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Understanding Addiction

INTRODUCTION

When one begins to use a mind-altering substance, the notion is that it will be used only on social occasions, with certain friends, or for specific purposes. I think it is safe to say no one intends to become addicted; however, the history of excessive use and abuse of alcohol and other drugs indicates that many do get trapped and experience severe life-altering problems as they progress through the use stages and ultimately reach the addicted stage. Interestingly, once an individual has reached the addiction stage, there is little chance of turning back.

From a broader perspective, not everyone that drinks alcohol or uses other drugs becomes addicted. Tempered use or abstinence from alcohol and other drugs is typical for most people, most of the time.  The occasional use of psychoactive substances may begin because of curiosity or the influence of family or friends. The early experimental stage of the use of a mood-altering substance usually occurs during the adolescent years, generally between 10 and 14 years of age. The typical progression of use is from tobacco and/or alcohol, followed by marijuana. As use continues, other illicit drugs that are either inhaled or ingested orally are added to the menu. Generally, the use of more potent drugs, particularly those requiring hypodermic administration, begins somewhat later.

 

THE STAGES OF DRUG USE 

The commonly accepted stages of alcohol and other drug use, along with some of the characteristics associated with each stage are as follows:

Experimental/Recreational Use Stage (drink/use a few times per month, typically on weekends when at a party or other social event, use is generally with friends; however, individual may drink/use alone).  

  • Person experiments with drugs to satisfy curiosity;
  • To acquiesce to peer pressure;
  • To obtain social acceptance;
  • To defy parental and other authority;
  • To take risks or seek a thrill;
  • To relieve boredom; appear grown-up;
  • To produce pleasurable feelings and to diminish inhibitions in social/personal settings;
  • Alter mood in social settings.
  • To mask social ineptness.

 

Regular Use/Abuse Stage (Drugs are used on a regular basis (several times per week); individuals may drink/use to intoxication/impairment; drug use is situational; may commence binge drinking; may use alone rather than with friends).

  • Experience the pleasure the drugs produce; alter emotions/moods;
  • Cope with stress and uncomfortable feeling such as pain, guilt, anxiety, and sadness;
  • Overcome feelings of inadequacy.
  • Avoid depression or other uncomfortable feelings when not using; substances are used to stay high or at least maintain normal feelings;
  • May begin to encounter legal problems (public intoxication; driving under the influence; spouse/child abuse).

 

Compulsive/Dependent Use Stage (Drug use on a daily or almost daily basis; individual is consumed with an uncontrollable and compulsive urge to seek and use, even in the face of negative health and social consequences). Note: Characteristics noted above are generally more applicable to the later phase of the Compulsive/Dependent Use stage. Characteristics may vary considerably during the early part of this stage.

  • Use is out-of-control
  • Time, energy, and money are focused on seeking and using drugs
  • Total preoccupation with drugs and drug-related activities
  • Most family, social and work functioning is impaired
  • Tolerance is noted (more of a drug is needed to reach the desired effect)
  • Relationships with others may become strained and stressful
  • Responsibilities such as family and job are neglected
  • Continue using to avoid withdrawal symptoms
  • Individuals’ major focus in life is when and where will I get my next fix
  • Drugs/alcohol are needed to avoid pain and depression
  • Individuals use to escape the realities of daily living
  • An individual may experience severe health, social and financial problem
  • Legal problems are a way of life

 

DIAGNOSIS 

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) describes criteria for the diagnosis of disorders related to the taking of drugs of abuse (including alcohol). The DSM-IV divides Substance-Related disorders into two groups: Substance Use Disorders (Substance Dependence and Substance Abuse) and Substance-Induced disorders (substance Intoxication, substance withdrawal, and others). The criteria to be used for a diagnosis of Substance Abuse will be presented first, followed by the criteria for Substance Dependence; the criteria for Substance Intoxication and Substance Withdrawal will follow.

Substance Abuse

A drug abuser is one who continues to use despite recurrent social, interpersonal, and legal difficulties as a result of his or her use. Harmful use implies use that results in physical, legal, or mental damage. The essential feature of Substance Abuse is a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of the substance. In order of an abuse criterion to be met, the substance-related problem must have occurred repeatedly during the same 12-month period or been persistent. There may be repeated failure to fulfill major role obligations, repeated use in situations in which it is physically hazardous, multiple legal problems, and recurrent social and interpersonal problems. Unlike the criteria for Substance Dependence, the criteria for Substance Abuse do not include tolerance, withdrawal, or a pattern of compulsive use and instead include only the harmful consequences that result from repeated use. The criteria for Substance Abuse is:

  1. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

(1) Recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household);

(2)  Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use);

(3)  Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct);

(4)  Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

  1. The symptoms have never met the criteria for Substance Dependence for this class of substance.

 

Substance Dependence:

The essential feature of Substance Dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues the use of the substance despite significant substance-related problems. In essence, it is a pattern of repeated self-administration that can result in tolerance, withdrawal, and compulsive drug-taking behavior. Those who are substance dependent meet all of the criteria of alcohol abuse, and they will also exhibit some or all of the criteria for dependence. The criteria for substance dependence is a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

(1)   Tolerance, as defined by either of the following:

(a)  A need for markedly increased amounts of the substance to achieve intoxication or desired effect;

(b)  A markedly diminished effect with continued use of the same amount of the substance;

(2)  Withdrawal as manifested by either of the following:

(a)  The characteristics of withdrawal syndrome for the substance (b)   the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms;

(3)  The substance is often taken in larger amounts or over a longer period than was intended;

(4)  There is a persistent desire or unsuccessful efforts to cut down or control substance use;

(5)  A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

(6)  Important social, occupational, or recreational activities are given up or reduced because of substance use;

(7)  The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by substance use (e.g., current use despite recognition of substance-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

        

Substance Intoxication 

The essential characteristic of substance intoxication is the development of a reversible substance-specific syndrome due to the recent ingestion of (or exposure to) a substance. The clinically significant maladaptive behavioral or psychological changes associated with intoxication (e.g., belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or occupational functioning) are due to the direct physiological effects of the substance on the Central Nervous System and develop during or shortly after use of the substance. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

 

Substance Withdrawal

The essential feature of substance withdrawal is the development of a substance-specific maladaptive behavioral change, with physiological and cognitive concomitants, that is due to the cessation of, or reduction in, heavy and prolonged substance use.  The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

The signs and symptoms of withdrawal vary according to the substance used, with most symptoms being the opposite of those observed in intoxication with the same substance. The dose and duration of use and other factors such as the presence or absence of additional illnesses also affect withdrawal symptoms. Withdrawal develops when doses are reduced or stopped, whereas signs and symptoms of intoxication improve (gradually in some cases) after dosing stops. 

 

Progression/Timeline Through the Stages 

When describing the stages of substance use, a factor that is often overlooked or under-evaluated is the timeline for each stage and the cumulative time it typically takes for an individual to progress through the stages and to become addicted to or dependent upon his or her drug of choice. The timeline depicted below is for alcohol; the stages and times for other types of drugs would vary considerably (time-wise), but the overall concept is valid for most psychoactive drugs. It should be noted that the stages are not absolute and do not have a precise timeline and may vary significantly from person-to-person. Also, the dependency stage is best characterized as three sub-stages: early dependency stage where individuals may very well have the ability to control their use if they are sufficiently motivated (spouse may require them to choose between alcohol and his or her family); however, in the middle and later stages, there is little chance of the individual being able to control their use without professional help.

An individual may remain in the experimental/recreational use stage for 10 to 15 years prior to progressing to the regular use/abuse stage. Typically, the regular use/abuse stage is shorter than either of the other stages.

Increased situational use (seeking out drinking functions), as well as psychological factors (need a drug to feel normal), helps to accelerate individuals through the Use/Abuse stage rather quickly. Also, during this stage, alcohol is often used as a crutch to help cope with all stressful situations and to enhance joy associated with celebratory occasions. Also, alcohol becomes the primary self-administered medication for all ills. It can become progressively more important to the individual and can become a dominant factor in all decisions and actions. As can be seen in Figure 1, the time frame for stage 2 is from three to five years.

The final stage is the Compulsive/Dependency stage. It is helpful to divide this stage into three sub-stages and look at the characteristics of each sub-stage independently. In each case, the point of focus is that alcohol is becoming more important to the individual and he/she is making more concessions to it in terms of withdrawing from family, work, and community responsibilities. Typically, early in the compulsive/dependency use stage, an individual can stop drinking. It typically takes a catastrophic life incident (serious illness, accident, loss of family/family member) for the individual to revert to abstinence on his/her own. Through my years of counseling, I have seen approximately 5 to 10% of early compulsive/dependency alcoholics undergo a successful recovery program motivated internally (self-initiated). The middle and late sub-stages are a different story. The most significant characteristic of an individual in this stage is that the most important thing on their mind is when will I get my next drink. I have met individuals in the compulsive/dependency stage that would lie, steal, cheat, or do almost anything to obtain alcohol or other drugs. They demonstrate uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences lifestyle every day of their life.   Unfortunately, few stage 2/3 alcoholics have the physiological and psychological underpinning to get into recovery themselves.

The Compulsive/Dependency stage typically extends for several years. The early sub-stage typically does not extend beyond five years. The middle sub-stage is characterized by a worsening of the early sub-stage and can last up to five additional years.  The final stage is characterized by total emersion into a drug-related lifestyle and will generally last until either recovery starts or death.

 

THE ESSENCE OF ADDICTION

Dr. Alan I Leshner, PhD., Director, National Institute of Drug Abuse, 2001, provided the following insight into drug addiction.   He states: The word Addiction calls up many different images and strong emotions. But what are we reacting to? Too often, we focus on the wrong aspects of Addiction, so our efforts to deal with this difficult issue can be badly misguided. Any discussion about psychoactive drugs, particularly drugs like nicotine and marijuana, inevitably moves to the question, but is it really addicting?   The conversation then shifts to the so-called types of Addiction, whether the drug is physically or psychologically addicting. The issue revolves around whether or not dramatic physical withdrawal symptoms occur when an individual stops taking the drug, which we in the field call physical dependence.

The assumption that follows then is that the more dramatic the physical symptoms, the more serious or dangerous the drug must be. Indeed, people always seem relieved to hear that a substance just produces psychological Addiction, or has only minimal physical withdrawal symptoms. Then they discount the dangers. They are wrong.

Defining Addiction Twenty years of scientific research, coupled with even longer clinical experience, has taught us that focusing on this physical vs. psychological distinction is off the mark and a distraction from the real issue. From both clinical and policy perspectives, it does not matter much what physical withdrawal symptoms occur. Other aspects of Addiction are far more important. Physical dependence is not that important because, first, even the florid withdrawal symptoms of heroin and alcohol addiction can be managed with appropriate medications. Therefore, physical withdrawal symptoms should not be at the core of our concern about these substances. Second (and more important), many of the most addicting and dangerous drugs do not even produce very severe physical symptoms upon withdrawal. Crack cocaine and methamphetamine are clear examples. Both are highly addicting, but stopping their use produces very few physical withdrawal symptoms; certainly, nothing liked the physical symptoms of alcohol or heroin withdrawal.

What does matter tremendously is whether or not a drug causes what we now know to be the essence of Addiction: uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences. This is the crux of how many professional organizations all define Addiction, and how we all should use the term. It is really only this expression of Addiction uncontrollable, compulsive craving, seeking, and use of drugs that matters to the addict and to his or her family, and that should matter to society as a whole. These are the elements responsible for the massive health and social problems caused by drug addiction.

The essence of Addiction Drug craving and the other compulsive behaviors are the essence of Addiction. They are extremely difficult to control, much more difficult than any physical dependence. They are the principal target symptoms for most drug treatment programs. For an addict, there is no motivation more powerful than a drug craving.

Rethinking Addiction focusing on Addiction as compulsive, uncontrollable drug use should help clarify everyone’s perception of the nature of Addiction and of potentially addicting drugs. For the addict and the clinician, this more accurate definition forces the focus of treatment away from simply managing physical withdrawal symptoms and toward dealing with the more meaningful, and powerful, concept of uncontrollable drug seeking and use. The task of treatment is to regain control over drug craving.

Rethinking addiction also affects which drugs we worry about, as well as the nature of our concerns. The message from modern science is that in deciding which drugs are addicting and those that require societal attention, we should focus primarily on whether taking them causes uncontrollable drug seeking and use. One important example is the use of opiates, like morphine, to treat cancer pain. In most circumstances, opiates are addicting. However, when administered for pain, although morphine treatment can produce physical dependence which now can be easily managed after stopping use, it typically does not cause compulsive, uncontrollable morphine seeking and use, Addiction as defined here. This is why so many cancer physicians find it acceptable to prescribe opiates for cancer pain.

Treating Addiction: Follow The Science It is important to emphasize that Addiction, as defined here, can be treated, both behaviorally and, in some cases, with medications, but it is not simple. We have a range of effective addiction treatments in our clinical toolbox, although admittedly not enough. This is why we continue to invest in research to improve existing treatments and to develop new approaches to help people deal with their compulsive drug use.

Our national attitudes and the ways we deal with Addiction and addicting drugs should follow the science and reflect the new, modern understanding of what matters in Addiction. We certainly will do a better job of serving everyone affected by addiction – addicts, their families, and their communities if we focus on what really matters to them. As a society, the success of our efforts to deal with the drug problem depends on an accurate understanding of the problem.

ADDICTION PROCESS 

The addiction process is presented to help the clinician and the drug user to better understand the why behind their use and abuse of drugs. Our hope is that the better this process is understood, the more effective counseling and other treatment modalities can be toward helping the user to achieve a drug-free life. It is imperative that clinicians in the field of addictions understand the cognitive, behavioral, and physical aspects of drug use. The objectives are for the clinician involved with treatment to recognize the special requirements of this sub-population and design treatment modalities aimed at their specific needs. For example, as it is beneficial for an insulin-dependent diabetic to be educated on all aspects of diabetes, it is equally important for the problematic drug user to be educated on all aspects of his or her drug of choice including impulse control, distorted cognitive ability, and the consequences of poor decision-making.

The essence of this process is that if an individual has a flawed or permissive value/belief system (based upon his or her perceptions of events, teachings, and influences of his family, friends, peers, and others during his or her early life) it leads to that individual having a distorted cognitive ability. That, in turn, enables the individual to continue to use and will ultimately result in unmanageability of his or her life (if the cycle is not disrupted). The following paragraphs describe each block and how it impacts the user’s life.

An individual’s value/belief system reflects his/her perception of self and represents values, judgments, and myths that he/she believes to be true. A person’s value/belief system is fairly well established by an early age and is refined and honed as life experiences make us into the person we are at any given time in our lives. It is a major control and decision-making guide and helps us to choose between right and wrong and things we do versus things we don’t do. Our value/belief system influences our thinking and decision-making throughout our lives. Most individuals have a value/belief system about:

  • Religion
  • Alcohol and other drugs use
  • Sexuality
  • Race
  • Careers
  • Age
  • Peer pressure/fitting in
  • Time management
  • Social involvement
  • Community involvement
  • Family Roles

A clinician should explore a client’s value/belief system to better understand what they believe about various topics, including topics related to drug use. An area I like to explore with clients is the environment they were exposed to during their early life. For example, I want to determine if their parents or caregivers had a permissive attitude toward drugs. I also want to know what type of neighborhood they lived in and what was the norm regarding the use of alcohol and other drugs. Other questions might include:

  • Were you exposed to limits or restrictions as a youth?
  • Did your parents use alcohol or other drugs?
  • Were you allowed to drink or use other drugs with your parents?
  • At what age did you start to drink or smoke?
  • Was there a permissive attitude toward alcohol and other drugs in your home/neighborhood?
  • Did you have a detailed schedule as a youth?
  • Did your parents involve themselves with your friends?
  • Did your parents monitor your activities?

Obviously, exposure to a permissive attitude/environment will enable a young person to form a positive image of most activities and/or to establish a distorted mental picture of a specific activity (such as the use of alcohol and/or other drugs). To give an example of how our beliefs/values work in the life of a drug user, let’s suppose a person forms a concept of a problem using as one who dropped out of school and is unemployed. Now, let’s suppose this individual is a compulsive user but does not meet his or her pre-programmed characteristics of how they perceive an addict to be or act. In this case, the individual would test his situation against his value/belief system and would conclude he or she does not have a drug problem. The cycle is repeated until there is a match between his/her behavior and his/her pre-programmed belief/value system for drug use. It should also be noted that an individual’s belief system about drug use might change in response to his or her own experiences and influences from clinicians and treatment programs. The cycle may also be disrupted by other factors (generally a crisis) in the user’s life.

Distorted Cognitive Ability
A flawed or permissive value/belief system results in a distorted cognitive ability that, in turn, results in illogical and impaired thinking. The affected individual continues to make high-risk decisions for themselves. With respect to the use of drugs, it results in compulsive, uncontrolled drug craving, seeking, and use. It follows that an individual is unable to comprehend the reality, consequences, or truth about events/actions/activities. When an individual cannot see the reality or truth about things, the distorted cognitive activity is generally referred to as denial. The most common forms of denial are:

  • Rationalizing: Making excuses for drug use. Examples include, I’m restless, and it helps me sleep; all of my friends use it more than me.
  • Minimizing:      Indicating his/her use is less serious than it really is. Example: Sure, I drink occasionally, but not that much; I only drink on weekends, real alcoholics drink every day.
  • Blaming: I drink because; everyone else does. The user admits involvement, but the responsibility for it lies with some else.

An important challenge facing most compulsive users to break through denial and accept the reality of their situation. The greatest challenge in counseling situations is to help the individual through this process. This generally takes patience, professionalism, research, and a willingness to face adversity. The client must adjust to a changing lifestyle and adopt new coping strategies and new ways to channel himself or herself away from his or her former lifestyle.   Learning new concepts is frequently met with resistance, as many individuals don’t want to change and will only change in response to pain or another strong motivator.   Distorted cognitive activity or impaired thoughts mask the reality of most situations, and truth (in many cases) ceases to exist. A drug user in a quagmire may gain insight as to their preconception (thinking) regarding excessive use by answering and analyzing the following questions:

Most frequently used form of denial (with respect to drug use) is:

_________________________ (rationalizing, minimizing, blaming or others).

Most frequently processed impaired thought: _________________________________________

I’m not a problem user because: ____________________________________________________

 

If an individual becomes emotionally stressed when asked these types of questions, it is a strong indication that the individual is in denial regarding their involvement with drugs, and they are in need of professional help. The key to any cognitive change is that the individual is open and honest and willing to accept that change is needed. If they have a good attitude, it is easier for them to see the perils associated with compulsive use. The net is that people can change, but in most cases, the change must be initiated at the cognitive level. If one is in denial regarding a problem, there is very little that anyone else can do to help that individual.

Cycle of Use
The cycle of use is an outcome of an individual continuing to live with distorted cognitive functioning. This ongoing activity results in Addiction (again, compulsive, uncontrolled drug craving, seeking, and use). This lifestyle is problematic and typically follows a well-established pattern (Reference Individual Addiction Cycle). At this stage of use, his or her drug-related choices begin to disrupt normal activities with family, work, school, and social and community. His or her use is increasing in importance to where it is masking most other activities/relationships. It generally results in behavioral problems or unmanageability of one’s life.

Unmanageability
As use continues, the individual begins to encounter the negative consequences of his/her behavior. In general, the consequences cause pain (psychological or physiological) that, when severe enough, may increase his or her willingness to accept help. The hypothesis is that deeply embedded in human nature is the tendency to resist all change until we finally experience pain, and only then may we stop to look at the cause. This process may manifest itself in any of the following:

  • Physical (health problems, increased risk-taking)
  • Social problems (family, work, school, community)
  • Emotional (feelings of guilt, shame or depression)
  • Spiritual (low self-esteem, feeling empty, isolated)
  • Financial (heavy debt load; inability to manage)

Another self-analysis assignment is for an individual to identify the negative consequences as a result of his/her drug use. This exercise is generally done over several counseling sessions and ultimately will lead the individual to accept responsibility for their decisions.

