Stages of Change in the
Treatment of
Co-occurring Disorders:
Creating a Congruency
Curtis Thornton, LMSW, CAADC, SAP
Melissa Tinervia, BSW
The Stages of Change
• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Relapse
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.
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).
Potential Sources of Barriers
to Stage Congruency
• Individual
(Client, Patient, Member, etc…)
• Support System
(Family, Friends, etc…)
• Social Service System
(Workers, agencies, policies, etc…)
10 Common Congruency
Barriers/Source Impacted
Barrier Name Individual Supports Systemic
Lack of
Acceptance
X
X
X
Lack of Info.
X
X
X
Fear
X
X
X
10 Common Congruency
Barriers/Source Impacted (Cont.)
Barrier Name Individual
Supports
Systemic
Past
Experiences
X
X
X
Past Diagnoses
X
X
X
Cognitive/
Functional
Impairments
X
X
X
10 Common Congruency
Barriers/Source Impacted (Cont.)
Barrier Name Individual Supports
Systemic
Lack of
Resources
X
X
X
Lack of Time
X
X
X
X
X
X
X
X
X
Lack of Trust
Treatment
Approaches
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.
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.”
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.
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.
•
Staff MUST be trained on Co-occurring Disorders.
•
Teach Mask, Mimic, Exacerbate or Independence of Co-occurring Disorders.
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?
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.
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.”
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.
Barrier: Past Diagnosis
• “I am diagnosed with Manic Depression, Bipolar, Depression,
Anxiety, PTSD, Opioid Dependence and Vicodin Dependence,
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.”
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.
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.
Effective Methods in Overcoming
Cognitive/Functional Impairments
• Make a comprehensive assessment and then meet
individuals “where they are at.”
o No “should’s” or “need to’s”
o 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.
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.
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!!!!!!!
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.
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.
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.
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).
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).
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.
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.
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
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 Cooccurring 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
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/s11469-0079098-0
• 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.