF CARE
Benefits of an Integrated
Model of Care
 Reduced need for coordination
 Reduced frustration for clients
 Shared decision-making responsibilities
 Families and significant others are included
BENEFITS OF AN INTEGRATED MODEL
OF CARE
Benefits of an Integrated
Model of Care
 Reduced need for coordination
 Reduced frustration for clients
 Shared decision-making responsibilities
 Families and significant others are included
 Transparent practices help everyone involved share responsibility
BENEFITS OF AN INTEGRATED MODEL
OF CARE
Benefits of an Integrated
Model of Care
 Reduced need for coordination
 Reduced frustration for clients
 Shared decision-making responsibilities
 Families and significant others are included
 Transparent practices help everyone involved share responsibility
 Clients are empowered to treat their own illness and manage their
own recovery
BENEFITS OF AN INTEGRATED MODEL
OF CARE
Benefits of an Integrated
Model of Care
 Reduced need for coordination
 Reduced frustration for clients
 Shared decision-making responsibilities
 Families and significant others are included
 Transparent practices help everyone involved share responsibility
 Clients are empowered to treat their own illness and manage their
own recovery
 The client and his/her family has more choice in treatment, more
ability for self-management, and a higher satisfaction with care
CO-OCCURRING DISORDERS INTERACTIONS
An integrated model of care assumes that:
 One disorder does not necessarily present as “primary.”
 There isn’t necessarily a causal relationship between co-occurring
disorders.
 These are co-occurring brain diseases that need to be treated
simultaneously.
SCREENING AND ASSESSMENT
Screening:
The first phase of evaluation where the
potential client is interviewed to determine
if he or she is appropriate for that specific
treatment facility and to determine the
possible presence or absence of a
substance use or mental health problem.
SCREENING AND ASSESSMENT
Assessment:
The second phase of evaluation where a
systematic interview is necessary to
verify the potential presence of a mental
health or substance use disorder
detected during the screening process.
SCREENING AND ASSESSMENT
Complexities of Screening and Assessment
Intoxication
Withdrawal
Substance-induced disorders
Motivational factors
Feelings, symptoms, and disorders
CO-OCCURRING DISORDERS INTERACTIONS
Substances and Negative Emotions
SCREENING AND ASSESSMENT
The choice of screening measures depends on:
1) The skill of the screening professional
2) The cost of the screening materials
3) How simple the scale is to interpret and use across
disciplines
4) Psychometric qualities
5) The relevance of screening to prevalent disorders
6) Movement from very sensitive (generic) measures
to more specific measures
SCREENING AND ASSESSMENT
Integrated Assessment
Process – 12 Steps
1. Engage the Client
SCREENING AND ASSESSMENT
Integrated Assessment
Process – 12 Steps
1. Engage the Client
2. Identify and Contact Collaterals
SCREENING AND ASSESSMENT
Integrated Assessment
Process – 12 Steps
1. Engage the Client
2. Identify and Contact Collaterals
3. Screen for and Detect Co-occurring Disorders
SCREENING AND ASSESSMENT
Integrated Assessment
Process – 12 Steps
1. Engage the Client
2. Identify and Contact Collaterals
3. Screen for and Detect Co-occurring Disorders
4. Determine Quadrant and Locus of Responsibility
SCREENING AND ASSESSMENT
Integrated Assessment
Process – 12 Steps
1. Engage the Client
2. Identify and Contact Collaterals
3. Screen for and Detect Co-occurring Disorders
4. Determine Quadrant and Locus of Responsibility
5. Determine Level of Care
SCREENING AND ASSESSMENT
Integrated Assessment
Process – 12 Steps
1. Engage the Client
2. Identify and Contact Collaterals
3. Screen for and Detect Co-occurring Disorders
