The Art and Science of Treating Clients with
Addictions and Dual Diagnosis Problems in
Community Counseling Setting.
Cathy Moonshine, Ph.D., MAC, CADC III
School of Professional Psychology
Pacific University
Abstract
This paper will focus on how to treat mild to moderate
addictions in a community counseling setting that
primarily provides mental health services. The paper
will discuss the process of diagnosing and initial level
of care placement. When to refer for medical
evaluation, detox services and formal addictions
treatment program will be reviewed. When and how to
chose an abstinence or harm reduction treatment
approach. Recommendations will be made for the use
of the evidence based practices of ASAM PPC-II-R,
Motivational Interviewing, Matrix Model, Dialectical
Behavior Therapy and 12-Step Facilitation.
Coordinating and collaborating care when client is
enrolled in treatment program.
Treatment Team
• Students received a brief overview of diagnosing
and treating addictions in the first year course
work.
• Self select to be placed on substance use disorder
treatment team at community counseling setting.
• Student clinicians receive individual and group
supervision focused on treating addictions and
dual diagnosis clients.
• Students can also take a semester long course on
addictions treatment as an elective.
Prevalence
According to the Center for Substance Abuse
Treatment (2005) anywhere from 20%-50% of
individuals seeking mental health treatment also
meet criteria for a co-occurring disorder (COD).
“The term co-occurring disorders (COD) refers to
co-occurring substance-related and mental
disorders. Clients said to have COD have one or
more substance-related disorders as well as one or
more mental disorders” (Center for Substance
Abuse Treatment, 2006).
Use
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Use can be defined as the ingestion of alcohol or
other drugs for encouragement, relaxation, etc that
does not negatively impact the individual’s life. This
impact can be in terms of:
Physical Health
Emotional Well-being
Social Skills
Relationships
Adequate Work Performance
Legal
Financial
Addiction
Complex progressive behavior patterns having
biological, psychological and behavioral
component’s with an individual’s pathological
involvement in or attachment to it, subjective
compulsion to continue it and reduced ability
to exert personal control over it.
Substance Intoxication
The results from the recent ingestion of a
substance such as alcohol, marijuana,
heroin or even caffeine (APA, 2000).
Substance Withdrawal
This occurs when an individual stops
using a substance in which he or she has
become physiologically, cognitively and
behaviorally dependent. It is most
important to intervene if there are medical
concerns. Alcohol and benzodiazepines
are the most medically compromising
(APA, 2000).
Substance Abuse
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A maladaptive pattern of substance use leading to
clinically significant impairment or distress, as
manifested by one or more of the following within
the last 12 months:
Failure to fulfill major life obligation
Use when physically hazardous
Legal problems related to use
Continued use despite having persistent or recurrent
social or interpersonal problems
(APA, 2000)
Substance Dependence
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A maladaptive pattern of substance use, leading to clinically
significant impairment or distress, as manifested by at least 3
of the following in the same 12 months:
Tolerance
Withdrawal
Substances taken in larger amounts than planned
Persistent desire or inability to cut down
Great deal of time spent in activities related to use
Important social, occupational or recreational activities given
up
Continued use despite knowledge of having a persistent or
recurrent physical or psychological problem
(APA, 2000)
Substances that qualify
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Alcohol
Amphetamine
Caffeine
Cannabis
Cocaine
Hallucinogens
Inhalant
Nicotine
Opioids
Phencyclidine
Sedatives, hypnotics or anxiolytics
(APA, 2000)
Polysubstance Dependence
This diagnosis is reserved for behavior during
a consecutive 12-month period in which the
person has repeatedly used at least three
groups of substances, not including caffeine
and nicotine, but no single substance
predominated. (APA, 2000)
Initial Screening Tools
• CAGE
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Cut down
Annoyed by use
Guilty about use
Use as an eye opener
• CRAFFT
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Car
Relax
Alone
Family & Friends
Forget
Trouble
Initial Screening Tools
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Alcohol Use Disorder Identification Test (AUDIT)
Drug Use Disorder Identification Test (DUDIT)
Michigan Screening Alcohol Test (MAST
Drug Abuse Screening Test (DAST)
Initial Level of Care Placement
• Is the client appropriate for outpatient therapy
in a student clinic?
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What substances are being use?
How often is the use?
Use may be physical risk?
When did use begin?
Any previous treatment?
Willingness to attend community support?
Medical Evaluation
In most cases it is recommended that the client
be evaluated by a primary care physician to
rule out any medical problems and support
treatment.
Detoxification
If the client requests detox or use indicates a need
for detox, then a referral should be made.
In particular, if the client is using alcohol and/or
benzodiazepines then detox is recommended.
While detox from heroin, methadone or opioid
pain pills may not be medically compromising,
social detox may be very useful in establishing
initial abstinence.