INDIVIDUAL ADDICTION CYCLE

Most clinicians believe that all addictions fit into a cycle and that it starts with a cognitive process related to the event (thinking about or preoccupation with the activity).

 

Preoccupation

Preoccupy is defined as to absorb wholly the mind or attention of or occupy beforehand or before another. It can be viewed as a locked-in mental state, where the main focus is on obtaining his or her drug of choice. Some individuals are so focused they appear to be in a somnolent state (as of deep hypnosis) where the individual may have limited sensory and motor contact with his or her surroundings and subsequent lack of recall. Most somnolent states vary in intensity, duration, and frequency. The initial onset may be mild but generally get more intense as time passes without satisfying the impulse.   The intensity of the state also varies depending on how long the individual has been a drug user as all individuals are creatures of habit, and we program ourselves to expect resolution within a predetermined timeframe, or the mind will increase the desire to satisfy the impulse.   An approach to understanding this phase of use is for clients to explore the answers to questions such as:

  • What thoughts did you focus on when you initially began the use of drugs?
  • Was your intent to be accepted by your peers?
  • Was your objective to prove your manhood or womanhood?
  •  Did you use it as an act of rebellion?
  • What role did peers play in your decision to experiment?
  • How did the focus items change as the compulsion to use increased?
  • What are your thoughts at present?
  • What do you think about using it again?
  • How often do you think about using it?

Remember that it takes time to break old habits and to re-program our minds to desire different things.   Also, remember the urge to continue to use will be very strong when an individual initially stops. Its also safe to say that everyone thinks about resuming again, and individuals must be resilient in their efforts to break the cycle. This exercise is intended as a tool that will help the individual to become familiar with how his/her mind works and the thought processes prior to previous relapses.   Again, the mind wants to continue to do those things that bring pleasure. Consequently, a big shopping spree or hanging out with the former using buddies are positive events in our minds, and we want to repeat them. There is a strong drive to set aside or dismiss concepts that would limit us from doing what we want to do. I have often stated in-group sessions that using is an extremely selfish action. It basically says I will do what I want to do without any consideration for my health, family, or other considerations. Unfortunately, we all know there is a negative side to compulsive use, but our mind is quick to “set aside” those thoughts when the other (positive) thoughts are being processed. As healthy, normal humans, it is always a good idea to keep the rewards versus consequences balanced in our minds. I often use the phrase, when one makes the decision (for example, to get high on drugs), they also accept the consequences. Sometimes good happens, but most of the time, bad and sometimes catastrophic events occur.

 

Habits/Ritual

The second part of the individualized addiction cycle is a set of habits that typically lead to use. Some counselors may refer to this as ritualistic or as a person being on autopilot where the behavior is almost fully automatic and, once initiated, the activities are generally done without thinking. The preceding cycle discusses preoccupation, which is thought without action (it may lead to action), whereas this cycle addresses a set of habits (rituals) that are typically completed without thought.

A using ritual is a behavior that leads to use. For example, it may be as simple as an urge to get together with old friends (former using buddies) or thinking about an event that previously included drug use (concert). It may also be triggered by an argument with a spouse, loss of a job, or another catastrophic event, or it could be as insignificant as driving through a neighborhood where his or her former supplier lived. In any event, it is something that triggers a thought in our minds that initiates a chain of events that leads to use. This is another view of compulsivity. Its also important to note that when a ritual is initiated, it is very difficult to stop the process. For a compulsive user, it is virtually impossible without professional help.

Another assignment for the addicted individual is to describe what keys they use. List and analyze the activities and behaviors leading to use. The objective is that the better we understand what motivates an individual, the easier it is to interrupt the cycle. The second part of the exercise is to identify what could be done to disrupt the process. This may be as simple as planning an evening of entertainment at home with the family. Whatever the case may be, the better one understands themselves, the easier it is to manage their life and to make better decisions.

 

Compulsivity    

The third block of Figure 2 is compulsivity. Compulsive actions are related to an irresistible impulse to perform an irrational act. In essence, the user has an impulse control problem and/or is susceptible to relapse. Consequently, compulsivity is characterized by continued use of the substance despite significant substance-related problems. Some clinicians refer to this phase as when the user begins to experience the consequences of his use. Also, most users are aware of their need to stop using and have made several unsuccessful attempts to stop. This tendency leads to a look at relapse where the clinician and user attempt to identify what triggered the action (resumption of use) and how he or she may avoid that activity in the future. The clinician must always be mindful that when the user resumes use, he or she expects to experience euphoria. Unfortunately, the opposite emotions, fear, hopelessness, and helplessness, shame, guilt, depression, and despair are often encountered. One must remember that our minds retain positive memories and have a tendency to set aside the negative ones.   The individual thinks he/she will experience a high when, in fact, he/she has been deceived by his/her own mind. Depression can result from an individual expecting an unrealistic outcome and finally realizing he/she has to deal with a set of negative consequences.

Despair

Despair is the end result of Addiction and is where feelings of hopelessness abound. This block represents the consequences of compulsive use (negative impact on family, work, society, health), and the user generally has feelings of shame and guilt following episodes of use.   However, the addicted individuals’ mind attempts to soften his/her despair by processing thoughts such as I will never use again; things will be different in the future. The effect of this mental defense mechanism is to alleviate the bad feeling as quickly as possible by processing neutralizing thoughts. So, instead of facing the Addiction, the individuals’ mind has found another way to deny the Addiction. Thereby, the cycle continues.

 

WHY DO PEOPLE USE ALCOHOL AND/OR OTHER DRUGS 

People begin to use drugs due to curiosity and a desire to fit into a social group (peer pressure). Certainly, a youth who has already begun to smoke cigarettes and/or to use alcohol is at a higher risk of experimenting with other drugs. Research suggests that the use of alcohol and/or other drugs by other family members is a risk factor as to whether children start using drugs. Parents, grandparents, older siblings, other relatives, and caregivers are all role models for children to copy and follow. I personally like to expand the model concept to everyone who is an authority figure or in a position to influence a child’s life. At times, parents blindly trust teachers, youth camps, sports figures, and others with their children without being aware of the negative influences that could surround these individuals. Studies of high school students and their patterns of drug use show that very few young people use other drugs without first trying marijuana, alcohol, or tobacco. The present trend is that only a few high school students use cocaine; however, the risk of doing so is much greater for youths who have tried marijuana than for those who have never tried it.

 

CONSEQUENCES

 The following trends have been observed for heavy users versus their non-using counterparts:

Lower educational achievement levels: This difference is more pronounced in math and science than in social studies and courses such as music and art. It appears that some students lack the drive or desire to remain focused on solving difficult problems, whereas it may very well increase their interest in non-technical studies. It should be noted that this is a generalized trend, and specific individuals may be able to excel in math and science and use drugs.

Experience increased personality disorders such as depression, anxiety, fear, impaired judgment, distorted sensory perceptions, difficulty in carrying out complex mental processes, and impaired motor performance: Some users experience unusual anti-social behaviors and a rebellious attitude.

Research has indicated an adverse impact on memory and retention that can last for days or weeks after the acute effects of the drug subside. For example, a study of over 100 college students found that among heavy users (of marijuana), their critical skills related to attention, memory, and learning were significantly impaired even after they had not used the drug for at least 24 hours. A follow-up to the initial study showed that a group of long-term heavy users’ ability to recall words from a list was impaired one week following cessation of use, but returned to normal by four weeks. The implication is that even after long-term heavy use, if an individual quits, some, if not most of his or her cognitive abilities, may be recovered.

 

PREVENTION/TREATMENT

The American Society of Addictive Medicines (ASAM) has taken the lead in the standardization of concepts and approaches for alcohol and other drug treatment programs. The levels of care established by ASAM are:

  • Level 0.5  Early Intervention
  • Level I      Outpatient services
  • Level II     Intensive Outpatient/Partial Hospitalization Services
  • Level III   Residential/Inpatient services
  • Level IV   Medically-Managed Intensive Inpatient Services 

A referral for a specific level of care must be based on a careful assessment of the patient with alcohol or other drug problem.   The overall objective is to place the patient in the most appropriate level of care (described as the least intensive level that could accomplish the treatment objectives while providing safety and security for the patients). The levels of care represent a continuum of care that can be used in a variety of ways depending on the patient’s needs and responses. For example, a patient could begin at a more intensive level and move to less intensive levels either in consecutive order or by skipping levels. A patient could also move to more intensive levels depending on need.

A study of adult drug users found that a 14-session cognitive-behavioral group and 2-sessions of individual counseling (this amount of counseling is similar to the American Society of Addictive Medicine, Level 1) are effective for some patients. This counseling includes motivational interviewing and advice on ways to reduce use.   The study also indicated that focusing on what triggers their use and then helping them to devise appropriate avoidance strategies could help patients. Outcome studies revealed the following results: (1) use and related problems (school, work, family), as well as psychological problems, decreased for at least one year after treatment; (2) approximately 30 percent of former users were drug-free after three months.

A significant challenge facing recovering addicts is to avoid relapse. Marlott and Gordon in 1995 provided a comprehensive relapse prevention technique for alcohol and other drug addicts. They suggested an approach where high-risk situations were assessed, and then coping strategies were developed for each situation. The following factors were analyzed for each situation: 

  • Self-Efficacy: The individual’s perception of his/her ability to cope with situations.
  • Expectations: What is the consequence to the user of a specific behavior?
  • Attribute: Why an individual exhibits a specific behavior.
  • Decision-Making: Methodology used when the individual chooses a specific action. 

Once this analysis is complete, Marlatt and Gordon suggest the following intervention strategies:         

Self-monitoring:  Maintaining a log of urges/needs to use drugs. Additional information, such as the intensity of urge and coping strategy employed may also be documented.

Direct observation:       The individual rates the degree of temptation due to various situations. The individual may respond to an imaginary past episode or a fantasy about a past episode and then describe what he/she may have done differently to avoid future encounters.

Coping Skills:     This analytical tool is used to document the client’s ability to cope once a high-risk behavior is encountered. This helps the individual to identify strengths and weaknesses and helps the client focus on areas that need improvement.


Decision Matrix:
The matrix is used to document the consequences of a specific decision or action. It may be used to gather immediate, as well as delayed consequences, and can document both positive and negative outcomes.


Behavioral Commitment:        This tool is intended to establish limits on drug use (if any). It is also a commitment to seek help at the first episode of use, to prevent a full-scale return to using.

Reminder Questions:    They are used to key specific avoidance actions in the event of a strong urge.

It follows that a primary goal of any prevention program is to enable the individual to cope with the future, inevitable urges to use. The initial step is to identify the coping strategies that can be used in high-risk situations. It is also important to discuss an implementation plan for how these skills will be used. Some have referred to this process as setting up a self-management program. According to Ricky George (1990), The goals of self-management programs are to teach the individual to anticipate and cope with the problem of relapse. This approach generally combines behavioral skills training, cognitive interventions, and lifestyle changes to help the individual modify their behavior.

The most frequently applied prevention method is the cognitive-behavioral approach. The primary feature of this approach is that it acknowledges the individual may have had little or no control over becoming a compulsive user but has total responsibility for the management of his/her recovery.

 

Recovery Model
This model is based on the concept that recovery is a process that requires the mastery of emotional, psychological, social, and recovery-related tasks. These tasks, which become increasingly more challenging, are the foundation for recovery. Recovery is defined as the ongoing process of improving one’s level of functioning while striving to remain drug-free. A brief overview of a recovery process follows:

Pre-treatment phase: The individual experiences or becomes aware of:

  • Unpleasant consequences associated with drug use (family problems, loss of friends, loss of a job, loss of freedom);
  • Loss of control of their life; and emotional pain (may motivate individuals to decide to enter treatment).

Initial stabilization:

  • Stop use of all drugs; avoid former using buddies;
  • Professionally managed coping and emotional strategies (to ease the discontent associated with urges to resume using);
  • Help with controlling impulsive behavior (counseling)

                   Phase 1:      Recovery (Getting Started)

  • Helps individuals to accept and comprehend the addiction process
  • Identify use triggers:
    • Develop a plan to avoid and control impulses.
    • Learn problem-solving, stress management, and anger management skill.
    • Accept personal responsibility for self (choices, decisions, behaviors, and consequences);
    • Express feelings. 

 

                    Phase 2:      Recovery (Early)

  • Accepts the need for recovery
  • Accepts responsibility for the management of drug use
  • Begins to develop a drug-free self-image
  • Acknowledges the need for lifestyle changes; new friends
  • Adjusts to non-use behavior applies new problem-solving skills as needed
  • May struggle with peer and family issues as the drug-free lifestyle is demonstrated
  •  Improved self-image.

 

                     Phase 3 (Middle)

  • Changed behavior and cognitive awareness aligned with new self-concept.
  • Accepts responsibility for own recovery.
  • Recognizes and embraces the success of recovery.
  • Incorporates problem-solving skills into a new lifestyle.
  • Comfortable with lifestyle changes.
  • Continues to struggle with peer and family issues.
  • Learns to balance and control life.

 

                    Phase 4 (Advanced)

  • Focuses on learning coping skills to help deal with peers and family.
  • Increases the scope of life; it starts to fulfill potential.
  • It develops balance and takes control of life.
  • Develops independence from the treatment program develops self-initiative.
  • Accepts identity as a recovering individual.

                      

                     After Care 

  • Positive experiences fuel personal growth.
  • Focus on the total person (activities, spiritual growth, and independence).

 

Keys To Avoid A Return To Problematic Use For Clients:

  • High Activity Level: An idle mind often wanders in the wrong direction.
  • Generate To-Do lists to guide daily activities.
  • Goal setting to acknowledge and reward success.
  • Individual reward system:      
  • Work toward a specific individualized reward—for example, a new car, trip, clothes.  
  • Plan pleasurable activities:      Hobbies, travel, reading, etc.
  • Plan self-improvement activities: Items that will help the individual feel good about themselves. 

-Exercise/active lifestyle

-Nutrition program

-Rest/relaxation time

-Manage stress

  • Think positive
  • Avoidance of high-risk situations and activities

 -Events that previously led to use

 -Avoid people/functions whose focus is on drug use

  • Avoid things that have triggered previous relapses
  • Develop mind-management techniques:  Block negative thought processes. The mind always leads the physical act (i.e., an individual thinks positively regarding an activity before they do the activity). Consequently, if we could train our minds to detect wrong thinking (about drug use), then we could alter or disrupt those thoughts and focus on different things or thought processes to avoid actually using.
  • Avoid overly confident feelings, such as discouraging clients from thinking, “I am in control, and I have this problem licked.”
  • Generally, overconfidence leads to high-risk behavior and poor decision-making.
  • Avoid out-of-balance emotional states. Either feeling too good (overconfident) or too bad (depression) can lead to the resumption of use.
  • They are forgetting or rationalizing away the pain and anguish of the former lifestyle. Our minds will sometimes focus only on the pleasurable aspects of a former activity and completely mask (or forget) the negative consequences. At times, individuals are convinced that returning to a former lifestyle would be wonderful (feeling, emotions, etc.) Also, when they actually return to that lifestyle, they become deeply depressed as the reality of their actual use is realized. The mind is a wonderful thing, but it too must be monitored and trained, and one must realize that the mind can be misleading in some cases.

 

Co-Occurring Disorders

All people are different when it comes to their experiences with addiction and mental illness. Some begin to experience mental health issues during childhood or adolescence and experiment with drugs and alcohol soon after, developing both an addiction problem and a serious mental illness at the same time.

Others may seek out drugs and alcohol in an attempt to “self-medicate” a mental health issue that develops in early adulthood or that develops out of an injury or trauma later in life.

Still, others may first develop an addiction problem that grows so severe that it causes mental health issues or triggers the onset of symptoms that may otherwise have remained dormant.

Formerly known as dual diagnosis or dual disorder, co-occurring disorders describe the presence of both mental health and a substance-use disorder.

People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder. Co-occurring disorders can be difficult to diagnose due to the complexity of symptoms, as both may vary in severity. In many cases, people receive treatment for one disorder, while the other disorder remains untreated. This may occur because both mental and substance use disorders can have biological, psychological, and social components. Other reasons may be inadequate provider training or screening, an overlap of symptoms, or other health issues that need to be addressed first. In any case, the consequences of undiagnosed untreated, or under-treated co-occurring disorders can lead to a higher likelihood of experiencing homelessness, incarceration, medical illnesses, suicide, or even early death.

People with co-occurring disorders are best served through integrated treatment. With integrated treatment, practitioners can address mental and substance use disorders at the same time, often lowering costs and creating better outcomes. Increasing awareness and building capacity in service systems are important in helping identify and treat co-occurring disorders. Early detection and treatment can improve treatment outcomes and the quality of life for those who need these services.

The term co-occurring disorder replaces the terms dual disorder and dual diagnosis when referring to an individual who has a co-existing mental illness and a substance-use disorder. While commonly used to refer to the combination of substance use and mental disorders, the term also refers to other combinations of disorders (such as mental disorders and intellectual disability).

Clients with co-occurring disorders (COD) typically have one or more disorders relating to the use of alcohol and/or other drugs, as well as one or more mental disorders. A client can be described as having co-occurring disorders when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from another disorder.

Common examples of co-occurring disorders include the combination of major depression with cocaine addiction, alcohol addiction with panic disorder, alcoholism, poly-drug addiction with schizophrenia, and borderline personality disorder with episodic poly-drug abuse. Thus, there is no single combination of co-occurring disorders; in fact, there is great variability among them.EDC 

The combination of a substance use disorder and a psychiatric disorder varies along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild, or one may be more severe than the other. Additionally, the severity of both disorders may change over time. Levels of disability and impairment in functioning may also vary.

People with co-occurring disorders often experience more severe and chronic medical, social, and emotional problems than people experiencing a mental health condition or substance-use disorder alone. Because they have two disorders, they are vulnerable to both relapse and a worsening of the psychiatric disorder. Further, addiction relapse often leads to psychiatric distress, and the worsening of psychiatric problems often leads to addiction relapse. Thus, relapse prevention must be specifically designed for the unique needs of people with co-occurring disorders. Compared to patients who have a single disorder, patients with co-existing conditions often require longer treatment, have more crises, and progress more gradually in treatment.

Terms

Over time, numerous terms have been used to describe co-occurring disorders and their treatment.

Substance Abuse, Substance Dependence, and Substance-Induced Disorders

In the DSM-IVTR, substance-related disorders are divided into substance use disorders and substance-induced disorders.

Substance use disorders are further divided into substance abuse and substance dependence.

There are 11 categories of substance use disorders (e.g., disorders related to alcohol, cannabis, cocaine, opioids, nicotine), which are separated by criteria into abuse and dependence. The term “substance abuse” has come to be used informally to refer to both abuse and dependence. By and large, the terms “substance dependence” and “addiction” have come to mean the same thing, though debate exists about the interchangeable use of these terms.

Finally, the system of care for substance-related disorders is usually referred to as the substance abuse treatment system.

Substance-induced disorders are important to consider in a discussion of co-occurring disorders. Although they actually represent the direct result of substance use, their presentation can be clinically identical to other mental disorders. Therefore, individuals with substance-induced disorders must be included in co-occurring disorder planning and service delivery.

Substance abuse, as defined in the DSM-IV-TR, is a “maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances.

Classes of Substance Use Disorders

-Alcohol
-Amphetamine or similarly acting sympathomimetics
-Caffeine
-Cannabis
-Cocaine
-Hallucinogens
-Inhalants
-Nicotine
-Opioids
-Phencyclidine (PCP) or similarly acting arylcyclohexylamines
-Sedatives, hypnotics, or anxiolytics

 

Substance dependence is “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues the use of the substance despite significant substance-related problems.   This maladaptive pattern of substance use includes all the features of abuse and additionally such features as:

  • Increased tolerance for the drug, resulting in the need for ever greater amounts of the substance to achieve the intended effect.
  • An obsession with securing the drug and with its use
  • Persistence in using the drug in the face of serious physical or psychological problems

Substance-induced disorders include substance intoxication, substance withdrawal, and groups of symptoms that are “in excess of those usually associated with the intoxication or withdrawal that is characteristic of the particular substance and are sufficiently severe to warrant independent clinical attention.