4. Determine Quadrant and Locus of Responsibility
5. Determine Level of Care
6. Determine Diagnosis
SCREENING AND ASSESSMENT
Integrated Assessment
Process – 12 Steps
7. Determine Disability and
Functional Impairment
SCREENING AND ASSESSMENT
Integrated Assessment
Process – 12 Steps
7. Determine Disability and
Functional Impairment
8. Identify Strengths and Supports
SCREENING AND ASSESSMENT
Integrated Assessment
Process – 12 Steps
7. Determine Disability and
Functional Impairment
8. Identify Strengths and Supports
9. Identify Cultural and Linguistic Needs and Supports
SCREENING AND ASSESSMENT
Integrated Assessment
Process – 12 Steps
7. Determine Disability and
Functional Impairment
8. Identify Strengths and Supports
9. Identify Cultural and Linguistic Needs and Supports
10. Identify Problem Domains
SCREENING AND ASSESSMENT
Integrated Assessment
Process – 12 Steps
7. Determine Disability and
Functional Impairment
8. Identify Strengths and Supports
9. Identify Cultural and Linguistic Needs and Supports
10. Identify Problem Domains
11. Determine Stage of Change
SCREENING AND ASSESSMENT
Integrated Assessment
Process – 12 Steps
7. Determine Disability and
Functional Impairment
8. Identify Strengths and Supports
9. Identify Cultural and Linguistic Needs and Supports
10. Identify Problem Domains
11. Determine Stage of Change
12. Plan Treatment
DETERMINING LEVEL OF CARE
American Society of Addiction Medicine Patient Placement Criteria –
2nd Edition Revised (ASAM PPC-2R) dimensions of care
 Dimension 1: Acute Intoxication and/or Withdrawal Potential
 Dimension 2: Biomedical Conditions and Complications
 Dimension 3: Emotional, Behavioral or Cognitive Conditions
and Complications
 Dimension 4: Readiness to Change
 Dimension 5: Relapse, Continued Use or Continued Problem
Potential
 Dimension 6: Recovery/Living Environment
DETERMINING LEVEL OF CARE
 Level I: Outpatient treatment.
 Level II: Intensive outpatient treatment, including
partial hospitalization.
 Level III: Residential/medically monitored
intensive inpatient treatment.
 Level IV: Medically managed intensive inpatient
treatment.
EVIDENCE-BASED PRACTICES
In most treatment addiction centers, the three primary
evidence-based practices used are:
 motivational enhancement therapy (MET)
 cognitive-behavioral therapy (CBT)
 twelve step facilitation (TSF)
All of these treatment models are widely used – often
without formal training – by addiction professionals
around the country and can be easily applied to clients
suffering from co-occurring disorders.
EVIDENCE-BASED PRACTICES
The Integrated Combined Therapies model combines
these three EBPs (Evidence-Based Practices) into a
stage-wise treatment plan whereby:
 motivational enhancement therapy is first utilized to
initiate change and engage the client in the therapeutic
process;
 cognitive-behavioral therapy is then used to help make
change within the client; and
 twelve step facilitation is essential to helping maintain
and sustain changes.
STAGES OF CHANGE/
STAGES OF TREATMENT
STAGES OF CHANGE/
STAGES OF TREATMENT
STAGES OF CHANGE/
STAGES OF TREATMENT
STAGES OF CHANGE/
STAGES OF TREATMENT
STAGES OF CHANGE/
STAGES OF TREATMENT
OTHER CONSIDERATIONS
Managing Medications
Involving the Family
Encouraging Participation in
Peer-Support Recovery Programs
Collaboration with the
prescriber
Even though the prescriber is ultimately responsible for
ensuring safety and effectiveness of pharmacotherapies,
addiction professionals can also help in this effort.
Since addiction professionals tend to see the client
more often, they are well-positioned to:
 recognize danger signs (including recent psychoactive
substance use)
 recognize abnormal side effects
 monitor and support medication compliance
MANAGING MEDICATIONS
Pharmacotherapy can only work if medications are taken
as prescribed.
