Strategies for Effective
Case-Planning in Clients with
Co-Occurring Mental Illness and
Substance Use Disorders
Ohio Justice Alliance for
Community Corrections
Conference
October 10, 2013
Christina M. Delos Reyes, MD
Chief Clinical Officer
ADAMHS Board of Cuyahoga County
www.centerforebp.cas
Learning Objectives
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Overview of mental illnesses and addiction
Strategic approach to clients with co-occurring
mental illness and substance use disorders
Principles of differential diagnosis to understand
client non-adherence and resistance to change
How to write an effective case-plan, which takes into
account individual client needs and goals
The Human Brain
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Most complex organ in the body
Different brain areas control different things:
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Brain stem critical life functions such as heart
rate, breathing, sleeping, etc.
Limbic system reward circuit (ability to feel
pleasure), perception of emotions, motivation, etc.
Cerebral cortex sensory processing, thinking,
planning, solving problems, making decisions, etc
What Is Mental Illness?

Mental illness or a mental disorder is a
diagnosable condition that:
–
–
Affects a person’s thinking, emotional state, and
behavior
Disrupts the person’s ability to
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Work
Carry out daily activities
Engage in satisfying relationships
Prevalence of Mental Illness
U.S. Adults with a Mental Disorder in Any One Year
Type of Mental Disorder
 Anxiety disorder
 Major depressive disorder
 Substance use disorder
 Bipolar disorder
 Eating disorders
 Schizophrenia
Any mental disorder
% Adults
18.1
6.7
3.8
2.6
2.1
1.1
26.2
Mood Disorders

Types of Mood Disorders
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–
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–
–
–
Major depressive disorder
Bipolar I disorder
Bipolar II disorder
Dysthymia
Postpartum depression
Seasonal depression
Depression vs.
Major Depressive Disorder

What Is Depression?
–
–

Everyday blues, sadness or a short-term depressed mood
is common
Many individuals may cope with these feelings without
significant impact on their everyday life.
Episodes of Major Depressive Disorder
–
–
–
last for at least 2 weeks
affect a person’s emotions, thinking, behavior, and physical
well-being
Ability to work and have satisfying relationships
Signs and Symptoms of Depression:
Emotions
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Sadness
Anxiety
Guilt
Anger
Mood swings
Lack of emotional responsiveness
Feelings of helplessness/hopelessness
Irritability
Signs and Symptoms of Depression:
Thoughts
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Frequent self-criticism
Self-blame
Pessimism
Impaired memory and concentration
Indecisiveness and confusion
Tendency to believe others see you in a
negative light
Thoughts of death and suicide
Signs and Symptoms of Depression:
Behaviors
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Crying spells
Withdrawal from others
Neglect of responsibilities
Loss of interest in personal appearance
Loss of motivation
Slow movement
Use of drugs and alcohol
Signs and Symptoms of Depression:
Physical
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Fatigue/lack of energy
Sleeping too much or too little
Overeating or loss of appetite
Weight loss or gain
Constipation
Headaches
Irregular menstrual cycle
Loss of sexual desire
Unexplained aches and pains
Some Risk Factors for Depression
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Distressing and
uncontrollable event
Exposure to stressful life
events
Difficult childhood
Ongoing stress and anxiety
Another mental illness
Previous episode of
depression
Family history
More sensitive emotional
nature
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Illness that is life
threatening, chronic, or
associated with pain
Medical conditions
Side effects of medication
Recent childbirth
Premenstrual changes in
hormone levels
Lack of exposure to bright
light in winter
Chemical (neurotransmitter)
imbalance
Substance misuse
Bipolar Disorder: Symptoms of Mania
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Increased energy and over activity
Need less sleep than usual
Elated mood or severe irritability
Rapid thinking and speech
Lack of inhibitions
Grandiose delusions
Lack of insight
What is Psychosis?
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Condition in which a person has lost some
contact with reality
A person may have severe disturbances in
thinking, emotion, and behavior
Usually occurs in episodes –not a constant
or static condition
Psychotic disorders are not as common as
depression and anxiety disorders
Psychotic Disorders