Substance-induced disorders present as a wide variety of symptoms that are characteristic of other mental disorders such as delirium, dementia, amnesia, psychosis, mood disturbance, anxiety, sleep disorders, and sexual dysfunction.

To meet diagnostic criteria, there must be evidence of substance intoxication or withdrawal, maladaptive behavior, and a temporal relationship between the symptoms and the substance use must be established. Clients will seek care for substance-induced disorders, such as cocaine-induced psychosis, and co-occurring disorder systems must be able to address these conditions.

 

Mental Disorders

The standard use of terms for non–substance-related mental disorders also derives from the DSM-V. These terms are used throughout the medical, social service, and behavioral health fields.

The major relevant disorders for co-occurring disorders include schizophrenia and other psychotic disorders, mood disorders, anxiety disorders, and personality disorders.

 

 

The major relevant categories of mental disorders that frequently occur with substance abuse issues include:

  • Schizophrenia and other psychotic disorders
  • Mood disorders
  • Anxiety disorders
  • Somatoform disorders
  • Factitious disorders
  • Dissociative disorders
  • Sexual and gender identity disorders
  • Eating disorders
  • Sleep disorders
  • Impulse-control disorders
  • Adjustment disorders
  • Personality disorders
  • Disorders usually first diagnosed in infancy, childhood, or adolescence

5 Most Common Mental Disorders Associated with Specific Addictions

Some conditions seem destined to come in pairs. Heart disease often follows a diagnosis of diabetes, for example, and allergies often come hand in hand with asthma. The same sort of joining effect sometimes takes hold when an addiction is in play. In fact, it’s quite common for certain drugs of abuse to be entangled with specific mental health disorders.  

These are five of the most common mental health/addiction combinations in play today.

Alcoholism and Antisocial Personality Disorder

Alcohol abuse is associated with a number of mental health concerns, including:

  • Mania
  • Dementia
  • Schizophrenia
  • Drug addiction

According to the National Institute on Alcoholism (NIAAA), antisocial personality disorder (ASPD) has the closest link with alcoholism, as people who drink to excess on a regular basis are 21 times more likely to deal with ASPD when compared to people who don’t have alcoholism. Often, the two disorders develop early in life, the NIAAA says, but alcoholism can make the underlying mental illness worse, as people who are intoxicated might have lowered inhibitions, which makes their antisocial behaviors more prevalent.  

 

Marijuana Addiction and Schizophrenia

It’s not unusual for people who have schizophrenia to develop addictions. In fact, a study in the American Journal of Psychiatry suggests that about half of all people with schizophrenia also have a substance abuse disorder. However, there’s a particularly striking association between marijuana abuse and schizophrenia. It’s unclear why people with schizophrenia would abuse this drug, as it seems to produce many of the same symptoms these people experience when in the midst of a schizophrenic episode, but it is clear that marijuana abuse is at least somewhat common in those who have schizophrenia.

 

Cocaine Addiction and Anxiety Disorders

People who abuse cocaine often take the drug because it makes them feel euphoric and powerful. However, continued use seems to lead to symptoms that are more indicative of an anxiety disorder, including:

  • Paranoia
  • Hallucinations
  • Suspiciousness
  • Insomnia
  • Violence

These symptoms may fade away in people, who achieve long-lasting sobriety, but sometimes the damage lingers, and the unusual thoughts and behaviors stick around even when sobriety has taken hold.

 

Opioid Addiction and PTSD

Post-traumatic stress disorder (PTSD) is a mental illness that takes hold in the aftermath of a very serious episode in which the person was either facing death or watching someone else die. Often, people who survive these episodes emerge with very serious physical injuries, and often, those injuries are treated with prescription painkillers. These drugs can also boost feelings of pleasure and calm inside the brain, and sometimes people who have PTSD are moved to abuse their drugs in order to experience euphoria. While people in physical pain do need help to overcome that pain, blending PTSD with painkillers can lead to tragic outcomes that no one wants.

 

Heroin Addiction and Depression

While heroin can make users feel remarkably pleasant in the short term, long-time users can burn out the portions of the brain responsible for producing signals of pleasure. In time, they may have a form of brain damage that leads to depression. They’re physically incapable of feeling happiness unless the drug is present. This drug/mental illness partnership is remarkably common, but thankfully, it can be amended with treatment and sobriety.

 

Symptoms

The symptoms of co-occurring disorders include those associated with the particular substance abuse and mental health conditions a person has. Co-occurring disorders can be difficult to diagnose because the symptoms of substance abuse or dependence can mask the symptoms of mental illness, and vice versa.

As stated, substance abuse is a maladaptive pattern of substance use that occurs despite the individual’s experiencing significant substance-related problems. Individuals who abuse substances may experience such harmful consequences of substance use as repeated failure to fulfill roles for which they are responsible, legal difficulties, or social and interpersonal problems. It is important to note that the chronic use of an illicit drug still constitutes a significant issue for treatment even when it does not meet the criteria for substance abuse.

For individuals with more severe or disabling mental disorders, as well as for those with developmental disabilities and traumatic brain injuries, substance use at lower levels might be more harmful (and therefore defined as abuse) than for individuals without such disorders.

People with co-occurring disorders are at high risk for many additional problems such as symptomatic relapses, hospitalizations, financial problems, social isolation, family problems, homelessness, suicide, violence, sexual and physical victimization, incarceration, serious medical illnesses such as HIV and hepatitis B and C, and early death. Anyone of these problems complicates the treatment of co-occurring disorders.

 

Causes

Mental health and substance abuse disorders often occur as a result of biological and environmental factors. Mental disorders and addiction are each a dynamic process, with varying degrees of severity, rate of progression, and symptom manifestation. Both types of disorders are greatly influenced by several factors, including genetic susceptibility, environment, and pharmacologic influences. Certain people have a high risk for these disorders (genetic risk); some situations can evoke or help to sustain these disorders (environmental risk), and some drugs are more likely than others to cause psychiatric or substance use disorder problems (pharmacologic risk).

People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder. Mental illness can lead people to use alcohol or drugs to make themselves feel better temporarily. In other cases, a substance-abuse disorder triggers or in some other way leads to severe emotional and mental distress.

 

Treatments

To provide appropriate treatment for co-occurring disorders, the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services recommends an integrated treatment approach. Integrated treatment is a means of coordinating substance abuse and mental health interventions, rather than treating each disorder separately and without consideration for the other.

Integrated treatment occurs when a person receives combined treatment for mental illness and substance use from the same clinician or treatment team. It helps people develop hope, knowledge, skills, and the support they need to manage their problems and pursue meaningful life goals. Integrated treatment may include the following:

  • Help patients think about the role that alcohol and other drugs play in their life. People feel freer to discuss these issues when the discussion is confidential, nonjudgmental, and not tied to legal consequences.
  • Offer patients a chance to learn more about alcohol and drugs—how they interact with mental illnesses and with other medications—and to discuss their own use of alcohol and drugs.
  • Help patients become involved with supportive employment and other services that may help the process of recovery.
  • Help patients identify and develop recovery goals. If a person decides that the use of alcohol or drugs may be a problem, a counselor trained in integrated treatment can help that person identify and develop personalized recovery goals. This process includes learning about steps toward recovery from both illnesses.
  • Provide counseling specifically designed for people with co-occurring disorders. This can be done individually, with a group of peers, with family members, or with a combination of these.

Successful strategies with important implications for clients with COD include interventions based on addiction work in contingency management, cognitive-behavioral therapy (CBT), relapse prevention, and motivational interviewing.

All substance-abuse treatment programs should have in place appropriate procedures for screening, assessing, and referring clients with CODs. It is the responsibility of each provider to identify clients with both mental and substance use disorders and to assure them that they have access to the care needed for each disorder.

A comprehensive assessment serves as the basis for an individualized treatment plan. Appropriate treatment plans and treatment interventions can be quite complex, depending on what might be discovered in each domain. This leads to another fundamental principle: There is no single, correct intervention or program for individuals with COD’s. Rather, the appropriate treatment plan must be matched to individual needs according to these multiple considerations.

An onsite addiction treatment psychiatrist can improve treatment retention and decrease substance use among patients. The onsite psychiatrist brings diagnostic, medication, and psychiatric counseling services directly to the location where clients are based on the major part of their treatment. This approach often is the most effective way to overcome barriers presented by offsite referral, including distance and travel limitations, the inconvenience of enrolling in another agency and of the separation of clinical services (more “red tape”), client fears of being seen as mentally ill (if referred to a mental health agency), cost, and the difficulty of becoming comfortable with different staff.

The National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders created a conceptual framework that classifies clients into four quadrants of care based on relative symptom severity, not the diagnosis. The four quadrants are

I.  low addiction/low mental illness severity
II.  low addiction/high mental illness
III. high addiction/low mental illness
IV.  high addiction/high mental illness

The four-quadrant model provides a structure for moving beyond minimal coordination to foster consultation, collaboration, and integration among systems and providers in order to deliver appropriate care to every client with co-occurring disorders.

Medication

Many clients with COD require medication to control their psychiatric symptoms. Pharmacological advances over the past decade have produced antipsychotics, antidepressants, anticonvulsants, and other medications with greater effectiveness and fewer side effects. With the support available from better medication regimens, many people who once would have been too unstable for substance abuse treatment, or institutionalized with a poor prognosis, have been able to lead more functional lives.

Psychoeducational Classes

Psychoeducational classes on mental and substance use disorders are important elements in basic COD programs. These classes typically focus on the signs and symptoms of mental disorders, medication, and the effects of mental disorders on substance-abuse problems. Psychoeducational classes of this kind increase client awareness of their specific problems and do so in a safe and positive context.

Relapse-prevention education presents strategies designed to help clients become aware of cues or “triggers” that make them more likely to abuse substances and help them develop alternative coping responses to those cues. Some providers suggest the use of “mood logs” that clients can use to increase their consciousness of the situational factors that underlie the urge to use drugs or drink.

Group Therapy

Group therapy provides a forum for discussion of the interrelated problems of mental disorders and substance abuse, helping participants to identify triggers for relapse. Clients describe their psychiatric symptoms (such as hearing voices) and their urges to use drugs. They are encouraged to discuss, rather than to act on, these impulses. Groups also can be used to monitor medication adherence, psychiatric symptoms, substance use, and adherence to scheduled activities. These groups can provide a constant framework for assessment, analysis, and planning. Through participation, the individual with COD develops a perspective on the interrelated nature of mental disorders and substance abuse and becomes better able to view his or her behavior within this framework.

Outpatient Substance Abuse Treatment Programs for Clients with COD

Treatment for substance abuse occurs most frequently in outpatient settings. Some offer several hours of weekly treatment, which can include mental health and other support services as well as individual and group counseling for substance abuse. Others provide minimal services, such as one or two brief sessions, to give clients information and refer them elsewhere. Some agencies offer intensive outpatient programs that provide services several hours per day and several days per week. Typically, treatment includes individual and group counseling, with referrals to appropriate community services.

Individuals with COD often need a range of services besides substance-abuse treatment and mental health services. Generally, important needs include housing and case management services to establish access to community health and social services. These can be essential to the successful recovery of the person with COD.

It is imperative that discharge planning for the client with COD ensures continuity of psychiatric assessment and medication management, without which client stability and recovery will be severely compromised. Relapse-prevention interventions after outpatient treatment need to be modified so that clients can recognize symptoms of psychiatric or substance abuse relapse on their own and can call on a learned repertoire of symptom management techniques (such as self-monitoring, reporting to a “buddy,” and group monitoring). This also includes the ability to access assessment services rapidly since the return of psychiatric symptoms can often trigger a substance-abuse relapse.

The Medical System

Although not substance-abuse treatment settings per se, acute care and other medical settings are included here because important substance abuse and mental health interventions do occur in medical units. Acute care refers to short-term care provided by intensive-care units, brief hospital stays, and emergency rooms (ERs). Providers in acute-care settings are not usually concerned with treating substance-use disorders beyond detoxification, stabilization, and/or referral.

In other medical settings, such as primary care offices, providers generally lack the resources to provide any kind of extensive substance-abuse treatment but may be able to provide brief interventions and treatment referrals.

Primary health care providers (physicians and nurses) have historically been the largest single point of contact for patients seeking help with co-occurring disorders. Physicians and nurses are uniquely qualified to manage life-threatening crises and to treat medical problems related and unrelated to psychiatric and substance use disorders. Because they are in contact with such large numbers of patients, they have an exceptional opportunity to screen and identify patients with co-occurring disorders. At that point, the person with COD can be referred for appropriate services in the proper setting.

 

Medication-Assisted Treatment

Medication-Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful. MAT is clinically driven with a focus on individualized patient care. 

A common misconception associated with MAT is that it substitutes one drug for another. Instead, these medications relieve the withdrawal symptoms and psychological cravings that cause chemical imbalances in the body. MAT programs provide a safe and controlled level of medication to overcome the use of an abused opioid. And research has shown that when provided at the proper dose, medications used in MAT have no adverse effects on a person’s intelligence, mental capability, physical functioning, or employability.

Medications used in MAT for opioid treatment can only be dispensed through a SAMHSA-certified OTP. Some of the medications used in MAT are controlled substances due to their potential for misuse. Drugs, substances, and certain chemicals used to make drugs are classified by the Drug Enforcement Administration (DEA) into five distinct categories, or schedules, depending upon a drug’s acceptable medical use and potential for misuse. 

People who provide medication-assisted treatment (MAT) services work in a range of prevention, health care, and social service settings. They include psychiatrists, psychologists, pharmacists, nurses, social workers, counselors, marriage and family therapists, peer professionals, clergy, and many others.

Florida requires an 8-hour (4 hours online and 4 hours face-to-face) waiver training for physicians to prescribe and dispense buprenorphine for the treatment of opioid use disorders as well as the other FDA-approved medications methadone and naltrexone. As a result of this training, the goal is to see a significant increase in the number of patients accessing necessary substance use disorder treatment.

 

BEHAVIORAL COMPONENT

Behavioral manifestations and complications of addiction, primarily due to impaired control, can include:
• Excessive use and/or engagement in addictive behaviors, at higher frequencies and/or quantities than the person intended, often associated
with a persistent desire for and unsuccessful attempts at behavioral control;
• Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviors, with a
significant adverse impact on social and occupational functioning (e.g. the development of interpersonal relationship problems or the
neglect of responsibilities at home, school or work);
• Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems
which may have been caused or exacerbated by substance use and/or related addictive behaviors.

We will explore the following four approaches to assist with behavioral issues.  

  • Motivational Interviewing
  • Cognitive Behavioral Therapy
  • Acceptance and Commitment Therapy
  • Twelve-Step Facilitation

Motivational Interviewing

  • Motivational Interviewing (MI) is a goal-directed, client-centered counseling style for eliciting behavioral change by helping clients to explore and resolve ambivalence.
  • The operational assumption in MI is that ambivalent attitudes or lack of resolve is the primary obstacle to behavioral change so the examination and resolution of ambivalence become its key goal.
  • MI has been applied to a wide range of problem behaviors related to alcohol and substance abuse as well as health promotion, medical treatment adherence, and mental health issues.

Processes of Motivational Interviewing include:

  • Establishing rapport with the client and listening reflectively.
  • Asking open-ended questions to explore the client’s motivations for change.
  • Affirming the client’s change-related statements and efforts.
  • Eliciting recognition of the gap between current behavior and desired life goals.
  • Asking permission before providing information or advice.
  • Responding to ’sustain talk’ and ‘discord’ without direct confrontation. (’sustain talk’ and ‘discord’ is used as a feedback signal to the
    therapist to adjust the approach.)
  • Encouraging the client’s self-efficacy for change.
  • Developing an action plan to which the client is willing to commit

Cognitive-Behavioral

  • Cognitive Behavioral Therapy (CBT) is the term used for a group of psychological treatments that are based on scientific evidence. These
    treatments have been proven to be effective in treating many psychological disorders.
  • Cognitive and behavioral therapies usually are short-term treatments (i.e., often between 6-20 sessions) that focus on teaching clients specific skills. CBT is different from many other therapy approaches by focusing on the ways that a person’s cognitions (i.e., thoughts), emotions, and behaviors are connected and affect one another.
  • Cognitive-behavioral therapy (CBT) for substance use disorders has demonstrated efficacy as both a monotherapy and as part of combination treatment strategies.

Process of Cognitive Behavioral:

  • The therapist and client work together with a mutual understanding that the therapist has the theoretical and technical expertise, but the client is the expert on him or herself.
  • The therapist seeks to help the client discover that he/she is powerful and capable of choosing positive thoughts and behaviors.
  • Treatment is often short-term. Clients actively participate in treatment in and out of the session. Homework assignments often are included in therapy. The skills that are taught in these therapies require practice
  • Treatment is goal-oriented to resolve present-day problems. Therapy involves working step-by-step to achieve goals.
  • The therapist and client develop goals for therapy together and track progress toward goals throughout the course of treatment.

Common Cognitive Distortions:

  • All-Or-Nothing Thinking – You see things in black-and-white categories. If your performance falls short of perfect, you see yourself as a total failure.
  • Overgeneralization – You see a single negative event as a never-ending pattern of defeat.
  • Mental Filter – You pick out a single negative defeat and dwell on it exclusively so that your vision of reality becomes darkened, like the drop of ink that colors the entire beaker of water.
  • Disqualifying the positive – You dismiss positive experiences by insisting they “don’t count” for some reason
    or other. In this way, you can maintain a negative belief that is contradicted by your everyday experiences.
  • Jumping to conclusions – You make a negative interpretation even though there are no definite facts that convincingly support
    your conclusion.
  • Mind reading. You arbitrarily conclude that someone is reacting negatively to you, and you don’t bother to check this
    out.
  • The fortune-teller error. You anticipate that things will turn out badly, and you feel convinced that your prediction is an
    already-established fact.
  •  Magnification (Catastrophizing) or Minimization- You exaggerate the importance of things (such as your goof-up or
    someone else’s achievement), or you inappropriately shrink things until they appear tiny (your own desirable qualities or the other fellow’s imperfections). This is also called the “binocular trick.”
  • Emotional Reasoning – You assume that your negative emotions necessarily reflect the way things
    really are: “I feel it, therefore it must be true.”
  • Should Statements – You try to motivate yourself with“shoulds” and “shouldn’t,” as if you had to be whipped and punished before you could be expected to do anything. “Musts” and “oughts” are also offenders. The emotional consequence is guilt. When you direct “should” statements toward others, you feel anger, frustration, and resentment.
  • Labeling and Mislabeling – This is an extreme form of overgeneralization. Instead of describing your error, you attach a negative label to yourself: “I’m a loser.” When someone else’s behavior rubs you the wrong way, you attach a negative label to him: “He’s a louse.” Mislabeling involves describing an event with language that is highly colored and emotionally loaded.
    • Personalization – You see yourself as the cause of some negative external event for which, in fact, you were not
    primarily responsible.

Acceptance and Commitment Therapy ACT

• Acceptance and Commitment Therapy (ACT) is a contextually focused form of cognitive-behavioral psychotherapy that uses mindfulness and behavioral activation to increase clients’ psychological flexibility–their ability to engage in values-based, positive behaviors while experiencing difficult thoughts, emotions, or sensations.
• ACT has been shown to increase effective action; reduce dysfunctional thoughts, feelings, and behaviors; and alleviate psychological distress for individuals with a broad range of mental health issues (including DSM-5 diagnoses, coping with chronic illness, and workplace stress).