Some clients with co-occurring disorders are required to
manage a regimen of multiple medications each day.
Clients often have difficulty
strictly adhering to a dosing
schedule, making them more
prone to relapse and
hospitalization.
Clinicians can help prepare clients
to manage their medications.
INVOLVING THE CLIENT’S FAMILY
Involving families in treatment
 It is a myth that people with co-occurring disorders are
disconnected from their families.
 Research has shown that outcomes for substance use and mental
health disorders are improved, including fewer relapses, when
families are actively engaged in the treatment process.
 Unfortunately, family members of a client who has co-occurring
disorders often experience considerable stress, heartbreak, and
confusion.
INVOLVING THE CLIENT’S FAMILY
Involving families in treatment
 Encourage family member involvement and develop a
collaborative relationship as early as possible in the
treatment process
 Use an evidence-based
practice for family treatment
 Encourage families to
attend self-help groups
such as Al-Anon and NAMI
DUAL-RECOVERY MUTUAL SELF-HELP
Specific dual-recovery groups can provide essential
peer support:
 Double Trouble in Recovery
 Mental Illness Anonymous
 Dual Disorders Anonymous
 Dual Recovery Anonymous
 Dual Diagnosis Anonymous
GUIDING PRINCIPLES OF RECOVERY
 There are many pathways to recovery.
 Recovery is self-directed and empowering, involving personal
recognition of the need for change and transformation.
 Recovery exists on a continuum of improved health and wellness.
 Recovery involves addressing discrimination and transcending
shame and stigma.
 Recovery is supported by peers and allies, and involves joining
and rebuilding a life in the community.
 Recovery is a reality.
 (from CSAT’s Regional Recovery Meetings, May 2008)
Part Three
Resources and
Training
Opportunities
CO-OCCURRING DISORDERS
PROGRAM from Dartmouth/Hazelden
Written by the
faculty from the
Dartmouth Medical
School, CDP
provides practical
tools for
implementing
evidence-based,
integrated
treatment practices.
CO-OCCURRING DISORDERS
PROGRAM from Dartmouth/Hazelden
Components of CDP include:
Clinical Administrator’s Guide
Curriculum 1: Screening and Assessment
Curriculum 2: Integrating Combined Therapies
Curriculum 3: Cognitive-Behavioral Therapy
Curriculum 4: Medication Management
Curriculum 5: Family Program
DVD A Guide for Living with Co-occurring Disorders
Training and technical assistance is available for all
components: Call 1-800-328-9000, ext. 4672 or e-mail
training@hazelden.org
NAADAC/HAZELDEN COURSE
Integrating Treatment for
Co-occurring Disorders:
An Introduction to What
Every Addiction
Counselor Needs to
Know
…is a skill-based training program that will help
addiction counselors improve their ability to assist
clients who have co-occurring disorders, within their
scope of practice.
NAADAC/HAZELDEN COURSE
Through case studies, video presentations, interactive
exercises and extensive written resources, participants
learn:
•
•
•
•
•
•
•
•
the many myths related to mental illness treatment
barriers to assessing and treating co-occurring disorders
relevant research and prevalence data
commonly encountered mental disorders
applicable screening and assessment instruments
issues surrounding medication management
coordinating with other mental health professionals
the integrated model of mental health and addiction treatment
services
NAADAC/HAZELDEN COURSE
NAADAC is now conducting
the Lifelong Learning Program:
Integrating Treatment for
Co-occurring Disorders:
An Introduction to What Every
Addiction Counselor Needs
To Know
Check the NAADAC website
for trainings coming to your
area at www.naadac.org
Interested in
hosting a training?
Contact: Diana Kamp
dkamp@naadac.org
Cynthia
Moreno Tuohy
moreno@naadac.org
NAADAC/HAZELDEN COURSE
Now available as a distance
learning program!