Formal Addictions Treatment Program Referral
• When using in a dangerous ways
• If drug screens are recommended
• Meets criteria for dependence of two or more
substances
• Needs significant case management services
• Will benefit from Intensive Outpatient or
Residential Services
• Refuses to attend community supports
• Indications of dishonesty and delinquency
Psychiatric Medications
• Based on the prevalence of co-occurring disorders,
psychiatric evaluation is likely appropriate
• Inform psychiatric prescriber of addictions issues
• Medications that are contraindicated for addictions
are
– Ritalin and Adderall
– Valium, Xanax, Klonopin or other benzodiazepines
– Vicodin, Oxycodone or other opiod pain killers
Abstinence or Harm Reduction
• Abstinence:
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Evidence of biological/genetic component
Demonstrated inability to cut down
Using when physically/psychological dangerous
Exacerbates mental health issues
Abstinence or Harm Reduction
• Harm Reduction:
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Young adults & college students
Use creates mild to moderate problems
Level of functioning not impacted by use
Other negative impacts of use are non-existent
• Harm Reduction as a means to Abstinence
ASAM PPC-II-R
• American Society of Addiction Medicine
publishes the Patient Placement Criteria 2nd
Edition Revised.
• This publication is used for initial evaluation,
placement, continued stay, transfer and
discharge planning.
ASAM PPC-II-R
Life Dimensions
1. Intoxication and Withdrawal Potential
2. Biomedical
3. Emotional, Behavioral and Cognitive
4. Readiness for Change
5. Relapse, Continued Use and Continued Problem
6. Recovery Environment
ASAM PPC-II-R
Levels of Care
0.5 Prevention & Early Intervention
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Outpatient Services
2
Intensive Outpatient Services
3
Residential Treatment
4
Inpatient Hospitalization
Stages of Change
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Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Relapse or return to old behavior/patterns
(Prochaski and DiClemente, 1996).
Motivational Interviewing
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Extrinsic & intrinsic motivation
Enlightened self-interest
Developing discrepancy
Rolling with resistance
– Supportive & strategic interventions
• Decisional balance
• Change plan worksheet
(Miller and Rollnick, 2002).
Matrix Model
The model integrates treatment elements from a number of
strategies, including relapse prevention, motivational interviewing,
psycho-education, family therapy, and 12-Step program
involvement.
Combines Evidence Based Practices:
• Motivational Interviewing
• CBT & Classic Conditioning
• Drug & Alcohol Education
• Brain Chemistry
• Stages of Recovery
The basic elements are group sessions, individual sessions, along
with encouragement to participate in 12-Step activities, delivered
over a 16-week intensive treatment period (Obert, Rawson,
McCann, & Ling, 2006).
Dialectical Behavior Therapy
• Learn and practice skills in the areas of:
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Mindfulness
Emotional Regulation
Distress Tolerance
Interpersonal Effectiveness
• Diary Cards
• Chain Analysis
• Ultimate goal to build a life worth living
(Moonshine, 2008).
12-Step Facilitation
12-Step Facilitation encourages acceptance of the addiction,
commitment to abstinence and willingness to participate
actively in 12-step fellowships as a means of establishing
recovery.
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Evaluate the substance use problems and advocate abstinence.
Explain basic 12-step structure and concepts.
Encourage client to engage in 12-Step meetings
Facilitate ongoing participation
Discuss and support client working each of the 12-Steps
Include support system in the therapeutic process
Utilizing 12-Step network when in crisis
Assist the client making a moral inventory and engaging in
amends
• Encourage involvement in 12-Step beyond formal therapy
Coordinating and Collaborating Care
• Regular conversations with treatment program
• Collaborative treatment planning
• Include ancillary providers such as PCP &
dentist
• On the same pages with community support
meetings
References
American Psychiatric Association, (2000). Diagnostic and statistical manual of
mental disorders (4th ed.) (DSM-IV-TR). Washington, D.C.
Center for Substance Abuse Treatment (2006). Definitions and terms relating
to co-occurring disorders. COE Overview Paper 1. DHHS Publication
No. (SMA) 06-4163. Rockville, MD: Substance Abuse and Mental Health
Services Administration, and Center for Mental Health Services.
Center for Substance Abuse Treatment (2005). Substance Abuse Treatment for
Persons with Co-Occurring Disorders. Treatment Improvement Protocol
(TIP) Series 42. DHHS Publication No. (SMA) 05-3992. Rockville, MD:
Substance Abuse and Mental Health Services Administration.
Obert, J.L., Rawson, R.A., McCann, M.J., & Ling W. (2006). Counselor’s treatment
manual: Matrix Intensive outpatient treatment for people with stimulant use
disorders. Rockville, MD: Substance Abuse and Mental Health Services
Administration