Processes of ACT:

ACT establishes psychological flexibility by focusing on six core processes:
• Acceptance of private experiences (i.e., willingness to experience odd or uncomfortable thoughts, feelings, or physical sensations in the
service of response flexibility)
• Cognitive diffusion or emotional separation/distancing (i.e., observing one’s own uncomfortable thoughts without automatically taking them
literally or attaching any particular value to them)
• Being present (i.e., being able to direct attention flexibly and voluntarily to present external and internal events rather than
automatically focusing on the past or future)
• A perspective-taking sense of self (i.e., being in touch with a sense of ongoing awareness)
• Identification of values that are personally important
• Commitment to action for achieving the personal values identified

Ten Steps to Trying on a Value:

  • Choose a Value. Choose valued directions that you are willing to try on for at least a week. This should be a value that you can enact and a
    a value that you care about. This is not a time to try to change others or manipulate them into changing.
  • Notice Reactions. Notice anything that comes up about whether or not this is a good value, or whether or not you really care about this value.  Just notice all thoughts for what they are. Remember that your mind’s job is to create thoughts. Let your mind do that and you stay on the exercise.
  • Make a List. Take a moment to list a few behaviors that one might say are related to the chosen value.
  • Choose a Behavior. From this list, choose one behavior or set of behaviors you can commit to between now and next session or the
    next few sessions.
  • Notice Judgments. Notice anything that comes up about whether or not that is a good behavior, whether or not you will enjoy it, or whether
    you can actually do that to which you are committing yourself.
  • Make a Plan. Write down how you will go about enacting this value in the very near future (today, tomorrow, this coming weekend, at the next meeting with your supervisor). Consider anything you will need to plan or get in order (e.g., call another person, clean the house, make an appointment, etc.). Choose when to do that – the sooner the better.
  • Just Behave. Even if this value involves other people, do not tell them what you are doing. See what you can notice if you just enact this value without telling them it is an ‘experiment’.
  • Keep a Daily Diary of Your Reactions. Things to look for are others’ reactions to you, any thoughts feelings or body sensations that occur before, during, and after the behavior, and how you feel doing it for the second (or fifth, or tenth, or hundredth) time.  Watch for evaluations that indicate whether this activity, value, or valued direction was ‘good’ or ‘bad’ or judgments about others, or yourself in relation to living this value.  Gently thank your mind for those thoughts, and see if you can choose not to buy into the judgments it makes about the activity.
  • Commit. Every day. Notice anything that shows up as you do so.
  • Reflect. Please bring your Daily Reactions Diary back to session on XX/XX/XXXX.

 

Twelve-Step Facilitation Therapy (TSF)

  • Twelve-Step Facilitation Therapy (TSF) is a brief, structured, and manual-driven approach to facilitating early recovery from
    alcohol abuse, alcoholism, and other drug abuse and addiction problems.
  • TSF has been implemented with individual clients or groups over 12-15 sessions.
  • The intervention is based on the behavioral, spiritual, and cognitive principles of 12-step fellowships such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).
  • These principles include acknowledging that willpower alone cannot achieve sustained sobriety, that reaching out to others must replace self-centeredness and that long-term recovery consists of a process of spiritual renewal.

Processes of TSF:

  • Therapy focuses on two general goals:
    1. acceptance of the need for abstinence from alcohol and other
    drug use
    2. surrender, or the willingness to participate actively in12-step fellowships as a means of sustaining sobriety.
  • The TSF counselor assesses the client’s alcohol or drug use, advocates abstinence, explains the basic 12-step concepts, and actively supports and facilitates initial involvement and ongoing participation in AA.
  • The counselor also discusses specific readings from the AA/NA literature with the client, aids the client in usingAA/NA resources in crisis times, and presents more advanced concepts such as moral inventories.

Twelve Steps of Alcoholics Anonymous
www.aa.org Copyright A.A. World Services, Inc.
1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or
10. Continued to take personal inventory, and when we were wrong, promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him,
praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and
to practice these principles in all our affairs.


• A.A., N.A., C.A.
• Group format
• Anonymous
• No cost
• No affiliations 

 

MEDICATION COMPONENT

FDA has approved several different medications to treat opioid addiction and alcohol dependence.

Opioid Dependency Medications

Methadone, buprenorphine, and naltrexone are used to treat opioid dependence and addiction to short-acting opioids such as heroin, morphine, and codeine, as well as semi-synthetic opioids like oxycodone and hydrocodone. People may safely take medications used in MAT for months, years, several years, or even a lifetime. Plans to stop a medication must always be discussed with a doctor.

Methadone

Methadone tricks the brain into thinking it’s still getting the abused drug. In fact, the person is not getting high from it and feels normal, so withdrawal doesn’t occur. Learn more about methadone.

Pregnant or breastfeeding women must inform their treatment provider before taking methadone. It is the only drug used in MAT approved for women who are pregnant or breastfeeding. Learn more about pregnant or breastfeeding women and methadone.   

Buprenorphine

Like methadone, buprenorphine suppresses and reduces cravings for the abused drug. It can come in a pill form or sublingual tablet that is placed under the tongue. Learn more about buprenorphine.

Naltrexone

Naltrexone works differently than methadone and buprenorphine in the treatment of opioid dependency. If a person using naltrexone relapses and uses the abused drug, naltrexone blocks the euphoric and sedative effects of the abused drug and prevents feelings of euphoria. Learn more about naltrexone.

Opioid Overdose Prevention Medication

FDA-approved naloxone, an injectable drug used to prevent an opioid overdose.  According to the World Health Organization (WHO), naloxone is one of several medications considered essential to a functioning health care system

Alcohol Use Disorder Medications

Disulfiram, acamprosate, and naltrexone are the most common drugs used to treat alcohol use disorder. None of these drugs provide a cure for the disorder, but they are most effective in people who participate in a MAT program. Learn more about the impact of alcohol misuse.

Disulfiram

Disulfiram is a medication that treats chronic alcoholism. It is most effective in people who have already gone through detoxification or are in the initial stage of abstinence. This drug is offered in tablet form and is taken once a day. Disulfiram should never be taken while intoxicated and it should not be taken for at least 12 hours after drinking alcohol. Unpleasant side effects (nausea, headache, vomiting, chest pains, difficulty breathing) can occur as soon as ten minutes after drinking even a small amount of alcohol and can last for an hour or more.

Acamprosate

Acamprosate is a medication for people in recovery who have already stopped drinking alcohol and want to avoid drinking. It works to prevent people from drinking alcohol, but it does not prevent withdrawal symptoms after people drink alcohol. It has not been shown to work in people who continue drinking alcohol, consumes illicit drugs, and/or engage in prescription drug misuse and abuse. The use of acamprosate typically begins on the fifth day of abstinence, reaching full effectiveness in five to eight days. It is offered in tablet form and taken three times a day, preferably at the same time every day. The medication’s side effects may include diarrhea, upset stomach, appetite loss, anxiety, dizziness, and difficulty sleeping.

Naltrexone

When used as a treatment for alcohol dependence, naltrexone blocks the euphoric effects and feelings of intoxication. This allows people with alcohol addiction to reduce their drinking behaviors enough to remain motivated to stay in treatment, avoid relapses, and take medications. Learn more about how naltrexone is to treat alcohol dependency.

MAT Medications and Child Safety

It’s important to remember that if medications can be kept at home, they must be locked in a safe place away from children. Methadone in its liquid form is colored and is sometimes mistaken for a soft drink. Children who take medications used in MAT may overdose and die.

The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act affords practitioners greater flexibility in the provision of medication-assisted treatment (MAT)

The SUPPORT Act extends the privilege of prescribing buprenorphine in office-based settings to Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, and Certified Nurse-Midwives (CNSs, CRNAs, and CNMs)* until October 1, 2023.

* NPs, PAs, CNSs, CRNAs, and CNMs are also referred to as “qualifying other practitioners.”

The SUPPORT Act expands the ability of certain physicians and qualifying other practitioners to treat up to 100 patients in the first year of waiver receipt if they satisfy one of the following two conditions:

  1. The physician holds a board certification in addiction medicine or addiction psychiatry by the American Board of Preventive Medicine or the American Board of Psychiatry and Neurology; or
  2. The practitioner provides medication-assisted treatment (MAT) in a “qualified practice setting.” A qualified practice setting is a practice setting that:
    1. provides professional coverage for patient medical emergencies during hours when the practitioner’s practice is closed;
    2. provides access to case-management services for patients including referral and follow-up services for programs that provide, or financially support, the provision of services such as medical, behavioral, social, housing, employment, educational, or other related services;
    3. uses health information technology systems such as electronic health records;
    4. is registered for their State prescription drug monitoring program (PDMP) were operational and in accordance with Federal and State law; and
    5. accepts third-party payment for costs in providing health services, including written billing, credit, and collection policies and procedures, or Federal health benefits.

After one year at the 100-patient limit, physicians and qualifying other practitioners who meet the above criteria can apply to increase their patient limit to 275.

MAT for opioid addiction is subject to federal legislation, regulations, and guidelines, including DATA 2000 and federal regulation 42 CFR 8.

More must be done to facilitate treatment options and the development of therapies to address OUD as a chronic disease with long-lasting effects. This means helping more people secure MAT, which requires us to break the stigma often associated with some of the medications used to treat OUD. It also requires us to find new and more effective ways to advance the use of medical therapy for the treatment of opioid use disorders.

 

MOTIVATIONAL INTERVIEWING

 

Change happens easily when there are clear punishments for continued same behavior and clear rewards for changed behavior.  We stop touching hot stoves early on because we get hurt. If we find out that something makes us feel happy and there are no costs, we’re going to do it more often. But sometimes, change can be more complex. Making the decision to leave a romantic partner, or to switch careers, might take years of thought and heartache. There are countless pros and cons that cannot easily be boiled down to “better” or “worse”.

Psychotherapy is the art and science of helping others create change through psychological means, and the countless approaches give us several ways to achieve these goals. Some theories view change as a purely behavioral process. Others focus on genetics as the influence on behavior.  Still others suggest that the answer is education. If a person learns about the possible consequences of a behavior, they will change.

Motivational interviewing, sometimes referred to as MI, is a client-centered, directive counseling method aimed at enhancing intrinsic motivation that helps people resolve ambivalent feelings and insecurities to find the internal motivation they need to change their behavior. It is a practical, empathetic, and short-term process that takes into consideration how difficult it is to make life changes.

Motivational interviewing is often used to address addiction and the management of physical conditions such as diabetes, heart disease, and asthma. This intervention helps people become motivated to change the behaviors that are preventing them from making healthier choices. It can also serve as a pre-curser to other types of therapies that can address other issues. Research has shown that this intervention works well with individuals who start off unmotivated or unprepared for change. Motivational interviewing is also appropriate for people who are angry or hostile regarding the changes that are necessary. They may not be ready to commit to change, but motivational interviewing can help them move through the emotional stages of change necessary to find their drive and make peace with change.

Motivational interviewing evolved from Carl Roger’s person-centered, or client-centered, approach to counseling and therapy. It shares Carl Rogers’ optimistic and humanistic theory about people’s capabilities for exercising free choice and changing through a process of self-actualization. The therapeutic relationship for both Rogerian and motivational interviewers is a democratic partnership.  Jumping off from this foundation, clinical psychologists William R. Miller and Stephen Rollnick elaborated on these fundamental concepts and approaches in 1991 in a more detailed description of clinical procedures. Core concepts evolved from experience in the treatment of problem drinkers, and Motivational Interviewing was first described by) in an article published in Behavioural Psychotherapy.   Compared with non-directive counseling, it is more focused and goal-directed, and departs from traditional Rogerian client-centered therapy through this use of direction, in which therapists attempt to influence clients to consider making changes, rather than engaging in non-directive therapeutic exploration. 

Client-Centered therapy uses an empathetic style of interaction.  The therapist expresses acceptance toward the client, even if they feel their behaviors are harming them or their loved ones.  The therapist does not need to condone the behavior, but acceptance is key.  Acceptance is the willingness to listen, understand, and to respect the client as a human being. 

The Motivational Interviewing process is aimed increasing an individual’s reason for change and then for the individual to fully commit to the change that is necessary. As opposed to simply stating a need or desire to change, hearing themselves express a commitment out loud has been shown to help improve a client’s ability to make those changes. The role of the therapist is more about listening than intervening. Motivational interviewing is often combined or followed up with other interventions, such as cognitive therapy, support groups such as Alcoholics Anonymous and stress management and coping strategy training.

There are four overlapping processes that comprise Motivational Interviewing: engaging, focusing, evoking and planning. They are both sequential and recursive, and often depicted in diagrams as stair steps, with engaging at the bottom as the first step.

  1. Engaging: the process of establishing a working relationship based on trust and respect. The client should be doing most of the talking, as the counselor utilizes the skill of reflective listening throughout the process. Both the client and counselor make an agreement on treatment goals and collaborate on the tasks that will help the client reach those goals.
  2. Focusing: the ongoing process of seeking and maintaining direction.
  3. Evoking: eliciting the client’s own motivations for change, while evoking hope and confidence.
  4. Planning: involves the client making a commitment to change, and together with the counselor, developing a specific plan of action.

 

Motivational interviewing is a counseling style based on the following assumptions:

  • Ambivalence about change is normal and constitutes an important motivational obstacle in recovery.
  • Ambivalence can be resolved by working with a client’s intrinsic motivations and values.
  • The alliance between the counselor and the client is a collaborative partnership to which each brings important expertise.
  • An empathic, supportive, yet directive, counseling style provides conditions under which change can occur. (Direct argument and aggressive confrontation may tend to increase client defensiveness and reduce the likelihood of behavioral change.)

 

This course will discuss ambivalence and its role in client motivation, overall and specific to substance abuse issues. We will explore the five basic principles of Motivational Interviewing that can be used to address ambivalence and to facilitate the change process. We will also look at approaches to use with clients in the early stages of treatment.

 

Ambivalence

Ambivalence is defined as the state of having mixed feelings or contradictory ideas about something whereas denial is defined as the action of declaring something untrue.  It is important to see the difference in these two.  They both might be part of an issue, but they are different.  An individual who is obese, addicted to substances or gambling, or perhaps has anger issues is usually aware of the dangers of their behavior but continues anyway. They are somewhat unsure of their ability to control these behaviors.  There is certainly an element of denial in the seriousness of the issue, but everyone knows that smoking is bad for your lungs.  Everyone is aware that donuts are not a healthy snack.  An individual may want to stop smoking, but at the same time, they don’t want to quit either.  There is a positive intention and most of the time a reward for their behavior despite the knowledge they have regarding the drawbacks of continuing the behavior.  They enter treatment programs because a family member or court system makes them while they express the problem isn’t that big.  These disparate feelings can be characterized as ambivalence, and they are natural, regardless of the client’s state of readiness. It is important to understand and accept the client’s ambivalence because ambivalence is often the central problem.  If a counselor interprets ambivalence as only denial or resistance, friction between the counselor and the client tends to occur.  Ambivalence is, “I want to quit drinking because I’m an angry drunk and always fight with my wife when I drink but I enjoy the social aspects and its so hard.”  Denial is, “the only issue with my drinking is my wife is no fun and gets on my case”. 

The motivational interviewing style facilitates the exploration of stage-specific motivational conflicts that can potentially hinder further progress. However, each dilemma also offers an opportunity to use the motivational style to help your client explore and resolve opposing attitudes.

To effectively implement Motivational Interviewing Dr. Miller and Dr. Rollnick developed three mnemonics to assist: RULEPACE, and OARS.

RULE can be used to remember the core principles of MI.  First, Resist the righting reflex, which means the counselor should resist giving suggestions to the client for his or her problem. While the counselor may mean well, offering suggestions might make the patient less likely to make a positive change. A counselor can attempt to Understand the client’s motivation by being a careful listener and attempting to elicit the client’s own underlying motivation for change. Listen with a patient-centered, empathic approach. Lastly, Empower the client. He must understand that he is in control of his actions, and any change he desires will require him to take steps toward that change.

 

PACE

PACE is the “spirit” or mindset that clinicians should have when conducting MI.  Always work in Partnership with the patient; this allows the patient and clinician to collaborate on the same level. While the counselor is a clinical expert, the client is an expert in prior efforts at trying to change his or her circumstances for the better. The therapeutic environment should be as positive as possible so that the client will find it comfortable to discuss change. The client should see the clinician as a guide who offers information about paths the patient may choose, not someone who decides the destination.  While the counselor continues to educate the client about the harms of behaviors such as excessive drinking or substance use, they recognize that ultimately the decision is the client’s. Every effort should be made to draw from the clients’ goals and values, so that the client, and not the clinician, can argue for why change is needed. This Acceptance helps foster an attitude that the counselor is on the client’s side and that his past choices in life do not negatively affect the counselor’s perception of him. The client should be accepted for who he is, and not met with disapproval over any personal decisions that he made. Exercise Compassion towards the client’s struggles and experiences, and never be punitive. Every attempt to have discussions that can be Evocative for the client should be made. Strong feelings and memories can be particularly salient to discuss, especially if they could help change the patient’s attitude towards maladaptive behaviors.

 

OARS

OARS is an acronym to represent core interviewing skills.  OARS stands for Open-ended questions, Affirmations, Reflection, and Summaries

Open-ended questions get the client to think before responding, providing frequent affirmations of the client’s positive traits, using reflective listening techniques while the client talks about his disorder, and providing succinct summaries of the experiences expressed by the client throughout the encounter to invite continued exploration of his behaviors are all skills for the counselor to develop.

Examples of open-ended questions include:

“What brought you here today?”
“Help me…” or “Tell me more about…”
“What will happen if you don’t….”
“Suppose you don’t make a change, what is the worst that might happen?”
“What would you like to see different about your current situation?”

Affirmations are used to recognize a client’s strengths, successes and efforts to change.  Examples of affirmations include:

“Your commitment really shows by….”
“You showed a lot of strength by…..”
“It is clear this is important to you because of you….”

Reflections keep the counselor connected to the client’s thoughts, suspending judgment, acknowledging what the client said, and helping them to feel validated.  Examples of reflections include:

“What I hear you saying is….”
“It seems as if….”
“I get the sense that your want to change, and you have concerns about…”
“It sounds like…”

Summaries can be used throughout an interaction.  They are a form of reflective listening.  Examples of summarizing include:

“So what I understand you have said is….”
“If I hear you….”

 

Five Principals in Motivational Interviewing

Motivational interviewing has been practical in focus. The strategies of motivational interviewing are more persuasive than coercive, more supportive than argumentative. The motivational interviewer must proceed with a strong sense of purpose, clear strategies and skills for pursuing that purpose, and a sense of timing to intervene in particular ways at incisive moments (Miller and Rollnick, 1991, pp. 51-51).

The clinician practices motivational interviewing with five general principles in mind:

  1. Express empathy through reflective listening.
  2. Develop discrepancy between clients’ goals or values and their current behavior.
  3. Avoid argument and direct confrontation.
  4. Adjust to client resistance rather than opposing it directly.
  5. Support self-efficacy and optimism.

 

Empathy

Empathy is the ability to understand and share the feelings of another.  It is the experience of understanding another person’s thoughts, feelings, and condition from his or her point of view, rather than from one’s own. Empathy facilitates pro-social or helping behaviors that come from within, rather than being forced, so that people behave in a more compassionate manner.  Reflective listening is sometimes used to build and show empathy through understanding.  It is a communication strategy involving seeking to understand a speaker’s idea, then offering the idea back to the speaker, to confirm the idea has been understood correctly. It attempts to reconstruct what the client is thinking and feeling and to relay this understanding back to the client.

Empathy should not be confused with identification with the client or the sharing of common past experiences. The key component to expressing empathy is reflective listening.

An empathetic style:

  • Communicates respect for and acceptance of clients and their feelings
  • Encourages a nonjudgmental, collaborative relationship
  • Allows you to be a supportive and knowledgeable consultant
  • Sincerely compliments rather than denigrates
  • Listens rather than tells
  • Gently persuades, with the understanding that the decision to change is the client’s
  • Provides support throughout the recovery process

Empathic motivational interviewing establishes a safe and open environment that is conducive to examining issues and eliciting personal reasons and methods for change. A fundamental component of motivational interviewing is understanding each client’s unique perspective, feelings, and values. The attitude of acceptance, but not necessarily approval or agreement, recognizing that ambivalence about change is to be expected is again a very important piece of this approach. Motivational interviewing is most successful when a trusting relationship is established between you and your client.

Understanding and empathy can be conveyed through skillful reflective listening with the knowledge that acceptance facilitates change and ambivalence is a normal feeling. 

 

Discrepancy Between Client’s Goals or Values and Current Behavior

Although MI is client-centered, unlike classic Rogerian therapy, it is more goal-driven and directional. That is, there is a clear positive behavioral outcome, e.g., quitting smoking, losing weight, adhering to medication. As clients experience a discrepancy between their current behavior and their personal core values or life goals through their own words a clarification of values occurs that often leads to an affliction of the comfortable.  When clients perceive discrepancies between their current situation and their hopes for the future change is likely to occur.