Types of Disorders in Which Psychosis
Occurs
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Schizophrenia
Schizoaffective disorder
Bipolar disorder
Psychotic depression
Drug-induced psychosis
Risk Factors for Psychotic Disorders
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Genetic factors
Biochemistry
Stress
Alcohol and Drug Use
Other factors
Characteristics of Schizophrenia
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Delusions
Hallucinations
Thinking difficulties
Loss of drive
Blunted emotions
Social withdrawal
Anxiety Disorders
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Anxiety disorders differ from normal stress and
anxiety
An anxiety disorder is more severe, lasts longer and
interferes with work, regular activities and
relationships
Anxiety can range in severity from mild uneasiness
to a panic attack or a flashback
Often co-occurs with mood disorders and substance
use
Types of Anxiety Disorders
–
Generalized Anxiety Disorder
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Panic Disorder
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Avoids or restricts activities due to fear of specific objects/situations
Post-Traumatic Stress Disorder & Acute Stress Disorder
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Recurring panic attacks & persistent worry about possibility of a future
attack
Phobic Disorders
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Persistent, overwhelming and unfounded anxiety/worry accompanied
by multiple physical and psychological symptoms
Anxiety after experiencing a distressing or catastrophic event
Obsessive-Compulsive Disorder
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Obsessive thoughts & behaviors accompanying anxiety
Prevalence of Anxiety Disorders
U.S. Adults with an Anxiety Disorder in Any One
Year
Type of Anxiety Disorder
% Adults
 Specific phobia
8.7
 Social phobia
6.8
 Post–traumatic stress disorder
3.5
 Generalized anxiety disorder
3.1
 Panic disorder
2.7
 Obsessive–compulsive disorder
1.0
 Agoraphobia (without panic)
0.8
Any anxiety disorder
18.1
Signs and Symptoms of Anxiety:
Physical
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Cardiovascular:pounding heart, chest pain, rapid
heartbeat, blushing
Respiratory: fast breathing, shortness of breath
Neurological: dizziness, headache, sweating,
tingling, numbness
Gastrointestinal: choking, dry mouth, stomach
pains, nausea, vomiting, diarrhea
Musculoskeletal: muscle aches and pains
(especially neck, shoulders and back), restlessness,
tremors and shaking, inability to relax
Signs and Symptoms of Anxiety:
Psychological and Behavioral
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Psychological
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Unrealistic or excessive fear and worry (about past and
future events), mind racing or going blank, decreased
concentration and memory, indecisiveness, irritability,
impatience, anger, confusion, restlessness or feeling “on
edge” or nervous, fatigue, sleep disturbance, vivid dreams
Behavioral
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Avoidance of situations, obsessive or compulsive behavior,
distress in social situations, phobic behavior
Symptoms of a Panic Attack
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Palpitations, pounding
heart, or rapid heart rate
Chest pain or discomfort
Sweating
Chills or hot flashes
Trembling and shaking
Numbness or tingling
Shortness of breath,
sensations of choking or
smothering
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Dizziness, lightheadedness, feeling
faint, unsteady
Abdominal distress or
nausea
Feelings of unreality
Feelings of being
detached from oneself
Fear of losing control or
going crazy
Fear of dying
Risk Factors for Anxiety Disorders
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People who are more likely to react with anxiety
when they feel threatened are those who:
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Have a more sensitive emotional nature
Have a history of anxiety in childhood or adolescence
Are female
Abuse alcohol
Experience a traumatic event
Medical conditions or side effects of some
prescription medications
Intoxication or withdrawal from alcohol, cocaine,
sedatives, and anti-anxiety medications
Substance Use Disorders
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The use of alcohol or drugs does not necessarily
mean a person has a substance use disorder
Substances affect a person’s brain in different ways,
and people may use alcohol or drugs because of
these effects.
Substance use disorders may be characterized as
mild, moderate, or severe
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“Mild” corresponds to the old concept of Substance ABUSE
“Moderate/severe” corresponds to the old concept of
Substance DEPENDENCE
Substance Use Disorders
 Deciding
31
to start drugs
and experimentation with
drugs are preventable
behaviors
 Drug Addiction is a
treatable brain disease
32
Explanatory Models of Addiction
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Moral  wrong
Spiritual  empty
Psychological  impulse control
Behavioral  habit
Medical  disease
Medical model of addiction
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Sick person seeking wellness
SUDs as chronic diseases
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Biological basis
Identifiable signs and symptoms
Predictable course and outcome
Treatment improves outcomes
Lack of treatment may lead to morbidity and
mortality
Medical model of addiction
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A chronic relapsing disease of the brain
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35
Drugs change brain structure and function
Brain changes can be long lasting and lead to
harmful behaviors
Characterized by compulsive drug seeking
and use despite harmful consequences
Facts About Substance Use Disorders
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Lifetime Prevalence is 13-14% (1 in 8)
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Annual Prevalence is 3.8%
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U.S. adults who have a SUD in their lifetime
U.S. adults who have a SUD in any given year
Alcohol use disorders are three times as
common as drug use disorders
75% of people who develop substance use
disorders do so by age 27
Substance use disorders can co-occur with
almost any mental illness
Signs and Symptoms
of Substance Use Disorders
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Increased use over time
Increased tolerance for the substance
Difficulty controlling use
Symptoms of withdrawal
Preoccupation with the substance
Giving up important activities (work, social, family,
etc.)
Continued use even after recognizing problems with
substance use
Commonly Used Substances