Integrating Treatment for Co-Occurring
Co-occurring Disorders:
An Introduction to What Every Addiction
Counselor Needs to Know.
Learn at your own pace through
presentations, videos, case studies, and
interactive exercises.
Available 24/7. $180.00
18 CEs from NAADAC; 6 CEs from APA
LEADERSHIP IN
CO-OCCURRING DISORDERS
Announcing the Focus on Integrated Recovery!
A collaboration between:
• Dartmouth Psychiatric Research Center
• Hazelden
• NAADAC, the Association for Addiction Professionals
• NAATP, the National Association of Addiction Treatment Providers
• The National Council for Community Behavioral Healthcare
• SAMHSA, the Substance Abuse and Mental Health Services
Administration, and
• WestBridge Community Services
• Active discussions with other leaders
FOCUS ON INTEGRATED RECOVERY
Co-Occurring Leadership
What you can expect from Focus on Integrated Recovery
•
•
•
•
•
•
Practical, evidence-based resources to aid in the integration of the
substance use and mental health disorders professions
Centralized source for consistent messaging about co-occurring disorders
Ongoing mechanism to capture the learning and experiences from
partners and constituents across the behavioral health spectrum
Opportunities for in-person and distance education on co-occurring
disorders
Support for the September 2011 Recovery Month
Collaboration on new initiatives: evidence-based scopes of practice,
outcome measurement, workforce development
FOCUS ON INTEGRATED RECOVERY
Co-Occurring Leadership
Where to find the Focus on Integrated Recovery
Communications begin during September, 2011 Recovery Month
National Public Relations efforts
E-mail campaigns
Focus on Integrated Recovery Website
Links on the partners’ websites
Recovery Month materials
Let us know what you think and how we can help!
contact Jon Hartman - jhartman@hazelden.org
UPCOMING WEBINARS 2011

August 18, 2011 - Strategies for Successful Test Taking

September 15, 2011 - Your Voice Counts: Advocacy and the NAADAC
Political Action Committee

October 13, 2011 - Conflict Resolution for Clients and Professionals

November 17, 2011 - What's Next in Your Career? Recap and Highlights
from the NAADAC Workforce Conference

December 15, 2011 - Clinical Supervision: Keys to Success
Register at: www.naadac.org/education or www.myaccucare.com/webinars
ARCHIVED WEBINARS
Alcohol SBIRT: Integrating Evidence-based Practice Into Your Practice
Medication Assisted Recovery: What Every Addiction Professional Needs to Know
Build Your Business With the Department of Transportation Substance Abuse Professional
(SAP) Qualification
Working with NAADAC to Express Your Professional Identity
Screening, Brief Intervention and Referral to Treatment (SBIRT)
Medicaid Expansion 2014 and Preparing to Bill for Medicaid
Understanding NAADAC’s Code of Ethics
Staying Informed: Trends of the Addiction Profession
Archived webinars located at: www.naadac.org/education or www.myaccucare.com/webinars
Time for
discussion!
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www.bhevolution.org
www.hazelden.org
www.westbridge.org
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helping addictions professionals excel in their field through the use of
information technology.
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Reporting
Billing
Visit us today!
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OBTAINING CE CREDIT
 The education delivered in this webinar is FREE to all professionals.
 2 CEs are FREE to NAADAC members and AccuCare subscribers who
attend this webinar. Non-members of NAADAC or non-subscribers of
AccuCare receive 2 CEs for $25.
 If you wish to receive CE credit, you MUST download, complete and
submit the “CE Quiz” that is located at:
 www.myaccucare.com/webinars
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 A CE certificate will be emailed to you within 30 days.
 Successfully passing the “CE Quiz” is the ONLY way to receive a CE
certificate.
Thank you for
participating!
www.naadac.org
www.bhevolution.org
www.hazelden.org
www.westbridge.org
www.myaccucare.com
Misti - misti@naadac.org
Emily - ehaverty@orionhealthcare.com