The counselor’s task is to help focus the client’s attention on how current behavior differs from ideal or desired behavior. The discrepancy is initially highlighted by raising your clients’ awareness of the negative personal, familial, or community consequences of problem behavior and helping them confront the behavior, i.e. substance use, that contributed to the consequences. Although helping a client perceive discrepancy can be difficult, carefully chosen and strategic reflecting can underscore incongruities.

A successful strategy is to separate the behavior from the person and help the client explore how important personal goals (e.g., good health, marital happiness, financial success) are being undermined by current behavior. This requires the counselor to listen carefully to the client’s statements about values and connections to community, family, and church. If the client shows concern about the effects of personal behavior, highlighting this concern to heighten the client’s perception and acknowledgment of discrepancy can help produce the client’s own cognitive shift.

Once a client begins to understand how the consequences or potential consequences of current behavior conflict with significant personal values, the counselor can amplify and focus on this discordance until the client can articulate consistent concern and commitment to change.

One useful tactic for helping a client perceive discrepancy is sometimes called the “Columbo approach” (Kanfer and Schefft, 1988). This approach is particularly useful with a client who prefers to be in control. Essentially, the clinician expresses understanding and continuously seeks clarification of the client’s problems but appears unable to perceive any solution. A stance of uncertainty or confusion can motivate the client to take control of the situation by offering a solution to the clinician (Van Bilsen, 1991).

Motivational Interviewing information is frequently presented using an ELICIT-PROVIDE-ELICIT framework. The counselor first elicits the person’s understanding and need for information, then provides new information in a neutral manner, followed by eliciting what this information might mean for the client, using a question such as, “What does this mean to you” or “How do you make sense of all this?” MI practitioners avoid trying to persuade clients with “pre-digested” health messages and instead allow clients to process information and find what is personally relevant for them. Autonomy is supported by also asking how much information the client might desire.

Developing discrepancies include:

  • Developing awareness of consequences helps clients to examine their behavior
  • A discrepancy between present behavior and important goals motivates change.
  • The client presents the arguments for change.

 

Avoid Argument

A counselor may occasionally be tempted to argue with a client who is unsure about changing or unwilling to change, especially if the client is hostile, defiant, or provocative. However, trying to convince a client that a problem exists or that change is needed could precipitate even more resistance. If the counselor tries to prove a point, the client predictably takes the opposite side. Arguments with the client can rapidly degenerate into a power struggle and do not enhance motivation for beneficial change. When it is the client, not the counselor, who voices arguments for change, progress can be made. The goal is to “walk” with clients (i.e., accompany clients through treatment), not “drag” them along (i.e., direct clients’ treatment).

Resistance can be seen as a signal to change strategies or listen more carefully to the client’s reasons for a particular behavior.  Resistance offers the counselor an opportunity to respond in a new, perhaps surprising way to gain an alliance toward overcoming a legitimate obstacle to new behavior.

 

Roll With Resistance

Confronting clients can evoke reactance and shut them down. Therefore, Motivational Interviewing counselors “roll with resistance” rather than attempt to argue with the client. Such reflections can be thought of as “comforting the afflicted.” The counselor can “pull up alongside clients,” essentially agreeing with the client, even if the statement is factually incorrect or unfairly places blame on others. Examples include: “You really enjoy smoking weed. You look forward to lighting up at night and giving it up seems very difficult” or “eating at McDonald’s has filled a need for you. It’s cheap, convenient, and really works given your busy schedule”. Such reflections help capture the client’s reasons for not changing and allow them to express their resistance without feeling pressured to change or worrying about being judged.

Resistance is a legitimate concern for the clinician because it is predictive of poor treatment outcomes and a lack of involvement in the therapeutic process. One view of resistance is that the client is behaving defiantly. Another, perhaps more constructive, the viewpoint is that resistance is a signal that the client views the situation differently. This requires the counselor to understand the client’s perspective and proceed from there.

Adjusting to resistance is similar to avoiding argument in that it offers another chance to express empathy by remaining non-judgmental and respectful, encouraging the client to talk and stay involved. Try to avoid evoking resistance whenever possible and divert or deflect the energy the client is investing in resistance toward positive change.

 

Simple Reflection:

The simplest approach to responding to resistance is with nonresistance, by repeating the client’s statement in a neutral way. This acknowledges and validates what the client has said and can elicit an opposite response.

Client: I don’t plan to quit drinking anytime soon.

Clinician: You don’t think that abstinence would work for you right now.

 

Amplified Reflection:

Another strategy is to reflect the client’s statement in an exaggerated form–to state it in a more extreme way but without sarcasm. This can move the client toward positive change rather than resistance.

Client: I don’t know why my wife is worried about this. I don’t drink any more than any of my friends.

Clinician: So, your wife is worrying needlessly.

Amplified negative reflections are a way of arguing against change by exaggerating the benefits of or minimizing the harm associated with risky behavior.  It may take the form of “, so you see no benefit in changing XX”.  The counselor, by arguing against change can exhaust the client’s negativity. In response, clients will often then reverse their course, and start to argue for change. This type of reflection poses some potential risks and can occasionally backfire. Important here, is for the counselor to avoid any tone of sarcasm. This type of reflection is particularly useful when clients appear stuck in a “yes, but” mindset.

 

Double-Sided Reflection:

A third strategy entails acknowledging what the client has said but then also stating contrary things they have said in the past. This requires the use of information that the client has offered previously, although perhaps not in the same session.

Client: I know you want me to give up drinking completely, but I’m not going to do that!

Clinician: You can see that there are some real problems here, but you’re not willing to think about quitting altogether.

Double-sided reflections capture client ambivalence and communicate to the client that the counselor heard their reasons both for and against change; that the counselor understands the decision is complex, and they are not going to prematurely push them to change. Double-sided reflections typically take the form of “on the one hand, you would like to change XX, but on the other hand, changing XX would mean giving up XX” or “you are torn about changing XX….”

 

Shifting Focus

A counselor can defuse resistance by helping the client shift focus away from obstacles and barriers. This method offers an opportunity to affirm the client’s personal choice regarding the conduct of his own life.

Client: I can’t stop smoking pot when all my friends are doing it.

Clinician: You’re way ahead of me. We’re still exploring your concerns about whether you can get into college. We’re not ready yet to decide how marijuana fits into your goals.

 

Reframing a client’s reflections can help them feel understood so the need for resistance is lower. 

Client:  I don’t understand why my wife attacks me about my drinking.  I drink a lot less than most people.  Everyone I know drinks after work.

Clinician:  It sounds like your wife really cares about you, but you feel judged by how she brings it to your attention.

Rolling with resistance can shift perceptions and create new ways of thinking without imposing on them on a client.  The client is a valuable resource for finding solutions to his or her problem.

 

Reflection On Omission:

Sometimes a counselor can reflect to clients what they have not said. This can include reflecting on the client’s silence or reluctance to talk about a particular issue; “you don’t seem like talking today or you didn’t have much of a reaction to what I just said. ” In such cases, an omission reflection is an extension of rolling with resistance. However, an additional permutation includes reflecting on the client’s beliefs, solutions to problems, sources of help, etc. that have not been raised. For example, if an otherwise happily married woman states that she has no one to exercise with, the counselor could reflect “so it sounds like your husband is not the answer.” Another variation might include, “so I assume you probably have thought about trying XX solution/option but that doesn’t seem to work for you.”

 

Support Self-Efficacy

The client’s feeling of selfefficacy through his or her having an active role in the decision-making process ultimately has a very positive effect on the outcome of therapy.  Many clients do not have a well-developed sense of self-efficacy and find it difficult to believe that they can begin or maintain behavioral change. Improving self-efficacy requires eliciting and supporting hope, optimism, and the feasibility of accomplishing change. This requires the counselor to recognize the client’s strengths and bring these to the forefront whenever possible. Unless a client believes change is possible, the perceived discrepancy between the desire for change and feelings of hopelessness about accomplishing change is likely to result in rationalizations or denial in order to reduce discomfort. Because self-efficacy is a critical component of behavior change, it is crucial the clinician also believes in the clients’ capacity to reach their goals.

A strong sense of efficacy can be developed through mastery experiences, vicarious learning experiences, and physical and emotional states.

Mastery experiences are personal experiences that give people a sense of accomplishment and a feeling of mastery. By managing challenges through successive achievable steps, people develop a sense of mastery. Mastery experiences are the most effective way to develop a strong sense of efficacy because they offer the most authentic evidence that one can do what it takes to succeed. Success experiences help build self-efficacy, while failures undermine it. For example, using the weight loss example, a person who has lost weight in the past is more likely to have higher self-efficacy in this area than someone who has not been able to lose weight previously. 

Vicarious experiences through social modeling are another way to develop self-efficacy. If people see others similar to themselves succeed through persistent effort, they may come to believe they, too, can succeed in similar activities. The impact vicarious experiences have on self-efficacy depends on how similar to the model people perceive themselves to be. The greater the perceived similarity, the more impact the model’s successes and failures will have on a person’s self-efficacy beliefs.

Clients frequently use their physical and emotional states to judge their capabilities. An elevated mood can enhance self-efficacy, while a negative mood may diminish it. Clients tend to associate stress, tension, and other unpleasant physiological signs with poor performance and perceived incompetence. In activities requiring strength and stamina, feelings of fatigue and pain cause self-efficacy beliefs to decrease. Clients with a strong sense of efficacy are more likely to view their state of emotional arousal as energizing, while people with a weak sense of efficacy will view their state of emotional arousal as debilitating.

Discussing treatment or change options that might still be attractive to clients is helpful when helping to develop self-efficacy, even though they may have had limited success in the past. It is also helpful to talk about how persons in similar situations have successfully changed their behavior. Other clients can serve as role models and offer encouragement. Nonetheless, clients must ultimately come to believe that change is their responsibility and that long-term success begins with a single step forward. The AA motto, “one day at a time,” may help clients focus and embark on the immediate and small changes that they believe are feasible.

Education can increase clients’ sense of self-efficacy. Credible, understandable, and accurate information helps clients understand how to make changes. A process that initially feels overwhelming and hopeless can be broken down into achievable small steps toward recovery.

A belief in the possibility of change is an important motivator.  The client is responsible for choosing and carrying out personal change. 

 

Overview Of Motivational Interviewing As A Therapy

(Parts of this section are from Stephen Rollnick, Ph.D., & William R. Miller, Ph.D. What is motivational interviewing? Behavioral and Cognitive Psychotherapy, 23, 325-334.  Dr. Rollnick and Dr. Miller are credited in part with the developed Motivational Interviewing.)

When implementing motivational interviewing it is important to distinguish between the spirit of motivational interviewing and the specific techniques of the therapy. Clinicians who become too focused on techniques can lose sight of the concepts that are central to the approach. A counselor should focus on the idea that motivation to change is elicited from the client, and not be imposed. Other motivational approaches have emphasized coercion, persuasion, constructive confrontation, and the use of external contingencies (e.g., the threatened loss of a job or family). Such strategies may have their place in evoking change, but they are quite different in spirit from motivational interviewing which relies upon identifying and mobilizing the client’s intrinsic values and goals to stimulate behavior change. 

It is the client’s task, not the counselor’s, to articulate and resolve his or her ambivalence. Ambivalence takes the form of a conflict between two courses of action (e.g., indulgence versus restraint), each of which has perceived benefits and costs associated with it. Many clients have never had the opportunity of expressing the often confusing, contradictory, and uniquely personal elements of this conflict. For example, “If I stop smoking, I will feel better about myself, but I may also put on weight, which will make me feel unhappy and unattractive.” The counselor’s task is to facilitate the expression of both sides of the ambivalence impasse and guide the client toward an acceptable resolution that triggers change.  

Direct persuasion is not an effective method for resolving ambivalence.  These tactics generally increase client resistance and diminish the probability of change.  

The counseling style is generally a quiet and eliciting one. Direct persuasion, aggressive confrontation, and argumentation are the conceptual opposite of motivational interviewing and are explicitly proscribed in this approach. To a counselor accustomed to confronting and giving advice, motivational interviewing can appear to be a hopelessly slow and passive process. The proof is in the outcome. More aggressive strategies, sometimes guided by a desire to “confront client denial,” easily slip into pushing clients to make changes for which they are not ready.  

The counselor is directive in helping the client to examine and resolve ambivalence. Motivational interviewing involves no training of clients in behavioral coping skills, although the two approaches are not incompatible. The operational assumption in motivational interviewing is that ambivalence or lack of resolve is the principal obstacle to be overcome in triggering change. Once that has been accomplished, there may or may not be a need for further intervention such as skill training. The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centered and respectful counseling atmosphere.

Resistance and “denial” are seen not as client traits, but as feedback regarding therapist behavior. Client resistance is often a signal that the counselor is assuming greater readiness to change than is the case, and it is a cue that the therapist needs to modify motivational strategies.

The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. The therapist respects the client’s autonomy and freedom of choice (and consequences) regarding his or her own behavior. Viewed in this way, it is inappropriate to think of motivational interviewing as a technique or set of techniques that are applied to or (worse) “used on” people. Rather, it is an interpersonal style, not at all restricted to formal counseling settings. It is a subtle balance of directive and client-centered components shaped by a guiding philosophy and understanding of what triggers change.

Motivational interviewing style includes:

  • Seeking to understand the person’s frame of reference, particularly via reflective listening
    Expressing acceptance and affirmation
  • Eliciting and selectively reinforcing the client’s own self-motivational statements and expressions of problem recognition, concern, desire and intention to change, and ability to change
  • Monitoring the client’s degree of readiness to change and ensuring that resistance is not generated by jumping ahead of the client.
  • Affirming the client’s freedom of choice and self-direction. The point is that it is the spirit of motivational interviewing that gives rise to these and other specific strategies and informs their use.

 

In early treatment sessions, a counselor should determine the client’s readiness to change by asking open-ended questions.  Open-ended questions help a counselor understand the clients’ point of view and elicit their feelings about a given topic or situation. Open-ended questions facilitate dialog; they cannot be answered with a single word or phrase and do not require any particular response. They are a means to solicit additional information in a neutral way. Open-ended questions encourage the client to do most of the talking, they help the counselor to avoid making premature judgments and keep communication moving forward.

Reflective listening, summarizing, affirming, eliciting self-motivational statements can all help the client move to new behaviors that better serve their values and goals.

Components of successful Motivational Interviewing:

  • Empathy– the ability to understand and identify another person’s experience and communicate that perception back to the person is one of the main components of establishing rapport. Empathy and Hope are the most important components of good counseling.
  • Active Listening– involves attending skills and reflective listening. This helps counselors connect with the client by reflecting what the client’s underlying thoughts and feelings are back to the client.  The counselor can also provide useful feedback to the client that may include observations that the client had not considered.
  • Concreteness– the counselor will translate the vague aspects of the client’s statements and experiences into specific concrete terms in order to help the client develop more effective coping skills.
  • Paraphrasing– includes the therapeutic qualities of empathy and warmth. Comprises the counselor’s verbal responses that rephrase the content of the client’s statements into a meaningful conclusion. It allows the client to hear what he or she has just said and applies added clarity of meaning for the client.  This helps increase trust and reduces the client’s resistance.
  • Reflecting– This occurs when the counselor rephrases content that generated emotion in the client. It reflects feeling.  Reflection captures the essence of what a client is feeling and states it back to the client. This helps the client be aware of his or her own expressed emotions and how the counselor understood the client’s emotional message.  Counselors are warned not to interpret their clients’ feelings.  Do not offer opinions, judgments, or advice at this point.
  • Simplifying– includes reflection and restatement of what the client is trying to convey in a concise and clear way. It removes confusion and avoids intellectualization. Simplifying helps clients stay focused on specific problems in the here and now.”
  • Summarizing– involves tying together the main points, themes, and issues.
  • Attending– refers to how the counselor pays attention to the client using cues.
  • Probing– consists of asking open-ended questions in order to clarify information and help the client gain insightful understanding.
  • Reframing– involves offering a different perspective on a problem or circumstance the client is facing.
  • Exploring Alternatives– helping the client develop and consider various options.
  • Self-disclosure– this is when the counselor shares something personal about himself or herself that is beneficial to the client.
  • Confrontation– this is when a counselor raises a point to challenge a discrepancy that the client presented.
  • Immediacy– this involves interpersonal counseling, where the clinician discusses issues between himself or herself and the client in the present.

Motivational interviewing has been shown to be a useful clinical intervention and is an effective, efficient, and adaptive therapeutic style.

Motivational interviewing has the following benefits:

  • Low cost. Motivational interviewing was designed from the outset to be a brief intervention and is normally delivered in two to four outpatient sessions.
  • Efficacy. There is strong evidence that motivational interviewing triggers change in high-risk lifestyle behaviors.
  • Effectiveness. Large effects from brief motivational counseling have held up across a wide variety of real-life clinical settings.
  • Mobilizing client resources. Motivational interviewing focuses on mobilizing the client’s own resources for change.
  • Compatibility with health care delivery. Motivational interviewing does not assume a long-term client-therapist relationship. Even a single session has been found to invoke behavior change, and motivational interviewing can be delivered within the context of larger health care delivery systems.
  • Emphasizing client motivation. Client motivation is a strong predictor of change, and this approach puts primary emphasis on first building client motivation for change. Thus, even if clients do not stay for a long course of treatment (as is often the case with substance abuse), they have been given something that is likely to help them within the first few sessions.
  • Enhancing adherence. Motivational interviewing is also a sensible prelude to other health care interventions because it has been shown to increase adherence, which in turn improves treatment outcomes.

Motivational interviewing is non-judgmental, non-confrontational, and non-adversarial. The approach attempts to increase the client’s awareness of the potential problems caused, consequences experienced, and risks faced as a result of the behavior in question. Therapists help clients envision a better future and become increasingly motivated to achieve it.  The strategy seeks to help clients think differently about their behavior and ultimately to consider what might be gained through change. 

 

Security

Security includes the processes implemented to effectively manage the security of everyone within the facility or home. This could include:

  • Access control
  • Panic/Intrusion Alarms
  • Visitor access (after-hours)
  • Cameras
  • Vehicle security
  • Security audit/Risk assessment
  • Policy enforcement-weapons, zero tolerance, background checks upon hire
  • Establishing protocols for a buddy system
  • HIPPA and EMTALA reviews
  • VIP/Media policy
  • Posting such as Property Subject To Search By Security and No Photography On-Premises

 

Aggression Control Training 

Defuse the Situation:

It is important that staff know how to defuse a potentially violent situation.  

  • Back off; give the person plenty of space
  • Speak in a calm voice
  • Work to build trust
  • Let the person talk about why they are upset
  • Listen carefully
  • Help define the problem by asking for examples of what the person means
  • Explore solutions by asking open-ended questions
  • Provide clear, responsive feedback

 

Grievance Systems

Emphasis on patient-centered care has increased, as have calls for transparency of patient satisfaction data. These trends in healthcare make seeking and responding to patient feedback increasingly important components of programs. Patients have the right to file complaints and grievances with the organization when they are unsatisfied with the treatment received, and healthcare organizations should have processes in place for handling both in a timely manner. In addition, tracking and trending of patient complaints and grievances may call attention to systems or individual performance problems and suggest quality improvement opportunities. For example, patient complaints are associated with both clinical complications and increased risk of malpractice litigation.

There must be processes for addressing patient complaints and grievances in order to comply with regulations and accreditation standards, as well as to protect patients and reduce liability. Complaints stem from minor issues that can typically be resolved by staff present at the time the concern is voiced, while grievances are more serious and generally require investigation into allegations regarding the quality of patient care. 

The Joint Commission and other accreditors’ complaint resolution standards also require that accredited facilities address and resolve complaints from patients and their families. 

The law also requires that these programs continually educate their staff on the importance of their specific grievance system. 

Each program should provide meaningful procedures for the timely hearing or and resolution of grievances.  Clients should be told upon admission to a program on how to initiate a grievance if it should become necessary.  The process should be covered in employee orientation.