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Alcohol
Tobacco
Marijuana
Heroin (and other opioids)
Sedatives and tranquilizers
Cocaine
Amphetamines and Methamphetamines
Ecstasy and other hallucinogens
Inhalants
Drug Use Disorders in the United
States, 2001-2003
National Epidemiologic Survey on Alcohol and Related Conditions, 2004
Risk Factors for
Substance Use Disorders
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Availability and tolerance of the substance in
society
Learning
Social factors
Genetic predisposition
Sensitivity to the substance
Other mental health problems
Does relapse = treatment failure?
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NO! Relapse is likely, and is a part of the
chronic nature of the disease
Relapse rates for drug addiction are similar
to relapse rates in other chronic diseases
–
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41
40-60% relapse rate for addiction in 1 yr period
Relapse often indicates that treatment needs
to be reinstated, adjusted, or changed to an
alternate form
Comparison of Addiction to
Other Chronic Diseases
42
Med
compliance
Required
Follow diet &
hospital stay behavior
annually
change
DM I
<60 %
~40 %
<30 %
HTN
<40 %
~60 %
<30 %
Asthma
<40 %
~60 %
<30 %
Addiction and Mental Illness
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Co-exist commonly
Mental illness may precede addiction
Drug use and abuse may trigger or worsen
mental illness in vulnerable individuals
Prevalence of substance use
disorders in mental illness
60
50
40
% of
respondents
30
with substance
use disorder 20
10
0
Gen pop
Schiz
Regier et al., JAMA, 1990
Bipolar Maj dep
OCD
Panic
A complex relationship…
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Substance use and mental illness may co-occur by
coincidence
Substance use may cause or increase severity of
mental illness
Mental illness may cause or increase severity of
substance use
Both conditions may be caused by a third condition
Substance use and withdrawal may mimic symptoms
of mental illness
STRATEGIC APPROACH TO
DUAL DISORDERS:
DECREASING RESISTANCE &
INCREASING ENGAGEMENT
Common Traps & How to Avoid Them
1.
2.
3.
4.
5.
6.
47
Question & Answer
Expert
Information Overload
Labeling
Blaming/shaming
Demanding change
1.
2.
3.
4.
5.
6.
Ask and Listen
Shared Responsibility
Check Understanding
Person-Centered
Acceptance of Person
Change is the
Person’s Decision
Question & Answer
Asking a series of close-ended
questions can lead to:
Restricted information
Frustration
Defensiveness
Passivity
48
Solution: Ask and Listen
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49
Use open-ended questions
Some closed questions, as needed
Yields more information
Communicates understanding
Doesn’t necessarily take more time
People feel heard and engaged in their
care
Expert
Provider telling person what to
do can lead to:
Passivity
Half-hearted commitments
Verbalized “compliance”
50
Solution: Shared Responsibility
51
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Ask permission to share information
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Avoid jargon
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Acknowledge person’s expertise
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Information sharing - a two way street
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Offer options/choices
Information Overload
Providing too much information at one
time can lead the person to:
Feel overwhelmed
Be unable to act
Stop listening
Not absorb Information
52
Solution: Check Understanding
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53
Share small amounts of information
Stop and check understanding before
offering further information
Labeling
Referring to person as their
condition or in negative terms can
lead to:
Barriers in relationship
Resistance (people don’t like
labels)
Dissatisfaction with provider
54
Solution: Person-Centered
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55
Be person-centered
Seek to understand the person’s
experience
Treat person with respect
Address person according to their
preference
View person as capable
Blaming/Shaming
Criticizing person for behavior that
may be worsening their health
condition can lead to:
56
Defensiveness
Not feeling empowered
Decreased motivation to change
Increase in unhealthy behavior
Solution: Acceptance of Person
57
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Acceptance of the person
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Learn what matters to the person
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Acknowledge behavior change is hard
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Repeated attempts at change are normal
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Affirm small change efforts
Demanding Change
Attempting to force behavior
change can lead to:
Resistance
Creates a power struggle nobody
wins!
58
Solution: Change is
the Person’s Decision
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59
It’s the Person’s Decision
Choice and control belongs to the
person
View person as capable
Express optimism about ability to change
Create opportunities for person to voice
need for change
Be a resource
Differential Diagnosis
of Difficult Behavior
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Mental illness symptoms
Addiction symptoms
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intoxication, withdrawal, codependency
Antisocial traits
Medication side effects
Other undiagnosed/untreated medical illness
Reaction to remote or recent trauma
Other reasons?
…or a combination…
Case-Planning Areas of Emphasis
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SUBSTANCE ABUSE
MENTAL HEALTH
PHYSICAL HEALTH
HOUSING
CRIMINAL THOUGHTS
CRIMINAL PEERS / FRIENDS
FAMILY / SOCIAL SUPPORT
EDU / EMPL / FINANCIAL
LEISURE / RECREATION
CASE-PLANNING EXAMPLES
Summary
Overview of mental illnesses and
substance use disorders
 Six strategies for increasing
engagement and six traps to avoid
 Differential diagnosis of difficult
behavior
 Effective case planning for co-occurring
disorders

Resources
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64
National Institute on Mental Health website:
http://www.nimh.nih.gov
National Institute on Drug Abuse website:
http://www.nida.nih.gov
National Alliance on Mental Illness website:
http://www.nami.org
Mental Health First Aid website:
http://www.thenationalcouncil.org/cs/about_the_prog
ram
Contact Information
Christina M. Delos Reyes, MD
Chief Clinical Officer
Alcohol, Drug Addiction, and Mental Health Services
[ADAMHS] Board of Cuyahoga County
2012 West 25th Street, Cleveland, Ohio 44113
Phone 216-241-3400 Fax 216-241-0805
delosreyes@adamhscc.org
Medical Consultant
Center for Evidence Based Practices at Case
http://www.centerforebp.case.edu