 

Mental Health Needs

All people are different when it comes to their experience with addiction and mental illness. Some begin to experience mental health issues during childhood or adolescence and experiment with drugs and alcohol soon after, developing both an addiction problem and a serious mental illness at the same time.  Others may seek out drugs and alcohol in an attempt to “self-medicate” a mental health issue that develops in early adulthood or that develops out of an injury or trauma later in life.  Still, others may first develop an addiction problem that grows so severe that it causes mental health issues or triggers the onset of symptoms that may otherwise have remained dormant.

Formerly known as dual diagnosis or dual disorder, co-occurring disorders describe the presence of both mental health and a substance-use disorder.

People with mental health disorders are more likely than people without mental health disorders to experience alcohol or substance use disorder. Co-occurring disorders can be difficult to diagnose due to the complexity of symptoms, as both may vary in severity. In many cases, people receive treatment for one disorder, while the other disorder remains untreated. This may occur because both mental and substance use disorders can have biological, psychological, and social components. Other reasons may be inadequate provider training or screening, an overlap of symptoms, or that other health issues need to be addressed first. In any case, the consequences of undiagnosed untreated, or under-treated co-occurring disorders can lead to a higher likelihood of experiencing homelessness, incarceration, medical illnesses, suicide, or even early death.

People with co-occurring disorders are best served through integrated treatment. With integrated treatment, practitioners can address mental and substance use disorders at the same time, often lowering costs and creating better outcomes. Increasing awareness and building capacity in service systems are important in helping identify and treat co-occurring disorders. Early detection and treatment can improve treatment outcomes and the quality of life for those who need these services.

The term co-occurring disorder replaces the terms dual disorder and dual diagnosis when referring to an individual who has a co-existing mental illness and a substance-use disorder. While commonly used to refer to the combination of substance use and mental disorders, the term also refers to other combinations of disorders (such as mental disorders and intellectual disability).

Clients with co-occurring disorders (COD) typically have one or more disorders relating to the use of alcohol and/or other drugs, as well as one or more mental disorders. A client can be described as having co-occurring disorders when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from another disorder.

Common examples of co-occurring disorders include the combination of major depression with cocaine addiction, alcohol addiction with panic disorder, alcoholism, and poly-drug addiction with schizophrenia and borderline personality disorder with episodic poly-drug abuse. Thus, there is no single combination of co-occurring disorders; in fact, there is great variability among them.

The combination of a substance use disorder and a psychiatric disorder varies along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild, or one may be more severe than the other. Additionally, the severity of both disorders may change over time. Levels of disability and impairment in functioning may also vary.

People with co-occurring disorders often experience more severe and chronic medical, social, and emotional problems than people experiencing a mental health condition or substance-use disorder alone. Because they have two disorders, they are vulnerable to both relapse and a worsening of the psychiatric disorder. Further, addiction relapse often leads to psychiatric distress, and the worsening of psychiatric problems often leads to addiction relapse. Thus, relapse prevention must be specifically designed for the unique needs of people with co-occurring disorders. Compared to patients who have a single disorder, patients with co-existing conditions often require longer treatment, have more crises, and progress more gradually in treatment.

 

Mental Disorders

The standard use of terms for non–substance-related mental disorders also derives from the DSM-IV-TR. These terms are used throughout the medical, social service, and behavioral health fields.

The major relevant disorders for co-occurring disorders include schizophrenia and other psychotic disorders, mood disorders, anxiety disorders, and personality disorders.

The major relevant categories of mental disorders that frequently occur with substance abuse issues include:

  • Schizophrenia and other psychotic disorders
  • Mood disorders
  • Anxiety disorders
  • Somatoform disorders
  • Factitious disorders
  • Dissociative disorders
  • Sexual and gender identity disorders
  • Eating disorders
  • Sleep disorders
  • Impulse-control disorders
  • Adjustment disorders
  • Personality disorders
  • Disorders usually first diagnosed in infancy, childhood, or adolescence

 

5 Most Common Mental Disorders Associated with Specific Addictions

Some conditions seem destined to come in pairs. Heart disease often follows a diagnosis of diabetes, for example, and allergies often come hand in hand with asthma. The same sort of joining effect sometimes takes hold when an addiction is in play. In fact, it’s quite common for certain drugs of abuse to be entangled with specific mental health disorders.  

These are five of the most common mental health/addiction combinations in play today.

 

Alcoholism and Antisocial Personality Disorder

Alcohol abuse is associated with a number of mental health concerns, including:

  • Mania
  • Dementia
  • Schizophrenia
  • Drug addiction

According to the National Institute on Alcoholism (NIAAA), antisocial personality disorder (ASPD) has the closest link with alcoholism, as people who drink to excess on a regular basis are 21 times more likely to deal with ASPD when compared to people who don’t have alcoholism. Often, the two disorders develop early in life, the NIAAA says, but alcoholism can make the underlying mental illness worse, as people who are intoxicated might have lowered inhibitions, which makes their antisocial behaviors more prevalent.  

 

Marijuana Addiction and Schizophrenia

It’s not unusual for people who have schizophrenia to develop addictions. In fact, a study in the American Journal of Psychiatry suggests that about half of all people with schizophrenia also have a substance abuse disorder. However, there’s a particularly striking association between marijuana abuse and schizophrenia. It’s unclear why people with schizophrenia would abuse this drug, as it seems to produce many of the same symptoms these people experience when in the midst of a schizophrenic episode, but it is clear that marijuana abuse is at least somewhat common in those who have schizophrenia.

 

Cocaine Addiction and Anxiety Disorders

People who abuse cocaine often take the drug because it makes them feel euphoric and powerful. However, continued use seems to lead to symptoms that are more indicative of an anxiety disorder, including:

  • Paranoia
  • Hallucinations
  • Suspiciousness
  • Insomnia
  • Violence

These symptoms may fade away in people, who achieve long-lasting sobriety, but sometimes the damage lingers, and the unusual thoughts and behaviors stick around even when sobriety has taken hold.

 

Opioid Addiction and PTSD

Post-traumatic stress disorder (PTSD) is a mental illness that takes hold in the aftermath of a very serious episode in which the person was either facing death or watching someone else die. Often, people who survive these episodes emerge with very serious physical injuries, and often, those injuries are treated with prescription painkillers. These drugs can also boost feelings of pleasure and calm inside the brain, and sometimes people who have PTSD are moved to abuse their drugs in order to experience euphoria. While people in physical pain do need help to overcome that pain, blending PTSD with painkillers can lead to tragic outcomes that no one wants.

 

Heroin Addiction and Depression

While heroin can make users feel remarkably pleasant in the short term, long-time users can burn out the portions of the brain responsible for producing signals of pleasure. In time, they may have a form of brain damage that leads to depression. They’re physically incapable of feeling happiness unless the drug is present. This drug/mental illness partnership is remarkably common, but thankfully, it can be amended with treatment and sobriety.

 

Symptoms

Everyone recovering from an addiction is going to go through some ups and downs.  That is very normal, expected.  It can be more serious though.  The symptoms of co-occurring disorders include those associated with the particular substance abuse and mental health conditions a person has. Co-occurring disorders can be difficult to diagnose because the symptoms of substance abuse or dependence can mask the symptoms of mental illness, and vice versa.

As stated, substance abuse is a maladaptive pattern of substance use that occurs despite the individual’s experiencing significant substance-related problems. Individuals who abuse substances may experience such harmful consequences of substance use as repeated failure to fulfill roles for which they are responsible, legal difficulties, or social and interpersonal problems. It is important to note that the chronic use of an illicit drug still constitutes a significant issue for treatment even when it does not meet the criteria for substance abuse.

For individuals with more severe or disabling mental disorders, as well as for those with developmental disabilities and traumatic brain injuries, substance use at lower levels might be more harmful (and therefore defined as abuse) than for individuals without such disorders.

People with co-occurring disorders are at high risk for many additional problems such as symptomatic relapses, hospitalizations, financial problems, social isolation, family problems, homelessness, suicide, violence, sexual and physical victimization, incarceration, serious medical illnesses such as HIV and hepatitis B and C, and early death. Anyone of these problems complicates the treatment of co-occurring disorders.

 

Causes

Mental health and substance abuse disorders often occur as a result of biological and environmental factors. Mental disorders and addiction are each a dynamic process, with varying degrees of severity, rate of progression, and symptom manifestation. Both types of disorders are greatly influenced by several factors, including genetic susceptibility, environment, and pharmacologic influences. Certain people have a high risk for these disorders (genetic risk); some situations can evoke or help to sustain these disorders (environmental risk), and some drugs are more likely than others to cause psychiatric or substance use disorder problems (pharmacologic risk).

People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder. Mental illness can lead people to use alcohol or drugs to make themselves feel better temporarily. In other cases, a substance-abuse disorder triggers or in some other way leads to severe emotional and mental distress.

 

Treatments

To provide appropriate treatment for co-occurring disorders, the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services recommends an integrated treatment approach. Integrated treatment is a means of coordinating substance abuse and mental health interventions, rather than treating each disorder separately and without consideration for the other.

Integrated treatment occurs when a person receives combined treatment for mental illness and substance use from the same clinician or treatment team. It helps people develop hope, knowledge, skills, and the support they need to manage their problems and to pursue meaningful life goals. Integrated treatment may include the following:

  • Help patients think about the role that alcohol and other drugs play in their life. People feel freer to discuss these issues when the discussion is confidential, nonjudgmental, and not tied to legal consequences.
  • Offer patients a chance to learn more about alcohol and drugs—how they interact with mental illnesses and with other medications—and to discuss their own use of alcohol and drugs.
  • Help patients become involved with supportive employment and other services that may help the process of recovery.
  • Help patients identify and develop recovery goals. If a person decides that the use of alcohol or drugs may be a problem, a counselor trained in integrated treatment can help that person identify and develop personalized recovery goals. This process includes learning about steps toward recovery from both illnesses.
  • Provide counseling specifically designed for people with co-occurring disorders. This can be done individually, with a group of peers, with family members, or with a combination of these.

Successful strategies with important implications for clients with COD include interventions based on addiction work in contingency management, cognitive-behavioral therapy (CBT), relapse prevention, and motivational interviewing.

All substance-abuse treatment programs should have in place appropriate procedures for screening, assessing, and referring clients with CODs. It is the responsibility of each provider to identify clients with both mental and substance use disorders and to assure them that they have access to the care needed for each disorder.

A comprehensive assessment serves as the basis for an individualized treatment plan. Appropriate treatment plans and treatment interventions can be quite complex, depending on what might be discovered in each domain. This leads to another fundamental principle: There is no single, correct intervention or program for individuals with CODs. Rather, the appropriate treatment plan must be matched to individual needs according to these multiple considerations.

An onsite addiction treatment psychiatrist can improve treatment retention and decrease substance use among patients. The onsite psychiatrist brings diagnostic, medication, and psychiatric counseling services directly to the location where clients are based on the major part of their treatment. This approach often is the most effective way to overcome barriers presented by offsite referral, including distance and travel limitations, the inconvenience of enrolling in another agency and of the separation of clinical services (more “red tape”), client fears of being seen as mentally ill (if referred to a mental health agency), cost, and the difficulty of becoming comfortable with different staff.

 

Medication

Many clients with COD require medication to control their psychiatric symptoms. Pharmacological advances over the past decade have produced antipsychotics, antidepressants, anticonvulsants, and other medications with greater effectiveness and fewer side effects. With the support available from better medication regimens, many people who once would have been too unstable for substance abuse treatment, or institutionalized with a poor prognosis, have been able to lead more functional lives.

 

Psychoeducational Classes

Psychoeducational classes on mental and substance use disorders are important elements in basic COD programs. These classes typically focus on the signs and symptoms of mental disorders, medication, and the effects of mental disorders on substance-abuse problems. Psychoeducational classes of this kind increase client awareness of their specific problems and do so in a safe and positive context.

Relapse-prevention education presents strategies designed to help clients become aware of cues or “triggers” that make them more likely to abuse substances and help them develop alternative coping responses to those cues. Some providers suggest the use of “mood logs” that clients can use to increase their consciousness of the situational factors that underlie the urge to use drugs or drink.

 

Group Therapy

Group therapy provides a forum for discussion of the interrelated problems of mental disorders and substance abuse, helping participants to identify triggers for relapse. Clients describe their psychiatric symptoms (such as hearing voices) and their urges to use drugs. They are encouraged to discuss, rather than to act on, these impulses. Groups also can be used to monitor medication adherence, psychiatric symptoms, substance use, and adherence to scheduled activities. These groups can provide a constant framework for assessment, analysis, and planning. Through participation, the individual with COD develops a perspective on the interrelated nature of mental disorders and substance abuse and becomes better able to view his or her behavior within this framework.

 

Outpatient Substance Abuse Treatment Programs for Clients with COD

Treatment for substance abuse occurs most frequently in outpatient settings. Some offer several hours of weekly treatment, which can include mental health and other support services as well as individual and group counseling for substance abuse. Others provide minimal services, such as one or two brief sessions, to give clients information and refer them elsewhere. Some agencies offer intensive outpatient programs that provide services several hours per day and several days per week. Typically, treatment includes individual and group counseling, with referrals to appropriate community services.

Individuals with COD often need a range of services besides substance-abuse treatment and mental health services. Generally, important needs include housing and case management services to establish access to community health and social services. These can be essential to the successful recovery of the person with COD.

It is imperative that discharge planning for the client with COD ensures continuity of psychiatric assessment and medication management, without which client stability and recovery will be severely compromised. Relapse-prevention interventions after outpatient treatment need to be modified so that clients can recognize symptoms of psychiatric or substance abuse relapse on their own and can call on a learned repertoire of symptom management techniques (such as self-monitoring, reporting to a “buddy,” and group monitoring). This also includes the ability to access assessment services rapidly since the return of psychiatric symptoms can often trigger a substance-abuse relapse.

One of the most important factors is to listen to residents.  They sometimes just need to talk through what they are feeling.

 

Reducing Leaving Against Medical Advice Discharges

Addiction is a stress-driven disease.  Addicts are impulsive.  Their decision-making is emotionally driven and poorly thought out.  They overvalue drugs and underate the consequences of their relapsing and they cannot see how their behavior negatively impacts the people that they love.

Leaving against medical advice (“AMA”) is defined as the patient’s decision to leave the facility after having been informed of and having the ability to appreciate the risk of leaving without completing treatment. Fully competent patients are legally able to discharge themselves without completing treatment.

Treatment Centers struggle with clients wanting to leave Against Medical Advice (AMA) and sometimes the length of their stay in treatment does not meet the goal of the treatment team. When a client wants to leave it creates a crisis disruption in the program for everyone. 

People seeking treatment for substance abuse and addiction are at heightened risk when they leave recovery treatment facilities against medical advice (AMA).

It is crucial for staff to understand why individuals leave and to know how to attempt to block these efforts in a therapeutic way. 

Understanding who is most at risk of leaving treatment against medical advice will help you recognize population prevalence, warning signs, and other factors that can worsen the already deteriorated state of a possible AMA discharge. These issues must always be recognized and interceded upon in order to give the best possible outcome.

Individuals most at risk for leaving AMA include:

  • Clients experiencing withdrawal symptoms and detoxification
  • Clients with prior treatment failures
  • Clients who report little to no problems
  • Clients with co-occurring disorders
  • Clients who are male and ages 18 to 29
  • Clients who isolate
  • Clients who are externally motivated
  • Clients with significant cultural differences
  • Clients who do not engage the family in the treatment process
  • Clients without primary care doctors.
  • Clients without medical coverage or poor coverage.

Even though certain people may be at higher risk, there is no way to predict exactly who will leave. Instead, it is best for physicians and recovery center professionals to be prepared to assess a patient’s desire to leave and help the patient work through what is a true immediate need, doing their best to calm a patient’s fear both of treatment and of letting go of personal endeavors to undergo treatment.

People leave medical or professional care for a myriad of reasons.  Some are legitimate obstacles to treatment and some lean more to the side of an excuse.  Treatment and sobriety are hard.  Life has responsibilities that are not easily postponed even in the case of needing critical care.

A leading cause for AMAs occurring within the residential setting is trait impulsivity and neurocognitive expressions of impulsivity.

Trait impulsivity has characteristics, such as:

  • lack of premeditation
  • sensation seeking
  • lack of resiliency
  • perseverance
  • difficulties in coping with strong impulses

Neurocognitive expressions of impulsivity separated into two categories:

  • impulsive action
  • impulsive choice

Impulsive action is defined more by poor inhibitory control, while impulsive choice refers to a distorted view or inability to see delayed consequences. These are a concern because clients leaving treatment AMA are doing so impulsively.

  • Emergencies
  • Family issues
  • Financial reasons: no insurance, insurance which would not cover an extended stay, or a general inability to pay for care
  • Personal reasons

In addition, a person may choose to leave rehab because he or she was not initially committed to attending in the first place, feels prematurely capable of maintaining sobriety, becomes overwhelmed by symptoms of withdrawal, or is experiencing an overwhelming urge to use drugs and/or alcohol. Regardless of the reason why, this is a decision that can have far-reaching implications, endangering both the individual’s health and their chance at sobriety.

People who wish to leave facilities AMA may not receive enough care. It is a challenge to provide quality healthcare when patients do not adhere to their provider’s recommendations for treatment. But not receiving proper care at the time of admission is not the only negative outcome of leaving AMA—it also puts people at risk for a number of adverse outcomes, including:

  • Higher readmission rates in comparison to people not discharged AMA
  • Lack of access and guidance to relapse prevention plans and critical aftercare support and programs
  • Failing to understand the full potential of treatment or leaving with a false perception of rehab, due to the fact a person did not have the full
  • opportunity to engage in the entire spectrum of care offered
  • A false and misleading sense of overconfidence may lead a person to put themselves in dangerous and tempting situations
  • Leaving without the full spectrum of skills rehab can teach
  • Failing to learn about the factors that drove them to drug or alcohol use in the first place, thus leaving them susceptible to these triggers in the future
  • A person is not fully prepared to maintain sobriety on their own, thus increasing the odds of relapse
  • If relapse occurs, an overdose may follow—especially after the period of sobriety experienced in rehab and the possibility of a reduced tolerance from this time
  • In the worst possible outcome even death—in some cases overdose may be fatal

 

As discussed earlier most clients with substance use disorders will have issues surrounding impulsive acts and impulsive choices. Learning to identify, interrupt, and intervene on clients who display these characteristics will not only reduce AMA discharges, but it also may help prevent a rise in readmission rates and relapse occurrences.  

Typically by the time the staff intervenes, a client is 90% out the door.  Early interventions and reachable goals are a necessity in reducing the possibility of a client leaving AMA and increasing the chances for long-term recovery.

The literature is consistent with concluding that patients will signal that they are thinking about leaving AMA before they actually leave AMA. Understanding this requires the providers to “hear” the patient and to have effective communication between all providers. Effective interpersonal communication includes interpreting verbal and nonverbal language.

Understanding the patient’s rationale for leaving AMA will provide opportunities to proactively address the issues.

Recovery produces uncomfortable feelings.  As a general rule, people like to avoid being uncomfortable. 

One of the most important factors in treatment outcomes is the client’s belief that they can successfully change their behaviors. The quality of the staff-client relationship is a critical component of this belief. In the end, how the staff feels about a client’s chances of success affect the client’s outcome. So the final question is, “Does the client believe there is hope?” For clients to feel hope, they must have movement, and to have movement, clients must have a plan. These plans must be individualized and reviewed with clients weekly to show them their progress or areas of concern.  Simply put, clients who experience success will be more invested in seeing treatment through.  Clients who do not see improvement will be more apt to quit.

People who are leaving may be worried about personal obligations, such as family or work. Maybe a person refuses to stay because he or she is unsure who will take over these responsibilities when he or she is gone. This may be especially true for patients undergoing inpatient substance abuse treatments whose stays can range from 30 days to 120 days and beyond. Treatment is essential for the health of addicted individuals and working through these worries could be the crucial deciding factor in securing much-needed treatment.

Physicians, nurses, counselors, behavioral technicians, family, and friends in support of a person’s substance abuse treatment may all play a role in helping quell the fears of someone wishing to be discharged AMA. People who enter emergency departments for care due to substance abuse may be panicked from the experience.  The support they receive or don’t receive can make a world of difference.

Addiction can also cause people to undergo changes in brain chemicals—many affected by addiction are unaware that their lives have changed to revolve around seeking and using substances. In addition, many substances may impede a person’s judgment and ability to think soundly, while also impairing their capacity to make rational decisions. Therefore, some people may be unaware of or unwilling to see that they need treatment. In these cases, it may be helpful to stage interventions or gatherings of people who care about addicted individuals and who want to show their support for recovery.

Counselors who handle patients at risk of leaving AMA should assess the patient’s fear of staying. For instance, is the patient’s need to leave an immediate one, or is there family who could be contacted to fulfill these obligations while the patient undergoes treatment? Further, does the patient want to leave because he or she is unwilling or not ready to admit to a substance use disorder? If so, it may be helpful to address this with the client. If a person is concerned about their financial responsibility for treatment, staff should spend time working with them on their options, including various scholarships and grants.

Professionals in addiction treatment facilities are in a unique position to help people stay and receive the treatment they need. Substance abuse treatment is not an easy time—from detoxification to the withdrawal process, too early recovery and continued care, those who undergo treatment have a long road ahead of them. It is the reason many enter recovery treatment:  to get professional support and monitoring in a substance-free environment. For this reason, it is important that all treatment staff are fully aware of the patient’s concerns, in line with the patient’s treatment plan and goals. This can greatly help towards identifying those at risk while helping to abate their fears and concerns.

 

Intervention Strategies

Interventions are most successful when the recovery professionals know their population. This reality, coupled with an understanding of why people leave treatment AMA, enables us to implement strategies to reduce the likelihood of leaving AMA.

The interventions used must make sense, be simple, and start before clients ever enter the treatment center.

  • Create a culture of watching for the signs
  • The admission process and orientation should be thorough so that the clients feel as comfortable as possible and understand what is expected of them so they can process what obstacles might interfere
  • Obtain Consents to Release Information upon admissions
  • Review AMA information with family and the referral source
  • Evening/Weekend Counselors should meet with all new admissions so the clients know who on the unit and when they can be expected to have different staff there
  • Create an environment of structure
  • Ask clients what they need to support their stay in treatment
  • Remain focused. Use clinical skills and client’s input to develop solutions
  • Be consistent with the guidelines and hold “Guidelines Group” frequently
  • Communicate. Read that again.
  • Listen.  Read that again.

 

Let’s look deeper and some of the strategies that can be used.

Preparing The Support System

It can help to talk with patients and their support system about how this will likely come up.  Those in a patient’s circle of support need to be prepared for the possibility of the patient coming to them to help them leave treatment. 

  • Who will make it easy for them?
    The staff should understand in advance who will make leaving easy for the patient.
  • Reduce the ability to manipulate.
    Ensure the phone calls occur with the counselor involved. Explain that it is common for addicts to play on a family’s hope that they are done using; to use guilt and anger and fear to get assistance in leaving.
  • Ensure financial resources are limited to necessity.

 

Utilize the Staff and Therapeutic Community

Staff should regularly assess the client’s risk level for wanting to leave treatment.  When a patient is expressing lower satisfaction and motivation work as a team to provide:

  • More attention
  • More group process
  • More individual sessions
  • Close off easy opportunities to leave
  • Confront impulsive thinking
  • Encourage the patient
  • Show empathy
  • Help them to better deal with emotions

The therapeutic community can also be employed to support the patient.  Other residents that might be further along in the treatment can provide support and understanding, as well. 

 

Appropriate Language and Key Questions

 

When a patient is contemplating leaving treatment against medical advice, they are usually in the mindset prepared to argue, to defend their position.  It is necessary to use non-argumentative language with them.  The most important piece is to listen to their concerns.  Don’t shrug them off.  Listening and letting them know that you understand what is pulling at them will go a long way in defusing their resistance to talking with you. 

  • Don’t ignore the patient who wants to leave AMA. If possible, stop what you are doing and address their concerns and feelings.
  • Determine the decision-making capacity of the patient. Do they comprehend the information and consequences and understand the risk and benefits of the options?
  • Don’t blame or berate them or anyone else for their desire to leave.
  • Don’t just ask them to sign a generic AMA form and leave. This course of action providers little protection for the treatment facility and doesn’t serve the client.
  • Talk with the client about their whys for entering treatment through questioning.
  • Suggest the client talk with friends or family that were in support of them entering treatment as a means of working out any possible obstacles and gaining support.
  • Don’t express your frustration and anger to the patient. Earnestly express to them that your overriding interest in their well-being.

 

Building Rapport Before, During, And After A Patient Wants To Leave AMA

When trust and rapport are not established, a client tends to be more guarded and resistant to the treatment process. A client should be able to trust the recovery staff and to feel comfortable with the treatment plan.  The rapport between the client and the counselor can build the trust necessary for the client to feel like the difficult process of change is both possible and worth it.

Building rapport and trust include genuineness, unconditional positive regard, and empathy.  Staff should be truthful and honest, accept the client but not the behavior, and have empathy for the client’s situation. 

This begins with a thorough evaluation and continues through to creating a treatment plan.  What are the obstacles that the client is aware of?  Are they afraid of losing their spouse or job?  Do they have kids or pets at home?  Are they concerned about cost or relapse?  Not every client has the same obstacles and understanding the concerns of each, individual, can help you understand them as a person.   The goal is to gain a clear understanding of the client’s perception of the problem at the deepest levels.  Does the client feel listened to?  Understood?

Rapport can be established through:

Active listening

Pay very close attention to the words and emotions of the client, and let them know that he or she is being heard and understood.

Verbally engaging

Research shows that rapport increases with counselor verbosity. The more you verbally engage the client in dialogue (rather than just listening), the better rapport will be.

Using fewer encouragers

Research shows that encouraging statements such as ‘uh-huh,’ ’yes’ and ‘go on’ do little or nothing for building rapport.

Asking open-ended questions

Who, where, what, when, and how (not why). Open-ended questions will require the client to give in-depth responses that promote dialogue and deepen the relationship.

Emulating the client’s speech

Having the flexibility to use words, phrases, and metaphors familiar to the client is important for rapport building. Listen carefully to the language the client uses, and attempt to adopt some words, phrases, and images the client feels comfortable with.

Finding common ground with opinions or beliefs

To help increase rapport, validate something the client knows to be true, before leading him to consider other possibilities. This is less damaging to rapport than challenging the client’s beliefs alone. Motivational interviewing shows us that the most likely result of too many direct challenges is defensiveness. However, do not compromise your integrity or pretend to believe in something you do not.

Using humor

Make an effort to slow and soften your conversational approach, and even try to work some humor into the dialogue. This personal touch may go a long way in helping to build relationships with clients.

Anticipating needs

Have you learned that every time the patient has a visit from their spouse they get upset?  Have you recognized that when a new resident arrives they get nervous?  Pay attention to the needs to get ahead of issues.

Providing stability

Your client needs to know that you will be a source of stability amidst his or her times of crisis. Make sure you always seem calm and controlled.

 

The most important factor in reducing the patient’s desire to leave treatment against medical advice is to recognize and combat the signs that a patient is going to want to leave to get ahead of the issue.  The second most important factor is to understand the patient’s needs.  If a patient tells you they want to leave treatment ask them the key question of:

 

“What do you need to support your continued treatment?” 

We can predict and guess all day what might be motivating the desire to leave.  Rather than fixing problems that may not exist, ask the client what they need to be addressed.  Engage the patient if being part of the solution. 

Handling The Angry and Obstinate Patient

As said before, usually when a client finally verbalizes the desire to leave they are ready for a fight.  They have built up the nerve to be direct and confrontational.  They have attempted to manipulate family and friends to support their desire to leave.  They can be angry and obstinate.

The following are important items to keep in mind when dealing with an angry patient:

Understand that addiction treatment is not easy. 

No person would ever want to be in a recovery facility.  Counseling and self-reflection can be painful.  Addiction causes feelings of being out of control.

Show empathy

As a recovery professional it is your role is to let the patients feel that you understand and care about them. You can show empathy by focusing your attention on your surroundings and to their feelings, expressions, and actions. Show them that you are interested and that they are important.

Allow the patient to calm down

Give an angry patient the opportunity to calm down and have space before continuing your “arguments” for them to stay in treatment.  Consider this a process not simply a request. 

Do not invade the patient’s personal space
Try not to get either too close or too far from them. Let them feel that they still have their own personal space that you wouldn’t be invading and that they are safe there.

Be sensitive
Think about how you would feel if you were in their shoes. Being sensitive to people’s feelings means accepting them and respecting them no matter what happens.

Be gentle
Gentleness is a quality that comes from the heart and soul. People who are gentle establish peace and are strong enough to remain calm and show restraint even when faced with difficult situations.

Think before you respond to anything the patient says. Sometimes, people react too quickly without taking time to think about how their responses might affect others.

If you are to respond, do it in a calm and kind manner. If you want to make the situation better, try to avoid negativity. Instead, focus on something that you can do to help the person.

Do not argue
Trying not to argue doesn’t mean you cannot voice out your opinion. It only means you have to state your point in a decent and respectful manner. Be truthful of everything you say, and try not to think that you are always right. Communicating better and having a positive behavior towards any issue will solve anything.

Set boundaries
It may come to a point when you have to set a boundary. Keep yourself safe but let them know that you are listening to them. Defuse situations before they even escalate. A patient has the right to be involved in their medical decision-making, but they cannot use that right for any unreasonable demands.

Communicate
Communication is one of the most important aspects of the counseling profession. Be honest with everything you say to the patient. Be available and responsive to your patients. Never let them feel that you are ignoring them. It will be much easier to fix things if effective communication is used.

Acknowledge the patient
Validating the person’s feelings will help them feel understood. Let them feel that their feelings make sense, that you hear them and you understand them. People, especially those who are angry, often need to know that you don’t think they are bad or crazy for feeling that way.

Validating a person’s feelings requires a temporary suppression of the impulse to explain your side. Focus your attention on what your patient or their family member feels and try to acknowledge their feelings.

Listen
Let the patient speak their mind without interrupting. Listening does not only expand your capacity for empathy, but it also sharpens your communication skills. Active listening also means you should look at the problems from the other person’s point of view. Focus on what the person is saying to you before offering any help.

Ask Open-Ended Questions
Ask gentle, probing questions to learn more about what the other person thinks and feels. Ask for clarifications if you don’t get what the patient is trying to say.

Remember that close-ended questions might make the situation worse because it will only let them feel that you are not interested in what they have to say. Open-ended questions, on the other hand, will show them that you care. Ask them questions like “Why do you feel this way?” or “How do you feel about it?”.

Don’t make defensive responses
Think first before responding. Learn how to pause and breathe. This will calm you down and control your response. It will also prevent an unnecessary outburst. Understand that many factors have led to a verbal attack from your patient or their family member. Consider that you may not be the sole reason for their anger and that there is no point in getting defensive.

Use appropriate language
“You are projecting your anger from your biological family on the therapeutic community” will not calm the patient down.  It is necessary to speak to the patient in language that is common for them to use and understand.  If you try to come off as the expert they will escalate.  Choose your words wisely.

Watch your body language
Never cross your arms when facing them and don’t turn your back from them while they are speaking. Maintain eye contact if necessary, just so you can let them feel that you are open to what they have to say. Openness means that you are willing and ready to listen to them without judgment.

Handling Guilt, Remorse, and Self-Sabotaging Behaviors to Avoid AMA

It is not the lack of knowledge, effort, or even desire that causes a client to abandon treatment, but rather the real obstacles such as finances, kids, and jobs as well as the mental chorus of self-dialogue that confuses the issue.

Self-sabotaging behavior includes:

  • Lack of personal responsibility
  • Lack of awareness
  • Poorly communicating with others
  • Negativity
  • Poor decision making
  • Refusal to accept a problem

Helping a client recognize self-sabotaging thoughts and behaviors can make a real difference in them following through on treatment.

  • Ask the client what is the payoff for self-defeating behavior? Is it a reason to go back to using?  Is it a way to get attention?
  • Help the client to avoid situations that trigger extreme emotional reactions. Extreme emotional reactions can provoke a relapse. If you can’t avoid these situations, at least try to get a realistic perspective on them. Ask yourself, “how important is it really?’”
  • Help the client to identify the origins of their belief system. Once you have identified where those defeating attitudes came from, let go of them. It is OK to acknowledge the past, but not to use it as an excuse to continue your behavior into the present.
  • Assist the client in feeling like they are in control and making good decisions. They are not a victim of their circumstances.

The Process of AMA As An Intervention Strategy

Understanding that leaving against medical advice is a process and not a signature on an AMA form can be one of the best interventions.  When a patient states that they are leaving treatment, rather than immediately arguing with them on the myriad of reasons to stay, let them know the “process” for discharging AMA.  The process can and should include:

  • The request of a specific amount of time such as 48 hours
  • An evaluation and documentation of their capacity for decision making addressing
  • The patient’s goals and values along with the treatment alternatives and referrals
  • Consequences such as risks of refusing and declining treatment. 
  • Including family and social resources when addressing post-care planning

By beginning a process that takes time and engages the patient in the planning and consequences of leaving treatment you have created the time, without the resistance, to help the client re-establish the desire for treatment and reduce the reason for wanting to leave.

Simply because a patient elects to leave AMA does not mean that he or she is always entitled to do so. In fact, there are situations in which the counselor is mandated to override the patient’s refusal to stay (i.e., not permit a patient to leave AMA), such as when the patient is: expressing suicidal ideation, lacks decisional capacity, or is a danger to others.

Some facilities require specific documentation when a client is leaving against medical advice.  Research has suggested though that these forms create an adversarial relationship and are not protective against liability.  Be aware of whether your facility utilizes these forms or not. 

When faced with a patient requesting to leave don’t refuse to provide treatment, this could be considered abandoning the patient.  Provide whatever treatment, follow-up appointments, discharge instructions, and referrals the patient will accept and document these in the patient’s chart.  Document all details of the AMA discussion, as well.  Include the documentation of the patient’s decision-making capacity, the specific benefits of your proposed treatment, and risk of leaving AMA.  Document what you did to attempt to get the patient to stay in treatment as well your expressed interest in the patient returning to treatment at any time.  If your facility uses a form have the client sign it with a witness. 

Some examples of documenting in a client’s chart:

  • The patient has decided to leave against medical advice because ______.
  • They have normal mental status and adequate capacity to make medical decisions.
  • The patient refuses treatment and wants to be discharged.
  • The risks have been explained to the patient including, _____________, worsening illness, relapse, etc.
  • The benefits of admission have also been explained, including the availability and proximity of caregivers.
  • The patient was able to understand and state the risks and benefits of treatment.
  • The patient had the opportunity to ask questions about their health and treatment.
  • The patient was treated to the extent that they would allow and knows that they may return for care at any time.
  • Follow up has been discussed and arranged with ________________.

Staff should be familiar with the AMA forms their facility chooses to use.

 

Leaving AMA When Intoxicated

The patient does not have the capacity to provide informed refusal when intoxicated. Diagnosis of intoxication is determined by the legal limit of intoxication in the jurisdiction and not by observation. Capacity refers to an assessment of the individual’s psychological abilities to form rational decisions, specifically the individual’s ability to understand, appreciate, and manipulate information and form rational decisions. If the physician evaluates a patient and determines that the patient lacks capacity, then the patient is referred to as de facto incompetent, i.e., incompetent in fact, but not determined to be so by legal procedures. Competency is a legal term and is determined by a court. Competency is a broad concept encompassing many legally recognized activities, such as the ability to enter into a contract, to prepare a will, to stand trial, and to make medical decisions.

Competency refers to the mental ability and cognitive capabilities required to execute a legally recognized act rationally. The patient does not have the capacity to provide informed consent or informed refusal/declination when intoxicated. As stated above, the diagnosis of intoxication is determined by the legal limit of intoxication (known as legal intoxication) in the jurisdiction and not by observation. However, alcohol tolerance is individualized. A person who has a long history of using alcohol may have a high tolerance level and not be clinically intoxicated at the same time that they are legally intoxicated. This should be documented, but because the patient is legally intoxicated, the patient does not have the capacity. If the patient’s blood alcohol level is under the legal limit but appears clinically intoxicated, this too should be documented and considered when making a capacity assessment. It is possible to not be legally intoxicated and not have decisional capacity. The universal question related to leaving AMA when intoxicated, but not at the legal limit of intoxication is, whether a patient who has been assessed to not have decisional capacity can be held against their will. Many times, this category of the patient (known as clinically but not legally intoxicated) will not meet the involuntary commitment requirements. In these cases, there may be a different route to provide a temporary legal/medical hold for a patient who may be a danger to themselves or others or who may not appreciate the risks of leaving AMA. The treatment or observation plan should be clearly articulated in the hospital policy and procedures.

Suggestions:
• Talking with the patient and asking if they would be willing to remain hospitalized until they are clinically sober
• Recognize that there is poor correlation between degree of intoxication and the patient’s clinical presentation
• Document the psychomotor and cognitive impairments
• Document the blood alcohol level
• Determine whether the patient will need to be observed until they are below the legal blood alcohol limit and/or are clinically sober

Clients rarely leave treatment because of what the facility staff does. More importantly, clients will most often leave treatment early for what facility staff is not doing. Learning to identify, intervene, and create a culture of prevention is required to be successful in reducing the impulsive decision to leave treatment AMA.

At the core of preventing and reducing AMA discharges are the underlying need for all clients to feel accepted, that they belong and that they have become competent about the disease of addiction and the recovery process. Understanding this and applying the above-listed interventions can lead to successful retention of clients in the residential.

If a patient cannot be stopped from leaving care AMA, professionals should be certain individuals are leaving with informed consent and have been given ample opportunity to ask questions regarding their health conditions. In other words, a patient being discharged against medical advice has to be mentally sound to make the decision to leave. However, before a person gets to that point, there are some things the addiction professionals can do to help them choose treatment instead.

  • Know your state involuntary commitment laws and regulations
    • Know your state duty to warn laws and regulations
    • Anticipate that patients may want to leave AMA

A person may have serious motivation to stop using or drinking, but that doesn’t necessarily mean they remain motivated to do the challenging, frightening, difficult work that treatment necessitates. Facing their past, facing their sadness, facing their fears; none of those things are easy, and doing it without the comfort of a drug or drink? That can be terrifying.

Even more challenging is the fact that their brains are working against them.  Drug and alcohol use have been related to deficits in the ways the brain processes information and emotions.  An addict will react to negative events and emotions more than they react to positive ones; the good things just do not hold as much weight as the bad.  They are impulsive and have a hard time planning.  Immediate rewards seem much more important than rewards that could be greater but are farther away. Logically, they know that the benefits of getting sober will be bigger than the brief pleasure or comfort of a drink or a drug, but it’s hard to remember that when they are uncomfortable or upset.

When the patient takes all of this into account, it makes perfect sense to want to leave.  As recovery professionals, we know that the moment may come where a client says, “I can’t do this.”  We must ask is there anything we could do differently? Is there any way to make the process more comfortable?

When a patient leaves AMA it is a heart-breaking outcome because we know that the best predictor of treatment success is the length of time in treatment; the longer someone stays, the better their chances of staying sober.  One of the hardest reasons for leaving to hear is also one of the most honest: “I’m just not ready.”

 

Medical Needs

From a stubbed two to a heart attack, residents look to us.  We all have different knowledge levels.  If you do not know what to do in an emergency, call 911.  The most basic skill needed when facing a medical issue is the willingness to help.

It is important to know any potential medical issues of the residents under your care.  Are they diabetic?  Do they have life-threatening allergies?   

 

What Is An Emergency and What is Not? 

It is critical to know how to recognize the signs of a medical emergency. Correctly interpreting and acting on these signs could make a real difference in a true emergency. Many people underreport the symptoms of a medical emergency, such as a heart attack or stroke. They sometimes want to see if the symptoms will go away on their own. They delay seeking care right away out of denial, fear, financial concerns, or for a myriad of other reasons. For many medical emergencies, time is of the essence, and delays in treatment can often lead to more serious consequences.

Emergency physicians believe it is the responsibility of every individual to learn to recognize the warning signs of a medical emergency. The following signs and symptoms and are not intended to represent every kind of medical emergency, but rather to provide examples of common issues.

What To Do In A Medical Emergency

This section does not contain all the signs or symptoms of medical emergencies, and the advice is not intended to be a substitute for consulting with a medical professional specializing in the symptoms the victim is reporting. Someone who is experiencing a medical emergency should seek immediate medical attention.

 

Adverse Drug Reactions     

Side effects are a normal occurrence with many drugs. Some are minimal, and some can be very serious and can trigger life-threatening reactions, both allergic and non-allergic.  Also, some medicines interact with other medications and cause adverse drug reactions. An adverse drug reaction is an expression that describes harm associated with the use of given medications at a normal dose. People who take three or four medications each day are more likely to have reactions to drugs. In addition, the use of herbal supplements and alternative medicines can interact with certain drugs and cause health issues.

Adverse drug reactions can occur within minutes or within hours of exposure. They are a leading cause of death in the United States, resulting in more than 100,000 deaths each year.

The most common symptoms of allergic reactions to drugs are:

  • Skin rash or hives
  • Itchy skin
  • Wheezing or other breathing problems
  • Swelling
  • Diarrhea or constipation

Penicillin is a frequent culprit for adverse drug reactions. Antibiotics, sulfa drugs, barbiturates, and insulin also can cause problems. Some medicines trigger a response from the immune system in people with drug hypersensitivity. The body’s immune system perceives the substance as attacking the body, so it attacks the system.

More than 90 percent of adverse drug reactions do not involve an allergic immune system response. Instead, these reactions may produce a range of symptoms involving almost any system or part of the body – which often makes them difficult to recognize.

Reactions to drugs may range from mild, such as upset stomach or drowsiness, to severe, life-threatening conditions, such as anaphylaxis. These reactions can occur with prescription medications, over-the-counter medications, and supplements or herbal remedies.

Everyone with known sensitivity should always tell their doctor if they have adverse reactions to medications, and they should wear an identifying bracelet or jewelry that alerts rescuers to their condition.

 

Advocacy Skills

Advocacy is an important means of raising awareness on mental health issues and ensuring that mental health is on the national agenda of governments. Advocacy can lead to improvements in policy, legislation, and service development.

Finally, getting into treatment for a mental health disorder can be life-changing.  Why then is it so difficult for some to seek treatment?

Experts overwhelmingly agree that getting help is the best way to manage a mental illness. Yet research shows the negative attitudes about mental health, both self-imposed and from others, can prevent people from seeking support.  Not to mention the fact that data shows the access to this kind of care is becoming increasingly more difficult, specifically in rural areas.

Below are some stats everyone should know about the way we treat mental health conditions today. If anything, the data is proof. This subject needs way more attention.

1 in 5

The number of American adults who will be diagnosed with a mental health disorder in a given year.

300 Million

The number of people globally who have depression, according to the World Health Organization. The prevalence of the condition has increased by 18 percent in the last decade.

56 Percent

The percentage of U.S. adults with a mental health condition who do not receive proper treatment according to a 2016 Mental Health America report. 

6 in 10

The number of young people in the U.S. with major depression that will not receive any treatment, according to the Mental Health America report.

24 Percent

The rate of increase in suicides in a 15 year period, according to 2016 data from the CDC. Those who die by suicide are often dealing with undiagnosed, untreated, or under-treated mental health issues.

1 in 6

The number of people who have taken a prescribed psychiatric drug, such as an antidepressant, at least once, according to a 2016 study published in the journal JAMA Internal Medicine.  

25 Percent

The percentage of people living with a mental health issue who feel like others are not caring or sympathetic about their condition, as noted by the CDC. That implies a majority of people with a mental illness may feel shamed or judged. As mentioned above, studies show stigma is a very real problem and stands in the way of people seeking treatment.

Getting treatment should be embraced, not denied. It’s time to do better ― with each other and as a country.

The human costs of an underfunded behavioral health care system are tragic.  While millions of individuals wait for affordable treatment, they are suffering from depression, schizophrenia,  substance use disorder, and a host of other issues that take a toll on their ability to work, go to school, attend to their physical health and maintain personal relationships, and at a time put others at risk.

While treating these disorders can certainly be expensive, the cost of not treating them is far greater. Mental illness and substance abuse are the leading causes of disability, job absenteeism, and lost productivity.

Employers, taxpayers, and health care providers shoulder these costs. Local indigent health care programs, prisons, and governments work to fill the service gaps created by systemic underfunding. For hospitals specifically, the costs of an underfunded behavioral health care system manifest themselves in reduced emergency department capacity, uncompensated care, and preventable hospital readmissions.

Because of the shortage of inpatient psychiatric beds statewide, hospital emergency departments often cannot immediately transfer patients with mental illness once they are stabilized. These patients may end up in an emergency department bed for 48 hours or more while they wait for appropriate treatment to become available. This practice, known as holding or boarding, has multiple causes: 

(1) the shortage of state hospital beds;

(2) the lack of insurance coverage for behavioral health conditions;

(3) shortage of mental health  professionals;

(4) the increasing number of forensic commitments; and

(5) the lack of a strong system of community-based care that keeps people with mental illness out of a crisis.

Boarding both delays the patient’s ability to be treated in the appropriate setting and strains the emergency department’s capacity to treat other patients. A busy, crowded emergency department is not conducive to treating a patient with a behavioral health condition.

The devastating effects of an underfunded behavioral health care system are felt most profoundly by individuals living with untreated disorders.

Advocacy is hard work. Collaboration is perhaps even harder work. Advocacy for and collaboration on efforts to promote effective approaches to mental health and alcohol and other drug treatment can be particularly challenging in light of the stigma that surrounds these issues and the difficulty in finding resources (money) to meet the demands of competing for public health priorities.  It may seem as if, more often than not, we make little to no progress in advancing the priorities of the mental health and substance use treatment fields. 

The good news is there are many examples of well-informed and prepared individuals making a difference when the opportunity presents itself to advocate for the right thing.  This course will explore how to advocate for the mental health and substance abuse fields.

 

Concept of mental health advocacy  

The concept of mental health advocacy has been developed to promote the human rights of persons with mental disorders and to reduce stigma and discrimination. It consists of various actions aimed at changing the major structural and attitudinal barriers to achieving positive mental health outcomes in populations.

Advocacy in this field began when the families of people with mental health issues and substance abuse issues first made their voices heard. The individuals in treatment then added their own contributions. Gradually, these people and their families were joined and supported by a range of organizations, many mental health workers and their associations, and some governments. Recently, the concept of advocacy has been broadened to include the needs and rights of persons with mild mental disorders and the mental health needs and rights of the general population.

Advocacy is considered to be one of the eleven areas for action in any mental health policy because of the benefits that it produces for people with mental disorders and their families.

The areas through which advocacy takes place include:   

> Awareness-raising

> Information

> Education

> Training

> Mutual help

> Counseling

> Mediating

> Defending

> Denouncing

 

Drawing attention to barriers to mental health

In most parts of the world, unfortunately, mental health and mental disorders are not regarded as anything like the same importance as physical health. Among the issues that have been raised in mental health advocacy are the following:

–      lack of mental health services

Some Americans have poor access to mental health care services because they live in a rural environment. Others cannot logistically get to treatment because of lack of transportation or overwhelming work and home responsibilities. In some areas, a mental health professional is available, but inpatient psychiatric hospitalization is not. Inner-city clinics may have such long waiting lists that mentally ill people give up on receiving care.

      unaffordable cost of mental health care through out-of-pocket payments

Many people do not seek mental health care for financial reasons. A lack of health insurance coverage, or coverage that leaves a large amount owed by the patient, leads many to avoid seeking care. Many Americans are unaware of the free or discounted mental health services available to them in city, county, state, private or Veterans Administration clinics and facilities. A report from former Surgeon General David Satcher, M.D., PhD., states that racial, age, cultural and gender disparities exist in the seeking of services, mostly linked to financial issues.

–      lack of parity between mental health and physical health

Unlike physical illnesses, it is the nature of many mental illnesses that the patient does not realize he is ill. Believing his behavior, emotions and mental status are normal, he may experience a lifetime of disordered thinking that could be greatly improved with appropriate treatment. Family intervention is critical to successful illness stabilization in these cases.

–      poor quality of care in mental hospitals and other psychiatric facilities

Not always the case, but staffing ratios can be low. When you have a population that do not have a voice the treatment can be poor. With funding being a concern the facilities can be in bad condition. All of these factors and more leave some with the question, is medication replacing care at mental health facilities?

–      need for alternative, consumer-run services

Again, because of treatment availability alternatives are needed in rural and inner city areas.

–      right to self-determination and need for information about treatments

–      violations of human rights of persons with mental disorders

Human rights violations against people with mental disorders occur in communities throughout the world in mental health institutions, hospitals, and in the wider community.

–      the stigma associated with mental disorders, resulting in the exclusion

The Community Action Network reports that many patients feel a stigma exists regarding the mentally ill and that negative stereotypes could damage their careers or relationships. Embarrassment and fear of what others may think prevent many from seeking or continuing the services they need.

–      the absence of promotion and prevention in schools, workplaces, and neighborhoods

–      insufficient implementation of mental health policy, plans, programs, and legislation

A study titled “Perceived Barriers to Mental Health Service Utilization in the United States, Ontario, and the Netherlands” reported that attitudinal barriers commonly caused Americans do not seek mental health care. These barriers include believing that the mental illness will resolve on its own and not believing that psychiatric care is beneficial.

Once we, and the public and policy-makers, are aware of these barriers, we can begin to break them down. The emergence of mental health and substance abuse advocacy movements in several countries has helped to change society’s perceptions of persons with disorders. Consumers have begun to articulate their own visions of the services they need. They are increasingly able to make informed decisions about treatment and other matters in their daily lives. Consumer and family participation in advocacy organizations may also have several positive outcomes.

 

Roles of different groups in advocacy 

Consumers and families

Consumer groups have played various roles in advocacy, ranging from influencing policies and legislation to providing help for people with mental disorders. Consumer groups have sensitized the general public about their cause and provided education and support to people with mental health and substance abuse disorders. They have denounced some forms of treatment that are believed to be negative. They have denounced poor service delivery, inaccessible care, and involuntary treatment. Consumers have also struggled for improved legal rights and the protection of existing rights.

The roles of families in advocacy overlap with many of the areas taken on by consumers. However, families have the distinctive role of caring for persons in treatment. In many places, they are the primary care providers, and their organizations are fundamental as support networks. In addition to providing mutual support and services, many family groups have become advocates, educating the community, increasing the support obtained from policy-makers, denouncing stigma and discrimination, and fighting for improved services.

Non-governmental organizations

These organizations may be professional, involving only mental health professionals, or interdisciplinary, involving people from diverse areas. In some non-governmental organizations, mental health professionals work with persons who have mental disorders, their families, and other concerned individuals.

Non-governmental organizations fulfill many of the advocacy roles described for consumers and families. Their distinctive contribution to the advocacy movement is that they support and empower consumers and families.

General health workers and mental health workers

In places where care has been shifted from psychiatric hospitals to community services, mental health workers have taken a more active role in protecting consumer rights and raising awareness for improved services. In traditional general health and mental health facilities, it is not unusual that workers feel empathy for persons with mental disorders and become advocates for them over some issues. However, there can also be conflicts of interest between general health workers or mental health workers and consumers.

Some specific advocacy roles for mental health workers relate to:

clinical work from a consumer and family perspective;

-participation in the activities of consumer and family groups;

-supporting the development of consumer groups and family groups;

-planning and evaluating programs together.

 

Principal steps for supporting consumer groups, family groups, and non-governmental organizations

Step 1: Seek information about mental health consumer groups, family groups, and non-governmental organizations in the country or region concerned.

Task 1: Develop a database with consumer groups, family groups, and non-governmental organizations.

Task 2: Establish a regular flow of information in both directions.

Task 3: Publish and distribute a directory of these organizations.

Step 2: Invite representatives of consumer groups, family groups, and non-governmental organizations to participate in activities at the ministry of health.

Task 1: Formulate and evaluate policy, plans, programs, legislation, or quality improvement standards.

Task 2: Establish committees, commissions, or other boards.

Task 3: Take educational initiatives.

Task 4: Conduct activities with the media.

Task 5: Organize public events in order to raise awareness

Step 3: Support the development of consumer groups, family groups, and non-governmental organizations at the national or regional level.

Task 1: Provide technical support.

Task 2: Provide funding.

Task 3: Support evaluations of consumer groups, family groups, and non-governmental organizations.

Task 4: Enhance alliances and coalitions of consumer groups.

Step 4: Train mental health workers and general health workers to work with consumer and family groups.

Step 5: Focus activities in advocacy groups.

Task 1: Identify the principal features of consumer groups.

Task 2: Identify the principal features of family groups.

Task 3: Identify the principal features of non-governmental organizations.

 

Principal steps for supporting general health workers and mental health workers

Step 1: Improve workers mental health:

Task 1: Build alliances with trade unions and other workers associations.

Task 2: Ensure that basic working conditions exist for general health and mental health workers.

Task 3: Implement mental health interventions for workers.

Step 2: Support advocacy activities with mental health workers

Task 1: Train mental health workers.

Task 2: Encourage community care and community participation.

Task 3: Facilitate interactions with consumer groups, family groups, and non-governmental organizations.

Step 3: Support advocacy activities with general health workers

Task 1: Define the role of general health workers in the field of mental health.

Task 2: Train general health workers in mental health.

Task 3: Establish joint activities with mental health specialists.

Task 4: Set up demonstration areas.

It is also vital to support advocacy activities with policy-makers and planners. The principal objective in respect to policy-makers and planners is to give appropriate attention to mental health on national agendas. This helps to enhance the development and implementation of mental health policy and legislation.

 

Principal steps for supporting policy-makers and planners

Step 1: Build technical evidence

Task 1: Determine the magnitude of mental disorders.

Task 2: Highlight the cost of mental disorders.

Task 3: Identify effective mental health interventions.

Task 4: Identify cost-effective interventions.

Step 2: Implement political strategies

Task 1: Identify themes ranking high in public opinion.

Task 2: Demonstrate the success of these themes.

Task 3: Empower alliances among mental health advocates.

 

Stigma associated with mental health and substance abuse treatment

What is a stigma?

Stigma is something about a person that causes her or him to have a deeply compromised social standing, a mark of shame or discredit.

The stigma associated with mental health and addiction treatment is one of the biggest challenges to recovery.

 

Common misconceptions about people in treatment for mental health issues or addiction:

People with disorders are often thought to be:

lazy

unintelligent

worthless

stupid

unsafe to be with

violent

out of control

always in need of supervision

possessed by demons

recipients of divine punishment

 

How to combat stigma

  1. Community education on mental disorders (prevalence, causes, symptoms, treatment, myths, and prejudices)
  1. Anti-stigma training for teachers and health workers
  2. Psycho-education for consumers and families on how to live with persons who have mental disorders
  3. Empowerment of consumer and family organizations
  4. Improvement of mental health services (quality, access, deinstitutionalization, community care)
  5. Legislation on the rights of persons with mental disorders
  6. Education of persons working in the mass media, aimed at changing stereotypes and misconceptions about mental disorders
  7. Development of demonstration areas with community care and social integration for persons with mental disorders.

 

Importance of advocacy 

The advocacy movement has led to major changes in the way persons who seek treatment are regarded. Consumers have begun to articulate their own vision of the services they need and want. They are also making increasingly informed decisions about treatment and other matters affecting their daily lives.

Advocacy has helped consumers make their voices heard and to show the real people behind the labels and diagnoses. Those who have been diagnosed with mental illness are not different from other people and want the same basic things out of life: adequate incomes; decent places to live; educational opportunities; job training leading to real, meaningful jobs; participation in the lives of their communities; friends and social relationships; and loving personal relationships.

Consumer and family participation in advocacy organizations may also have several positive effects decreases in the duration of inpatient treatment and in the number of visits to health services. There has been a reinforcement of knowledge and skills acquired through contact with services. Other possible beneficial effects of advocacy are the building of self-esteem, feelings of well-being, enhanced coping skills, the strengthening of social support networks, and the improvement of family relationships. These findings were reinforced by the United States Surgeon Generals report on mental health (Department of Health and Human Services, 1999). Consumer advocates and consumer researchers participated in planning, contributing to, and reviewing sections of this report.

Because many barriers prevent people in most countries from gaining access to mental health services, advocacy represents an essential area for action in national or regional policy. Advocacy can help the development and implementation of programs on mental health promotion for the general population and on the prevention of mental disorders for persons with risk factors. It can also help with treatment programs for persons with mental disorders and with the rehabilitation of persons with mental disabilities.

Moreover, advocacy by consumer groups, family groups, and non-governmental organizations can make valuable contributions to improving and implementing mental health legislation, and improve the financing, quality, and organization of services.

 

State Rankings for Mental Health Treatment

Mental Health America (MHA) released its annual State of Mental Health Report, which ranks all 50 states and the District of Columbia based on several mental health and access measures. The results show a country that is more insured but still falls dramatically short in meeting the needs of those with mental health concerns. 

 

  • Health care reform has reduced the rates of uninsured adults with mental health conditions—19 percent remain uninsured in states that did not expand Medicaid, 13 percent remain uninsured in states that did expand Medicaid.
  • Over 40 million Americans are dealing with a mental health concern—more than the populations of New York and Florida combined.

  • There are over 1.2 million people currently residing in prisons and/or jails with a mental health condition, and lack of access to mental health care is linked with higher rates of incarceration.

  • Fifty-six percent of adults still don’t receive treatment.

  • Youth mental health problems are on the rise, and 6 out of 10 young people with major depression do not receive ANY mental health treatment.

  • In states with the lowest workforce, there’s only one mental health professional per 1,000 individuals—that includes psychiatrists, psychologists, social workers, counselors, and psychiatric nurses combined.

  • In the overall rankings, Connecticut came out as #1, while Nevada landed at #51.

“Once again, our report shows that too many Americans are suffering, and far too many are not receiving the treatment they need to live healthy and productive lives,” said Paul Gionfriddo, president, and CEO, Mental Health America. “Mental illness touches everyone. We must improve access to care and treatments, and we need to put a premium on early identification and early intervention for everyone with mental health concerns.”

In developing the report, MHA looked at 15 different measures to determine the rankings. MHA hoped to provide a snapshot of mental health status among youth and adults for policy and program planning, analysis, and evaluation; to track changes in the prevalence of mental health issues and access to mental health care; to understand how changes in national data reflect the impact of legislation and policies, and to increase the dialogues and improve outcomes for individuals and families with mental health needs.

States in order of ranking:  

One being the best at access and use and 51 being the worst.

Connecticut

Massachusetts

Vermont

South Dakota

Minnesota

New Jersey

Iowa

North Dakota

Pennsylvania

Maine

Delaware

New York

Alaska

Maryland

Illinois

Hawaii

Michigan

District of Columbia

Kentucky

New Hampshire

Kansas

New Mexico

California

Oklahoma

Colorado

Ohio

Nebraska

Florida

Wyoming 

Washington

Missouri

Texas

North Carolina

Georgia

Wisconsin

Rhode Island

South Carolina

Virginia

Montana

Utah

Tennessee

Louisiana

West Virginia

Mississippi

Indiana

Alabama

Arkansas

Idaho

Oregon

Arizona

Nevada

 

Each one of us can make a difference by advocating for mental health and addiction recovery. Reduce the stigma by telling your story, if you have one. Listen to those in need and support their efforts. Speak kindly regarding treatment options and support systems. 

Whether you are a mental health or substance abuse professional, have a friend or family member in treatment, or just care about mental health care, consider getting involved in advocacy.

By becoming involved, you can:

  • help erase the remaining stigma surrounding mental health
  • help others learn from your experiences
  • suggest improvements or changes
  • lobby your representatives on mental health issues

 

 Thank you for taking this course through BaysideCEU.com.

We appreciate you!